Patellar Instability Non-Surgical Treatment

Nonoperative treatment is typically the first step for patients who:

• Had a first-time dislocation and are at a low recurrence risk: First-time dislocations without additional injury and with low recurrence risk are initially treated without surgery. Recurrence risk is determined by many factors that Dr. Rynecki Baker will evaluate in your history, on your physical exam, and through your imaging. Some of these are listed below.
• Have favorable anatomy: The groove, kneecap height, and alignment are normal or only mildly abnormal.
• Have a lower-risk profile: Patients who are skeletally mature, have no history of instability in the opposite knee, and do not have significant trochlear dysplasia are less likely to have repeat episodes.
• Do not have a loose fragment: Imaging shows no displaced piece of cartilage or bone within the joint.

Nonoperative treatment is generally not the right first step for certain patients. A dislocation that breaks off a significant piece of cartilage or bone is usually best treated with surgery to repair or remove the fragment, ideally soon after the injury. Surgery may also be recommended earlier for patients with recurrent dislocations or with high-risk anatomy, particularly young patients with trochlear dysplasia, a high-riding kneecap, or a prior dislocation in the opposite knee. In these patients, the chance of another dislocation is substantially higher, and every additional episode risks further cartilage damage.

After a first-time dislocation, roughly one in three patients will go on to have another episode, although this varies widely depending on age and anatomy. Patients with few risk factors often do well with nonoperative care, while young patients with multiple anatomic risk factors have a much higher likelihood of recurrence. Research from the JUPITER Study Group and others has focused on identifying these risk factors so that treatment can be matched to each patient’s individual risk, rather than applying a single approach to everyone. This risk-based approach is central to how Dr. Rynecki Baker counsels patients after a first dislocation.

Nonoperative treatment is an active process that typically progresses in phases.

Early phase (first few weeks)

• Knee cap reduction and evaluation: If the kneecap has not returned to place on its own, it is gently put back. X-rays and often an MRI are obtained to check for fragments and assess anatomy.
• Protection: A brace may be used for a short period for comfort and to protect the healing tissues, with crutches as needed.
• Swelling control: Ice, compression, elevation, and anti-inflammatory medications help control pain and swelling. A large, painful effusion may occasionally be drained.
• Early motion: Gentle range of motion and quadriceps activation begin early to prevent stiffness and muscle shutdown.

Rehabilitation phase

• Quadriceps strengthening: Restoring quadriceps strength is essential for controlling the kneecap and absorbing load.
• Hip and core strengthening: Weakness in the hip muscles allows the knee to collapse inward, increasing outward force on the kneecap. Strengthening the hip abductors, hip external rotators, and core improves control of the entire limb.
• Neuromuscular and movement retraining: Balance, landing, and cutting mechanics are retrained to reduce the positions that place the kneecap at risk.
• Bracing or taping: A patellar stabilizing brace or taping may provide added support during the return to activity.

Return to activity

• Return to sport is guided by milestones rather than the calendar alone.
• Patients should have full motion, no swelling, restored strength compared with the other leg, and the confidence to cut, pivot, and land without apprehension.
• Low-impact activities such as cycling and swimming help patients stay active in the meantime.

Choosing nonoperative treatment is not a permanent decision. Dr. Rynecki Baker follows patients closely through rehabilitation and afterward. Surgery may be recommended if a patient:

• Has another dislocation or recurrent subluxations
• Continues to feel unstable or apprehensive despite a dedicated course of physical therapy
• Develops catching, locking, or swelling suggesting a loose fragment or cartilage injury
• Is found to have anatomic risk factors that make further episodes likely

Because each dislocation can injure the joint surface, Dr. Rynecki Baker does not recommend waiting through repeated episodes when the pattern is clear. The goal is always to protect the cartilage and the long-term health of the knee.