Knee cap cartilage repair – Patellofemoral Instability treatments
If you have been diagnosed that you have Patellofemoral Instability or Patellofemoral Pain Syndrome, you are likely a person who has a physically demanding job, or someone who is very active in a sports lifestyle. In your diagnostic examination you may have been told that the cartilage under your kneecap has been damaged by wear and tear or that your knee cap is not sitting properly in its groove and that you also have patellar instability and/or chondromalacia patellae. On x-ray this damage or erosion is seen as a decrease in the amount of cartilage underneath the kneecap.
Knee instability from the patellar is a common injury that can result in significant limitations of activity and long-term arthritis. You may have also been told that there is a high risk of recurrence in patients and surgery is often indicated. Advances in the understanding of patellofemoral anatomy, such as knowledge about the medial patellofemoral ligament (MPTL), tibial tubercle-trochlear groove distance (another indicator of abnormal anatomy), and trochlear dysplasia (The trochlear groove is the area of the knee that the knee cap glides in when bent – the knee cap and the groove should be near parallel to each other. Abnormal anatomy – a bad fit – is a major cause of dislocation).
However, some techniques such as reconstruction are technically demanding and may result in significant complication.1 This research is in agreement with other citations that suggest:
- Doctors note that many treatments can make symptoms of patellofemoral instability and pain worse in some patients.
- One paper says more than 25% of patients had significant side effects after surgical treatment of patellofemoral instability.
Treatments for patellofemoral instability
Medical literature has much to say about conventional treatment options including knee surgery. Some cases of patellofemoral instability are difficult to manage and in fact some treatments can make the patient feel worse. Frequently, the patient often bounces from practitioner to practitioner, physiotherapist to surgeon, seeking some relief of symptoms. However, their underlying source of pain is not well understood, so treatment can aggravate the symptoms.3
Doctors have put a lot of emphasis on medial patellofemoral ligament (MPFL) reconstruction for the treatment of recurrent patellar dislocations/subluxations. Numerous techniques have been reported; however, there is no consensus regarding optimal reconstruction and in one paper a total of 164 complications occurred in 26% of patients. Side effects included patellar fracture, failures, and clinical instability on postoperative examination, loss of knee flexion, wound complications, and pain.3
In the latest research doctors say that patients with medial patellofemoral ligament (MPFL) reconstruction without additional stabilizing treatments suffered from high rate of continued problems including 5% who continued with recurrent dislocations.4
In the March 2016 issue of Arthroscopy, researchers found conflicting evidence for the use of Medial Patellofemoral Ligament Reconstruction combined With Bony Procedures (bone reshaping) for Patellar Instability. Enough so that they were unable to identify an absolute indication for this type of surgery.5
This supports research that says when you have multiple knee ligament damages – such as in degenerative wear and tear or acute injury – the medial patellofemoral ligament play a very insignificant role in knee instability and does not even need to be addressed. 6 Of course to a doctor experienced in regenerating ligaments, all ligaments play an important role. In surgery many times supportive tissue is discarded.
Athletes with pain often feel there is no other choice but surgical procedures, even drastic ones. A good example of drastic surgery is the recommendation to surgically remove the patella in order to remove the pain. This sometimes does relieve the pain, but at a significant cost to the body. The strength to extend the knee is reduced by about 30 percent, and the force exerted in the knee is increased.
There are a host of other risks associated with surgery. The patient must realize that with each procedure and each shaving or cutting of tissue, NSAID (non-steroidal anti-inflammatory drug) prescription, or cortisone shot, the odds of developing long-term arthritis are greatly increased. The key to keeping the knee strong is to stimulate the area to heal, not to cover up the pain with a cortisone shot or NSAID. Even worse is to eliminate the painful area by shaving or cutting. This just delays the pain for a few years until the remaining tissue becomes degenerated. The best approach for the athlete is to stimulate the area to heal. The best way to do that is with Prolotherapy, Platelet Rich Plasma Therapy and Stem Cell Therapy.
Prolotherapy Treatment for Patellofemoral Pain Syndrome
With Patellofemoral Pain Syndrome, the patella should be tracking in the groove in the femur, but oftentimes tracks laterally. A sunrise view X-Ray will show how the patella is tracking. An examination by the physician that includes moving the knee will reveal the tracking of the patella. Strengthening the vastus medialis may be helpful, but often that alone will not resolve the Patellofemoral Pain Syndrome.
Prolotherapy injections to the medial side of the patella, to strengthen the attachment of the vastus medialis to the patella, will pull the patella into the groove.
Prolotherapy injections cause a mild and localized inflammatory reaction that causes a wound healing event. Blood supply increases at the weakened area, along with an influx of reparative cells. Collagen cells will also be deposited, which as they mature, strengthen the soft tissue. This results in a strengthening of the vastus medialis attachment enabling the realignment of the patella.
Exercises, such as cycling, would be encouraged as well, because they will help to strengthen the vastus medialis. Prolotherapy along with vastus medialis strengthening will get rid of the pain and speed up the process to normalize the patellar tracking. Prolotherapy for patellofemoral pain syndrome gets people back to running, jumping, playing tennis, or doing their favorite activities very quickly.
References for this article
1. Koh JL, Stewart C. Patellar instability.Orthop Clin North Am. 2015 Jan;46(1):147-57. doi: 10.1016/j.ocl.2014.09.011.
2. McConnell J. Management of a difficult knee problem. Man Ther. 2012 Jun 27. [Epub ahead of print]
3. Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A Systematic Review of Complications and Failures Associated With Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocation. Am J Sports Med. 2012 Jun 7. [Epub ahead of print]
4. Kita K, Tanaka Y, Toritsuka Y, Amano H, Uchida R, Takao R, Horibe S. Factors Affecting the Outcomes of Double-Bundle Medial Patellofemoral Ligament Reconstruction for Recurrent Patellar Dislocations Evaluated by Multivariate Analysis. Am J Sports Med. 2015 Oct 4. pii: 0363546515606102. [Epub ahead of print]
5. Longo UG, Berton A, Salvatore G, Migliorini F, Ciuffreda M, Nazarian A, Denaro V. Medial Patellofemoral Ligament Reconstruction Combined With Bony Procedures for Patellar Instability: Current Indications, Outcomes, and Complications. Arthroscopy. 2016 Mar 28. pii: S0749-8063(16)00043-8. doi: 10.1016/j.arthro.2016.01.013. [Epub ahead of print] Review.
6. Allen BJ, Krych AJ, Engasser W, Levy BA, Stuart MJ, Collins MS, Dahm DL. Medial patellofemoral ligament tears in the setting of multiligament knee injuries rarely cause patellar instability. Am J Sports Med. 2015 Jun;43(6):1386-90. doi: 10.1177/0363546515576902. Epub 2015 Mar 25.