Looking for non-surgical cure to tilted patellas

[kneepaincure]

Hello all, this is my first post here and I'm really hoping for some answers..

I developed severe knee pain after going for a trek 2 years ago.. the pain reduced after rest and PT, but remained as a nagging pain for several months..Now it is 2 years later and I get mild sharp pains if I squat low, descend stairs or sit in one position for too long..Recently I went in for another consultation with an OS and after doing merchant's view x-rays, he said that I have tilted patellas in both knees and recommended lateral release as well as plica excision..According to him I will be back to normal in a month's time and if I elect to not do the surgery, I could develop arthritis by 30-35 years of age.. I am 23 now and was terrified to hear this prognosis..

Does anyone think that if I did PT consistently (I have never carried on for more than a month at a time) I would see the patella move into its correct location? I am hesitant to go for an invasive procedure because my pain is not so much as long as I don't do the wrong activities..Does no pain during activities like using an elliptical trainer mean that no damage is occurring or that nerves do not sense it?

Looking forward to some replies.. thanks 

[JFVolleygirl27]

Do you have any instability or maltracking in your knee?

I would tread very carefully with any surgeon who recommends the LR? Those are done in very specific cases in people with no instability. If not done correctly or if you really do not need that, it can cause more problems than help. Those are done far too often and you will see on the forums here that many people will have problems with it.

I am 19 and was recommended to get a LR, MPFL, and TTT last year by two local OS's that I met with. After doing a lot of my own research though, particularly on here, I realized that that would not have been the right surgery for me and would have caused more problems than helped because it was only treating the symptoms of my knee problems (dislocation), but not the underlying problem. It's very important to find the right surgeon who knows what to look for and how to treat it. I went to a surgeon that performed CT scans, orthoradiograms, and standing leg xrays that revealed I had patella alta and slight valgus deformity. So I just got surgery with him about 11 days ago - I got a distal femoral osteotomy, medial ligament reconstruction, and distal/medial TTT that fixed my patella alta. My knee is now doing better than ever - the tracking is good and centered and there is no more instability. My doctor also has a very aggressive rehab protocol  which I prefer - I am not in any brace and I am already riding a stationary bike and have full range of motion.

Its very important to find the right surgeon and research the procedure - make sure it is treating your underlying problems, not just the symptoms caused by the problem. And rehab protocols will vary wildly too from OS to OS, so be sure to ask about that. Some are very conservative and will have you in an immobilizer brace for anywhere between 2-6 weeks....ick! My OS last year would have had in my a straight leg brace for 4 weeks and I wouldn't have even started therapy till 2 weeks after surgery. Right now, I don't even feel like I had surgery - recovery is going very quick and good!

Hope this helped! Any questions, feel free to ask! Many people on this board are very knowledgeable and will have good advice! as far as I know, there are really no no surgical cures to a tilted patella.

[kneepaincure]

Thanks for your advice! How do I get to know whether I have instability or maltracking? Is there a diagnostic test to determine that?

I did get the standing x-rays but the doctor said that I don't have a patella alta.. just a lateral tilt.. 

Again, I'm wondering whether his prognosis of me getting arthritis at an early age is correct? It's a scary prospect

[crankerchick]

You have already been given some sound advice. I will only add:

-Definitely don't proceed with any surgery recommendations if yo are not 100% comfortable with the idea of surgery. Don't let 1 doctor's claim of future arthritis scare you into action either. As hard as it is to do in these situations where something is painful and or limiting us from the the things we want to do, taking the time to be sure and comfortable with what course of action to take remains one of the best things patients can do for themselves

-There is test to determine maltracking. CT scan or x-ray of the knee bent various degrees of flexion will show how the patella moves through flexion. Some doctors are getting quite fancy and do this x-ray while the patient is standing/squatting.

-Do not let claims of how invasive a procedure is or is not steer you in any particular direction. The recovery from a lateral release or any other procedure, if it isn't the right procedure for YOUR knee, could be forever. What's important is having the right procedure for your particular anatomy of your knee, not acting quickly to stave off arthritis, or opting for a particular procedure because the procedure is less invasive.

