Skip to main content
Download PDF

Conservative management following patellar dislocation: a level I systematic review

Journal of Orthopaedic Surgery and Research volume 18, Article number: 393 (2023) Cite this article

Abstract

Background

Patellar instability is a common and disabling clinical condition. Treatment of acute primary patellar dislocation aims to reduce the risk of recurrence or painful subluxation and improve function. However, the actual clinical efficacy of any management modality following an acute dislocation has never been demonstrated in prospective or retrospective studies, and the optimal way in which the various management modalities should be used is at best unclear.

Methods

A search was conducted in PubMed, Bireme and Embase databases. Inclusion criteria followed the acronym PICOS, (P) subjects with patellar instability, (I) therapeutic interventions, (C) placebo or control or surgical treatments, (O) rate of dislocations and function, and (S) clinical trials. The Medical Subject Headings (MeSH) terms used were: ((“patellar instability”) OR (“patellar dislocation”)) AND ((physiotherapy) OR (rehabilitation) OR (“conservative treatment”) OR (therapy) OR (therapeutic)). The risk of bias was analysed using the PeDRO scale.

Results

Seven randomized controlled trials including 282 patients were considered. The quality of studies detailing the results of conservative treatment was higher than that of surgical procedures, but all studies have relatively low methodological quality. Four studies compared physiotherapeutic interventions with surgical procedures, and three studies compared conservative intervention techniques.

Conclusion

An unstructured lower limb physical therapy programme evidences similar outcomes to specific exercises. Surgical management is associated with a lower rate of re-dislocation; however, whether surgery produces greater functional outcomes than conservative management is still unclear. The use of a knee brace with a limited range of motion, stretching and neuromuscular exercises are the most commonly recommended physiotherapy methodologies.

Introduction

Patients with patellofemoral instability exhibit abnormal patellar tracking over the femoral trochlea during motion [1, 2] and report discomfort during prolonged knee flexion or during sports activities [3,4,5]. Several risk factors predispose to patellofemoral instability, including patella alta, trochlear dysplasia, muscle imbalance, increased distance between the tibial tubercle (TT) and trochlear groove (TG), valgus, and femoral deformity, especially anteversion [6,7,8,9]. Patellar dislocation accounts for 2–3% of all knee injuries [10]. The incidence of patellar dislocation is between 2 and 77 per 100,000 people per year [11,12,13,14]. Furthermore, 61% of primary dislocations occur during sports activities and are mostly seen in teenagers and young adults [15, 16].

The management of patellar dislocation is controversial [17,18,19]. Following an acute episode of patellar dislocation, in patients without osteochondral damage or intraarticular loose bodies, conservative management could be undertaken [20]. Conservative management should provide rapid functional recovery and minimize the evolution to recurrent patellar dislocation [21,22,23]. The current literature emphasizes isometric quadriceps strengthening, specific strengthening of the vastus medialis obliquus, and progression to more dynamic exercises involving the core and gluteal muscles [23,24,25]. However, international consensus or guidelines on conservative management are lacking, and high-quality evidence is required [26]. Recent guidelines on first-time patellar dislocation cite that, despite the lack of rigorous clinical evidence, many reviews report opinions and recommendations derive from the expertise and experience of the authors [27]. This systematic review assessed the efficacy of conservative interventions for patients with patellar instability. This study investigates the outcomes of conservative and surgical management in adults with patellofemoral instability. The efficacy of conservative management in adults with patellofemoral instability is still controversial. About one-third of patients treated conservatively have activity limitations 6 months to 3 years following the patellar dislocation, even in the absence of re-dislocation. Surgical treatment is associated with a low rate of recidivism and good outcomes and levels of sport participation. However, whether surgery is associated with better outcomes than conservative management remains unclear.

Methods

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [28, 29] and registered in PROSPERO (ID CRD42022370928).

Search strategy and database

The literature search was performed by two authors (GWF and DFO) independently. The search keywords were determined through the acronym PICOS:

  • P (population): adult patients (> 18 years old) with patellar instability

  • I (intervention): conservative management

  • C (comparator): placebo, control, surgical management

  • O (outcomes): joint function, failures

  • S (studies): Randomized controlled trials (RCTs) level I of evidence

The databases used were PubMed, Bireme, and Embase; the search took place on May 2023. The Medical Subject Headings (MeSH) terms in English used were: ((“patellar instability”) OR (“patellar dislocation”)) AND ((physiotherapy) OR (rehabilitation) OR (“conservative treatment”) OR (therapy) OR (therapeutic)).

Eligibility

All the clinical studies investigating the outcome of conservative management of patellofemoral instability, such as physiotherapy treatment, rehabilitation, exercise, and immobilization, were included. The eligibility of study participants for each study was confirmed if they had a reported history of patellar dislocation, either primary or recurrent. Only RCT level I of evidence, according to the Oxford Centre of Evidence Based Medicine [30], were eligible. Studies that reported quantitative data joint function and the rate of failures were eligible. Articles in English, Spanish, Italian, and Portuguese were considered.

Comments, reviews, case reports, editorials, letters to the editor, and technical notes were not eligible. Studies missing quantitative data under the outcomes of interest were excluded. Two authors extracted data independently using Rayaan® Free Trial [31], and discrepancies were resolved by a third one (**).

