Patella alta, often described as a “high-riding kneecap,” is a condition where the patella sits abnormally high within the groove of the femur. This elevated position disrupts the normal mechanics of the knee joint, preventing the kneecap from engaging correctly during movement. This structural misalignment frequently leads to anterior knee pain, instability, and an increased risk of recurrent dislocation. Addressing this condition requires medical intervention to stabilize or reposition the patella and restore proper joint function.
Conservative Management through Physical Therapy
Physical therapy is the standard first-line approach for managing patella alta, focusing on improving the dynamic stability of the knee without surgical intervention. The primary goal is to enhance muscle strength and flexibility surrounding the knee to encourage the patella to track more centrally in the groove. This treatment specifically targets the quadriceps muscle group, particularly the vastus medialis oblique (VMO), which functions as a medial stabilizer for the kneecap.
Strengthening the VMO is achieved through exercises like quad sets and low-arc leg extensions, often performed with a slight external rotation of the hip to maximize VMO activation. Progression moves toward closed-chain exercises, such as miniature squats and step-ups, which mimic functional movements and improve overall patellofemoral joint mechanics. These exercises are crucial because they build stability while the foot is fixed on the ground.
Balancing the entire lower kinetic chain is also important, involving strengthening the hip abductors and external rotators, such as the gluteus medius and maximus. Weakness in these hip muscles can cause the thigh bone to rotate inward, placing excessive strain on the knee joint and worsening patellar tracking issues. Exercises like side-lying leg raises and clamshells help build this necessary hip stability, directly supporting the knee from above.
Flexibility training, particularly for the hamstrings and calf muscles, is incorporated to ensure proper muscle length and relieve tension that might contribute to misalignment. Adjunctive treatments like patellar taping, such as McConnell taping, can temporarily correct the kneecap’s position and provide immediate feedback to the patient on proper tracking. This combination of targeted strengthening, flexibility work, and external support aims to improve the alignment and stability of the knee, often providing significant symptom relief in cases that are not severe or chronic.
When Surgical Intervention is Necessary
Surgical treatment is typically reserved for individuals who experience chronic patellar instability, recurrent dislocations, or symptoms that persist despite a dedicated physical therapy program lasting six months or more. The fundamental issue of patella alta is an anatomical problem that often requires a structural solution to achieve long-term stability. The most direct and common procedure used to correct this high-riding position is a Tibial Tubercle Osteotomy (TTO).
The TTO procedure involves carefully detaching the tibial tubercle, which is the bony prominence on the shinbone where the patellar tendon attaches. Moving the tubercle essentially changes the anchor point of the entire quadriceps mechanism. For patella alta, the tubercle is moved distally, or further down the tibia, which lowers the position of the kneecap into correct alignment with the femoral groove.
Surgeons use precise measurements, often based on preoperative imaging, to calculate the exact distance the tubercle needs to be moved to restore normal patellar height. The osteotomy is performed as a bone block resection, and the detached bone fragment is secured in its new, lower position using screws. This distalization allows the kneecap to engage earlier and more securely in the trochlear groove of the femur, significantly reducing the risk of instability and dislocation.
In many cases, the TTO is combined with a soft-tissue procedure, such as a Medial Patellofemoral Ligament (MPFL) reconstruction, especially if the patient has had multiple dislocations. While the TTO corrects the height of the patella, MPFL reconstruction uses a tendon graft to replace the primary ligament that stabilizes the kneecap on the inner side of the knee. This combined approach provides both the necessary bony realignment and increased soft-tissue restraint, creating a much more stable joint environment.
Recovery and Long-Term Functional Maintenance
The path to full recovery varies significantly depending on the initial treatment, with surgical intervention requiring a substantially longer rehabilitation period than conservative management. Following a TTO, the patient is typically required to use crutches and a brace for approximately six weeks to protect the surgical site and allow the bone fragment to heal. During this initial phase, the focus is on managing pain and swelling, followed by gradually restoring a safe range of motion.
For all patients, whether treated conservatively or surgically, the structured rehabilitation program must transition into a long-term maintenance plan. Full recovery from TTO can take six to twelve months, during which consistent adherence to strengthening exercises is required to ensure the long-term success of the realignment. This continued effort prevents muscle atrophy and maintains the dynamic stability achieved through the initial therapy or surgical correction.
The long-term outlook involves lifestyle adjustments to protect the knee, such as carefully integrating high-impact activities back into a routine or switching to lower-impact sports. Maintaining strong quadriceps and hip musculature is a life-long requirement to prevent the return of symptoms and to protect the joint from future wear. With successful treatment and a commitment to the maintenance program, patients can generally expect a return to full function.