I like to think if you were having instability, particularly lateral instability, you would know. For me at least, I could literally feel my kneecap popping out of the groove. Sometimes it happened traumatically and so quick I couldn't really tell what happened, save for the fact that I was all of a sudden on the ground, but it also happened just "leisurely" as in it would pop out when I was walking and I could just feel it not in the right place.

[kneepaincure]

Thank you for your inputs!!

The thing that is preventing me from opting for surgery is that my pain is not severe at all.. As long as I don't do the wrong activity like too much climbing, or squatting, I am fine.. I don't see the point in wrecking my knees at 23..I don't have to compete in sports or anything, just need to keep up a general fitness level, and if I can do that on an elliptical, why not?

I don't think I have lateral instability.. I have never felt my kneecap moving around ever.. I feel I am unbalanced as a whole though.. Sometimes I lose balance just standing in one place.. I think I place my weight on the outer sides of my feet and am consciously trying to change that..

Just wondering, if symptoms reduce by doing physio, then does that mean my kneecaps are moving to their right positions? Or is it just symptomatic relief?

[crankerchick]

Just wondering, if symptoms reduce by doing physio, then does that mean my kneecaps are moving to their right positions? Or is it just symptomatic relief?

I'm no doctor, so take this for what it's worth, but I think the answer really depends on what is causing the tilt and what else might be going on in the legs besides what this particular doctor told you. If it is something structural in nature causing your pain, then physio isn't really fixing the problem. If you feel better with physio, that's a good thing of course, but it's not changing the structural make-up of your legs, it's just something helps you keep things under control, which may be enough for you. On the other hand, if the problem really is just tilt due to tight structures or muscular imbalance, then of course if the physio helps, it's probably a legitimate fix to the problem. I just think if that was the case, the physio would have helped by now.

There's nothing wrong with conservative treatment to start and for as long as it takes until you are either satisfied or comfortable to pursue other options. Whether physio is "curing" you, though, really depends on what is going on in the knee in the first place, and without a good workup of the appropriate x-rays, CT scan, and physical examination, it's tough to say what is really going on.

[Turtlebug]

I get mild sharp pains if I squat low, descend stairs or sit in one position for too long..

This is how mine started a few years ago.  I had a scope done, which to me made things worse, but the OS basically wrote me off when I told him that.  Then I had surgery....The first few weeks, I thought "hmm...seems to be better"....Then the more active I have tried to become, the worse my knees feel.  In the end, I've had surgeries, spent alot of money for, well, nothing.  My knees feel worse now than they ever have.  23 is too young to go through anything like that.  As for surgery, there is always a risk - some people have had good results, I didn't.  There's no guarantee.  I would however, stay away from a LR.  I would continue to work on strengthening your core.  My PT did tell me that if your core isn't strong, you will have problems.  So, even when I went to PT he didn't have me doing alot of leg exercises-it was more of a total body workout.  If you have access to a pool, you may want to try doing some water workouts as well - as they won't put as much stress on your knees, but will still give you a good workout.

If you don't like or don't feel comfortable with what your current OS says, find another one, or two or three.  Unfortunately, even if they claim to be "sports medicine" focused, from my experiences, that doesn't mean that they are more interested in getting someone "back in the game" either.  I'm still searching for an OS who will listen and believe what I say.
Good luck

[kneepaincure]

@crankerchick: That's what I have been thinking too.. I guess physio just reduces the symptoms, but I have only been told to do quad strengthening exercises all this time.. It's only now that I have found out about a whole range of leg exercises that need to be done, and am hoping that they will help me..

@Turtlebug: Yes I too think that I am too young to have an OS mess up my knee and then try to fix it with more surgeries.. Unfortunately, where I live, there are no great knee specialists and no one I know has ever been through knee surgery at this age, or ever had such problems for that matter.. It's depressing to be singled out but have to keep moving forward..

