THE CLINIC: Patellofemoral Syndrome: When to Operate?

QUESTION:

I am 47 years old and have been running for 30 years, competitively in high school and college, and 10K to marathon as an adult. My weight ranges from 130 to 136 lbs. and I am 5' 6". In April of last year I developed lateral knee pain and in June I was diagnosed with patellofemoral syndrome. The pain is directly on the site of the lateral retinaculum. I was in physical therapy twice a week in the summer, with persistent—but not worsening—pain. I continued to train for and race a half-marathon that September. 

 

By December I had reduced mileage to 15 to 20 miles a week, without hard runs. I had an adjustment to my custom orthotics in June and again in October. 

 

By this January, I was diagnosed with “atypical” PFS and sent for an MRI. That revealed a "small joint effusion” and “thin medial plica,” with a “small, septated popliteal cyst.” My patella is “laterally tilted” and “slightly laterally subluxed,” and there is “moderate to marked” thinning and irregularity of the patellar cartilage, “esp[ecially] along the lateral facet.” There are “broad areas of subchondral bone marrow edema” The patellar retinacula are intact, as are my cruciate ligaments, quadriceps, and patellar tendons. They found no meniscal tears.

 

I have had two orthopedic surgical opinions since, and both say I am an ideal candidate for a lateral release of the retinaculum. Self-research on this arthoscopic procedure does not reveal favorable results to a pain-free return to running. I have taken the past six weeks to evaluate things and during that time, the knee pain has grown worse. Stairs are now a problem; cycling and most exercise machines create the pain. When I do weight-bearing things like spinning class I now have discomfort along the left patella tendon.

 

The surgeons are optimistic but runners I have spoken to are not. The research indicates that certain ideal conditions need to be present in the injured knee for this surgery to be effective and not make things worse. Is surgery my only option? What happens if I push myself to run and pass on the surgery. Am I creating more problems? 

 

Claire Anniston

Reno, NV

 

ANSWER:

There are innumerable names for problems related to the patella. The basic

problem is a loss of the normal muscle balance that controls the patella.

This goes under multiple names. The most common is patellar malalignment

syndrome or patellar maltracking syndrome. It has also been called an

excessive lateral pressure syndrome. It is commonly known as

"chondromalacia" in the lay press but that is inaccurate. Chondromalacia is

a pathological finding of wear and tear of the articular cartilage and is

not a specific diagnosis. Something causes chondromalacia. Chondromalacia is

not the problem, it is the result of the problem. 

 

The MRI absolutely confirms your diagnosis. You have subluxation and tilt of

the patella which has resulted in excessive pressure on the lateral facet of

the patella and has caused premature wear of the articular cartilage.

Whether this has crossed the magic line to be called osteoarthritis of the

patellofemoral joint or not is probably irrelevant. You have pain and a

degenerative process. The initial treatment for this is anti-inflammatory

medication, ice, and straight leg raising exercises in an attempt to improve

the balance of forces on the patella. A cortisone injection or even a series

of hyaluronic acid injections would also be reasonable if one felt that this

was truly arthritis. A brace can sometimes improve symptoms but is much less

predictable. If nonsurgical care fails, then a subcutaneous lateral release

is ordinarily the next step.

 

However, there is significant disagreement among orthopedic surgeons. While

the subcutaneous lateral release would be successful in improving the

alignment of the patella, it would also have absolutely no effect on the

degenerative changes. It is unclear how much the degenerative changes are

contributing to your current symptoms. 

 

You could have perfectly normal x-rays after surgery and still have little if any improvement in your pain. Because of the degenerative changes, some orthopedic surgeons would advocate a tibial tubercle elevation, which has the

capability of addressing the degenerative changes because it not only

realigns the patella to take pressure off the lateral side, it also

redistributes the forces proximal and distal to try to relieve some of the

pressure on the "worn" area. 

 

Therefore, while you are a candidate for subcutaneous lateral release, in my opinion, you are definitely not an "ideal" candidate. To a certain extent, it gets into philosophies. The

arthroscopic subcutaneous lateral release is an outpatient procedure with a

very low risk of complications when done properly but there is no question

that the tibial tubercle elevation would have a greater chance of

symptomatic improvement. However, the tibial tubercle elevation is an open

procedure, requires several weeks in a cast, has a higher risk of infection,

and the recovery time is longer. 

 

In my opinion, running is not dangerous but certainly may be painful. You

can rely upon the intensity of your symptoms. However, I am also not sure

that any surgery, including the tibial tubercle elevation, would allow you

to return to significant running. Under any circumstances, I would

definitely avoid hills and StairMasters as much as possible because going up and down stairs and going up and down hills definitely aggravates patellofemoral pain.

 

G. Klaud Miller, MD

Evanston, IL