While surgical treatment (lateral patellar retinacular release) for maltracking of the patella has shown promising results,1 it is becoming less popular as an isolated procedure.² The surgery appears less successful in patients that have severe chondromalacia, patella instability, or evidence of trochlear dysplasia.^3–5 Latterman and associates⁶ state that “isolated lateral retinacular release has little or no role in the treatment of acute or recurrent patella instability. This procedure should be reserved for the few patients with a clearly identified lateral patella compression syndrome in presence of a tight lateral retinaculum and clearly discernable lateral retinacular pain.” Currently it appears that lateral patellar retinacular release is usually performed as an adjunct to other knee surgeries where patellofemoral misalignment is an issue.⁶ This chapter will deal with patellofemoral rehabilitation that should be considered an adjunct to any knee surgery where patella pain is an issue.

Adaptation resulting from chronic compression in the patellofemoral joint can lead to significant arthrosis in a wide variety of patients, both young and old. Pain, attributed to increased patellofemoral compression, occurs in different aspects of the joint, but the most common site is along the lateral aspect. This patellofemoral pain can originate from mechanical malalignment, the static or dynamic soft tissue stabilizers, or increased load placed across the joint as a result of various activities.⁷ Symptoms may include diffuse aches and pains that are exacerbated by stair climbing or prolonged sitting (i.e., flexion of the knees). Crepitus and mild effusion are often associated with patellofemoral arthralgia. Although complaints of “giving way” or collapse are more often linked with ligamentous instability, these symptoms also can be associated with patellofemoral pain. Patients may even complain of joint pain and “locking” when they are experiencing poor patella stabilization during flexion of the knee.

In examining the way lateral retinacular release procedures may affect the arthrokinematics of the patellofemoral joint, the focus should be on the relationship between patella tilt compression and associated tightness in the lateral retinaculum. The function of the patella is to increase the lever of the quadriceps muscle, thus increasing its mechanical advantage. For functional and efficient knee motion, the patella must be aligned so that it can travel in the trochlear groove of the femur. The ability of the patella to track properly depends on the bony configuration of the trochlear groove and the balance of forces of the connective tissue surrounding the joint.

Weakness and stiffness from the hip are factors that appear to influence poor patella alignment (gluteus medius weakness and iliotibial band [ITB] tension). Tensor fascia latae and gluteus maximus fibers combine to form a very thick, fibrous structure that attaches distally into the lateral tibial tubercle (Gerdy tubercle).⁸ The ITB slips into the lateral border of the patella, which interdigitates with the superficial and deep fibers of the lateral retinaculum. This design often leads to excessive compression over the lateral condyle and lateral border of the patella during dynamic activity.

Tilt compression is a clinical radiographic condition of the patellofemoral joint that can lead to retinacular strain (i.e., peripatellar effect) and excessive lateral pressure syndrome (i.e., articular effect).⁹ A case can definitely be made for a cause-and-effect relationship between tilt compression and retinacular strain. Chronic patella tilting and associated retinacular shortening cannot only produce significant lateral facet overload but also a resultant deficiency in medial contact pressure. This tilt compression syndrome may have simple soft tissue pain related to the shortening of the lateral retinacular tissue. If left untreated, then histologic studies of painful retinacular biopsies may reveal degenerative fibroneuromas within the lateral retinaculum of patients with chronic patellofemoral malalignment.¹⁰ Excessive lateral pressure syndrome results from chronic lateral patella tilt, adaptive lateral retinacular shortening, and resultant chronic imbalance of facet loads. It is prevalent in active, middle-aged adults. In younger patient populations, excessive lateral pressure during growth and development can alter the shape and formation of both the patella and trochlea.¹⁰

Nonoperative treatment of patella tilt should focus on mobilization of tight quadriceps muscles and the lateral retinaculum. Patellofemoral taping, bracing, and antiinflammatory medications also are quite helpful. Gait deviation and excessive foot pronation should be corrected to eliminate possible secondary influences on patellofemoral malalignment.⁷ The use of resistant weight training or isokinetic exercise (in conjunction with patella taping) can be beneficial in building quadriceps muscle strength.¹¹

Patellofemoral Taping

McConnell patellofemoral taping has become a useful technique in the conservative (nonsurgical) rehabilitation of patellofemoral pain; it can also benefit patients after surgical lateral release as well. Controversy exists as to the mechanism behind the pain relief from taping. Whether via cutaneous stimulation, enhancement of patellofemoral ligaments, or improved vastus medialis oblique (VMO) timing, clinically we know that patellofemoral pain can be reduced or eliminated via its appropriate application.12,13

Patellar taping has been shown to increase vasti muscle activity^14,15 and may enhance knee joint proprioception after surgery.¹⁶ The McConnell patellofemoral program emphasizes closed-chain exercises to correct patella glide (Fig. 23-1), tilt (Fig. 23-2), and rotation, (Fig. 23-3) and allows for pain-free rehabilitation. The patient is evaluated dynamically during a functional activity such as walking, stepping down, or squatting. According to Maitland,¹⁷ “The aim of examining movements is to find one or more comparable signs in an appropriate joint or joints.” These comparable signs, or reassessment signs, are reevaluated after each patella correction to determine the effectiveness of the treatment. After an assessment of patella orientation, a specifically designed tape is used to correct for each patella orientation. The patellofemoral joint is principally a soft tissue joint, which suggests that it can be adjusted through appropriate mechanical means (i.e., physical therapy). Two primary components (glide and tilt) may be present either statically or dynamically. Patella orientation varies among patients and even from left to right extremities.