[kneepaincure]

The strange thing is, though I have assumed that my problem is runner's knee, I have no pain when I run (when necessary, not as a sport anymore) but only when squatting or sitting/standing for too long.. Maybe it could be plica? The MRI report said 'medial plica appear thickened'..

[kneepaincure]

Can someone please give me an idea of how I should proceed? Very confused and worried..

[Fathead D]

My advice would be to try every non-surgical avenue first. 

I have had 2 failed lateral releases (one on each knee) and now my Dr is telling me that she thinks it is a muscle imbalance that is causing the maltracking.  I am supposed to work on strengthening my VMO and check back in 3 months.  So my question back was "so why did I undergo 2 surgeries when my problem may be a muscle imbalance?"  She had no answer.  My answer is that she gets paid to operate and not to suggest PT.

The morale of my story is simple.  Investigate and get second oppinions.  Surgery should be your last option.

[Turtlebug]

My advice would be to try every non-surgical avenue first. 

 My answer is that she gets paid to operate and not to suggest PT.

The morale of my story is simple.  Investigate and get second oppinions.  Surgery should be your last option.

I couldn't agree more....And I say that from wishing that I had never had surgery.  The post-op pain is by far much worse than any pain I had prior.  And by post-op, I mean the pain just from, as you said, sitting, stairs and doing any kind of squatting.

You mentioned in your original post that your OS indicated that if you did nothing you COULD develop arthritis by the time you are 30-35.  Does he/she have a crystal ball?  I was told by one OS that I had arthritis, another one said neither my x-rays nor my MRI showed any signs of arthritis and that my knees were "perfect".  So, who do you believe?  If there are no other orthopedic docs/knee specialists in your area, then your option is to travel to get a 2nd, 3rd or 4th opinion.  Don't be surprised though if you get a different outcome from each one.  I would though continue to do exercises and stretching to improve the muscles in your leg/knee.  Have you tried using a brace?  Icing?  From my understanding, runner's knee is more of a "generic term" vs. it being associated specifically with those that run.  Overuse, muscle imbalance, not stretching - that's what the OS told me.

Even after surgery, my PT had me on one of those "mini stepper" type machines.  Now my surgical knee/leg, when I step down, doesn't go straight as the knee goes inward towards the other knee, not forward/straight. In the end, I've taken 2 steps forward and 3 steps back (no pun intended....)

[crankerchick]

Can someone please give me an idea of how I should proceed? Very confused and worried..

I would limp away from any doctor recommending isolated lateral release without having done the requisite imaging of standing lateral x-ray, Merchant x-ray, orthoradiogram, and CT scan to rule any other problems.

I would seek more opinions, preferable from someone that will do the imaging mentioned.

I would not let anyone touch my knee until I was comfortable with the surgical recommendations. I almost went down that route and it's none to pleasant a feeling. Even now after canceling the surgery, getting another opinion, and ultimately having what I believe was the right surgery for me, I still cringe at the thought that I almost let a doctor cut on me when in my gut I wasn't convinced on the surgical recommendation from the start, only to find out that indeed said doctor hadn't tested me for everything, yet was all too happy break my bones.

Indeed, there is good research to be had here, and I wouldn't settle for anything less than a full patellofemoral workup from a doctor that knows the patellofemoral joint before choosing surgery. If seeing said doctor isn't an option, then I would recommend waiting on any surgery until you find the right doctor for you.

[kneepaincure]

Thank you all.. This has really helped me get an insight on how to go ahead with this, because no one in my age group (or even above it) had ever had this sort of problem, so sources of advice are non-existent.

I began doing some physio at home while waiting for my next appointment with a sports doctor, and have found that it has increased my pain!! The same exercises that I did in January of this year had reduced it instead!! This makes no sense to me at all, so I am going to just do stretching and walking and ask the doctor for an opinion.. The pain shifts to below my kneecap sometimes..  Maybe I have jumper's knee? Can one condition turn into another?

[kneepaincure]

After paying the sports doctor a visit I am much more at ease.. Given me different exercises to do .. It will take a long time to get back to normal but if it means avoiding surgery I'm all for it.