Injury Centre | Knee | Patella Disclocation

Patella Dislocation

The patella, or kneecap, is one of three bones that come together at the knee joint. All of these bones have a layer of cartilage at points where their surfaces come into contact. The patella is also enveloped by a tendon. This tendon connects the quadriceps muscle of the thigh to the shin bone below the knee.

The dislocation of the patella occurs when the kneecap comes completely out of its groove, and rests on the outside of the knee joint. Kneecap dislocations usually occur as a significant injury the first time the injury occurs, but the kneecap may dilocate much more easily after the first injury.

What is patellar subluxation?

The kneecap slides up and down a groove on the end of the thigh bone as the knee bends. This groove is called the trochlea. The kneecap is designed to fit in the center of this groove, and slide evenly within the groove. In some people, the kneecap is pulled towards the outside of the knee. As this happens, the kneecap does not slide centrally within its groove.

Also called patellar subluxation, patients who experience an unstable kneecap have a kneecap that does not slide centrally within its groove. Depending on the severity of the patellar subluxation, this improper tracking may not cause the patient any problems, or it may lead to dislocation of the patella (where the kneecap fully dislocates out of the groove). Most commonly, the tracking problem causes discomfort with activity, and pain around the sides of the kneecap. Patellar subluxation is a condition that usually affects adolescent, and sometimes younger children.

What causes patellar subluxation?

There are dozens of factors implicated in the cause of patellar subluxation. The bottom line is that it is probably the contribution of several factors that lead to instablitiy of the kneecap. Possible factors include:

• A wider pelvis
• A shallow groove for the kneecap
• Abnormalaties in gait

What else may be causing kneecap pain?
The most common cause of kneecap pain is chondromalacia, or an irritation of the cartilage on the undersurface of the kneecap. Patellar subluxation and chondromalacia can go hand in hand, but they should be considered separate entities. That said, if chondromalacia is being caused by subluxation, then the instability of the kneecap must be addressed for treatment to be successful. Other causes of kneecap pain include osteoarthritis, patellar tendonitis (Jumper's knee), and plica syndrome.

Is there any treatment for patellar subluxation?
Treatment of the unstable patella is first to ensure that the patella is not dislocated. Your doctor can determine by examining your knee and obtaining x-rays, to see if the kneecap is outside of its groove. In patients with a kneecap dislocation, the kneecap may need to be repositioned, or "reduced."

Treatment of patellar subluxation includes:

• Physical Therapy
  Traditionally, patients were sent to physical therapy to strengthen their VMO (part of the quadriceps muscle) to realign the pull on the kneecap. More recent research has shown that this is probably not the critical factor in eliminating kneecap problems. Focusing instead on strengthening of the hip abductors and hip flexors (so-called pelvic stabilization exercises) offers better control of the kneecap.
• Bracing and Taping
  Bracing and taping of the kneecap are also a conroversial topic in the rehabilitation of kneecap problems. These often provide symptomatic relief, but are certainly not a long-term solution. Caertianly if symptomatic relief is found with a brace or tape, it is certainly appropriate to continue with this as a treatment.
• Better Footwear
  Footwear contributes to the gait cycle. Motion control running shoes may help control your gait while running and decrease the pressure on the kneecap.

Is surgery ever needed for patellar subluxation or dislocation?
Some patients are not cured by conservative therapy, and it may be determined that surgery is needed, especially in patients who have significant pain or recurrent dislocation. By looking into the knee with an arthroscope, the surgeon can assess the mechanics of the knee joint to ascertain if there is an anatomic malalignment that could be corrected. One common malalignment is the result of too much lateral tension that pulls the kneecap out from its groove; this can place increased pressure on cartilage and lead to dislocation. For this problem, a procedure known as a lateral release can be performed. This procedure involves cutting the tight lateral ligaments to allow the patella to resume its normal position.

Why do kneecap dislocations become a recurrent problem?
When the kneecap comes out of joint the first time, ligaments that were holding the kneecap in position are torn. The most commonly torn structure is called the medial patellofemoral ligament, or MPFL. This ligament secures the patella to the inside (medial) of the knee. When a kneecap dislocation occurs, something must fail to allow the kneecap out of the groove, and usually it is the MPFL.

Once the MPFL is torn, it often does not heal with proper tension, and the kneecap can subsequently dislocate more easily. That is why recurrent dislocation of the kneecap occurs in a high percentage of patients who have this injury.

What can be done to treat a kneecap dislocation?
Traditionally, kneecap dislocations were treated by bracing a patient, and allowing the MPFL to heal. Unfortunately, bracing does not seem to be terribly effective, and no matter how long a brace is worn after a kneecap dislocation, the redislocation rate is still quite high.

In patients who have recurrent (repeat) dislocations, there are surgical options. The usual treatment is to loosen the lateral (outside) ligaments that pull the kneecap; a so-called lateral release. At the same time, the muscle of the medial side of the knee (the VMO) is advanced to pull the kneecap more centrally.

What about surgery after a first-time kneecap dislocation?
Recent interest has developed in preventing these recurrent dislocations. Each time the kneecap dislocates, the cartilage can be injured, and the ligaments can become more stretched out. Some surgeons are trying to restore the normal anatomy by repairing the MPFL after a first-time dislocation. This surgery is controversial, because not all patients who dislocate their kneecap will have another dislocation. However, some patients would rather have the ligament repaired in an effort to lower the chance of having this become a repeat problem.