Glide Component

The amount of glide correction depends on the tightness of the structures and the relative amount of activity in the entire quadriceps musculature. The corrective procedure involves securing the edge of the tape over the lateral border of the patella and pulling or gliding the patella more medially. Although this technique is useful for most patellofemoral pain, it is not often used in the postoperative care of patients recovering from lateral retinacular release (see Fig. 23-1).

Tilt Component

Tilt correction is quite often used to stretch the deep retinacular fibers along the lateral borders of the knee. Increased tension in the lateral retinaculum along with a tight ITB (which inserts into the lateral retinaculum) can produce a lateral “dipping,” or tilt, of the lateral border of the patella (see Fig. 23-2).

When focusing on patients recovering from lateral retinacular release, the physical therapist (PT) should remember that the very tissues these taping techniques address have been surgically released. Although patella orientations have definitely been altered in patients after surgical release, muscle recruitment patterns and joint loading characteristics that may have contributed to the symptoms are still present.

McConnell taping procedures produce improved joint loading and allow the patient to return to a more active, pain-free lifestyle when used in conjunction with closed-chain functional exercises.^18,19

Although conservative management remains the cornerstone of treatment for patients with anterior knee pain, some patients will not respond and continue to have pain and functional disability. If conservative (nonsurgical) treatment is unsuccessful in providing the patient with appropriate pain relief and function, then surgical intervention should be considered.²⁰

In addition to subjective complaints and functional limitations, other indications for surgery include dislocation, subluxation, and failure of previous surgery with or without medial patella position.

Operative procedures that modify patella mechanics are most successful in treating patients with patella articular cartilage lesions. Lateral release procedures should ultimately produce a mechanical benefit to the patient, such as relieving documented tilt.²¹

Review of the literature suggests strict indications for lateral release9:

Results may be disappointing for lateral release in the presence of the following conditions:

Patients with instability may require medial retinacular imbrication or a distal realignment in addition to an isolated lateral release.

The Southern California Orthopedic Institute (SCOI) technique of arthroscopic lateral release is performed in the supine position without the use of a leg holder; the tourniquet is inflated only when necessary. The procedure is performed with the arthroscope in the anteromedial portal. Routine arthroscopic fluid is used. An 18-gauge spinal needle is inserted at the superior pole of the patella and is used as a marker for the proximal extent of the release. The needle must be withdrawn as the electrosurgical electrode approaches it. With experience, the surgeon can omit the needle marker. The electrosurgical lateral release electrode is inserted through the inferior anterolateral portal using a plastic cannula to protect the skin. The procedure is performed with the generator setting at approximately 10 to 12 W of power. With the patient’s knee extended, the surgeon performs the release approximately 1 cm from the patella edge, progressing from distal to proximal using the cutting mode. The deep and superficial retinaculum, as well as the lateral patellotibial ligament, are released under direct visualization until subcutaneous fat is exposed. The extent of the proximal release is only to the deforming tight structures and should never extend beyond the superior pole of the patella.

An incomplete release is often secondary to inadequate release of the patellotibial ligament. Again, the tourniquet is not inflated during the procedure, and vessels are coagulated as they are encountered. An adequate release is confirmed by the ability to evert the patella 60°. After the release, the knee is passively moved through a range of motion (ROM) and correction of lateral overhang during knee flexion is confirmed. The arthroscope should be switched back to the accessory superolateral portal for this assessment. Usual postoperative dressings are applied after the arthroscopic procedure (sterile dressings and an absorbent pad held in place by an elastic toe-to-groin support stocking previously measured for the patient).

Postoperative rehabilitation includes muscle strengthening and ROM exercises the day of surgery, including quadriceps sets and straight leg raising. The patient continues to do these exercises at home the night of surgery and is given weight bearing as tolerated status with crutches immediately. Crutches are discontinued when adequate quadriceps muscle control has been obtained and patients can walk safely. The vast majority of patients use their crutches for less than 7 days, although some may need them for 2 to 3 weeks depending on quadriceps control.

The SCOI experience with arthroscopic lateral retinaculum release (ALRR) has been reported previously.²² The researchers monitored 39 patients with a history of recurrent patella subluxation or dislocation in 45 knees for an average of 28 months and noted good to excellent results in 76% of patients. Similar experiences with ALRR have been reported in the literature, with favorable results in 60% to 85% of cases.²³ Arthroscopic treatment compares favorably with open realignment and has a lower complication rate. No postoperative hemarthrosis occurred in the SCOI series; hemarthrosis is the main complication reported in the literature, occurring in 2% to 42% of cases. Small’s review²⁴ of 194 cases of ALRR, performed by 21 arthroscopic surgeons, found hemarthrosis associated with 89% of the 4.6% total complications. Careful coagulation of vessels without an inflated tourniquet can reduce hemarthrosis. If strict criteria are met and proper surgical techniques are used, then a consistent result can be obtained with these patients.

The complexity of the patellofemoral articulation and its associated disorders are evident by the significant body of literature on the subject and the abundant surgical procedures involving the joint. A thorough clinical evaluation, including history and physical and radiographic examination, helps to clarify the diagnosis of patellofemoral disorder. Use of the arthroscope for the electrosurgical lateral release is an effective component in the armament of knee surgeons for patients with persistently symptomatic patellofemoral disorders who meet the surgical indications described.