Assessment of methodological quality

The methodological quality assessment was conducted by two reviewers (GWF and APSR), using the PeDRO Scale [32]. Discrepancies were resolved by a third reviewer (**). This scale is a tool developed to measure the methodological quality of studies of physiotherapy interventions. It consists of 10 items plus selection criteria: (1) randomization of the sample; (2) concealed allocation; (3) initial comparability between groups; (4) all subjects blinded; (5) all therapists who administer therapy blinded; (6) all evaluators measuring key outcomes blinded; (7) adequacy of follow-up; (8) statistical analysis with intention to treat; (9) statistical comparison of results between groups; and (10) existence of specific measures and variability for at least one key result. These items are dichotomous, and each question is scored as 1 or 0 [32, 33]. The PeDRO Scale has been widely used in previous systematic reviews [34,35,36,37].

Results

Selection of studies

The literature search resulted in 612 articles: 130 in Bireme, 178 in Embase, and 304 in PubMed. After removing duplicates, 291 remained for consideration. After reading the titles, 40 abstracts remained. After this screening, 27 articles were excluded because they were observational studies (n = 21) or congress summaries (n = 1); therefore, 13 complete articles were selected for the reading stage. In the last stage, 6 articles were excluded since they were feasibility studies (n = 5) and function or instability was not a primary outcome (n = 1). Finally, seven articles were included in the present investigation (Fig. 1).

Fig. 1
figure 1

PRISMA flowchart of search in the literature

Full size image

Methodological quality

No study performed participants blinding, negatively impacting the final result. High between studies variability in the PeDRO scale was evidenced, with values ranging from seven to three points. Concluding, the average score of the PeDRO scale was 4.1 points, demonstrating the low quality of the methodology (Table 1).

Table 1 Analysis of the methodological quality of the selected studies—PeDRO (n = 7)
Full size table

Characteristics of the studies and participants

Data from 282 patients were retrieved (Table 2). Four studies compared physiotherapeutic interventions with surgical procedures [20, 38, 39, 41], and three studies compared conservative intervention techniques [21, 40, 42].

Table 2 Results of studies performing conservative strategies
Full size table

Conservative intervention

All studies suggested the use of braces (with total or partial immobilization) for the initial period of the first 3 weeks. Concerning weight bearing, one RCT recommended progressive weight according to pain [42], and another investigation recommended 15 kg partial weight bearing for the first 3 weeks [20]. The conservative interventions implemented were: strengthening the quadriceps, in particular the vastus medialis muscle [38, 40, 41] and hamstring [38, 41], closed kinetic chain exercises [39, 42]; increasing proprioception and balance [39, 41].

Smith et al. [40] observed a statistical difference in the Lysholm knee score and Tegner Level of Activity score between general quadriceps and VM exercise groups at 12 months; however, there was no statistically or clinically significant difference for these measures during the first 12 months post-commencement of rehabilitation following patellar dislocation.

Honkonen et al. [42], in addition to quadriceps muscle strengthening exercises, closed kinetic chain lower limb, and full weight bearing as tolerated by pain for both groups, compared the efficacy of a patella-stabilizing, motion-restricting knee brace versus a neoprene non-hinged knee brace for the treatment of first-time traumatic patellar dislocation. Knee immobilization was associated with quadriceps muscle atrophy, more restricted knee ROM, and worse functional outcomes in the first 6 months after the injury. In another study, cylinder cast immobilization was compared to taping in terms of intensive training of isometric and isotonic exercises to strengthen quadriceps muscles. Both groups were allowed the full weight-bearing [21]. After 12 weeks and 5 years, the Lysholm Knee Scoring Scale was significantly better in the taping group.

Conservative and surgical treatment

Four RCTs compared conservative versus surgical management [20, 38, 39, 41]. Surgical management included reconstruction of the medial patellofemoral ligament (MPFL-R) [38, 39, 41], femoral re-insertion [38] and “repair the tear” [20]. Surgical management evidenced greater functional results and a lower rate of recurrence of dislocations [38, 39]. Camanho et al. [38] reported a higher number of recurrent dislocations (8 patients) in the conservative treatment group compared to the surgical treatment group, which did not experience any relapses. In addition, the surgical management group obtained a better mean score on the Kujala test (92) than the conservative treatment group. Bitar et al. [39] showed that the surgical group presented a higher percentage of ‘‘good/excellent’’ results (71.43%) on the Kujala score when compared with the non-operative group (25.0%; p = 0.003). The non-operative group presented a large number of recurrences and subluxations (7 patients; 35% of cases), whereas no recurrences or subluxations occurred in the surgical group.

One study showed no differences in function between treatments, but more dislocations in patients managed non-operatively [41]. Straume‑Næsheim et al. [41] showed persistent patellar instability at 12 months in 13 (41.9%) controls, versus 2 (6.7%) in the surgical group (RR 6.3 (95% CI 1.5–25.5). The patients with persistent instability at 12 months did not score significantly lower on any of the PROMs compared to their stable peers, regardless of the study group.

One study showed no differences in function and dislocation rate between treatments [20]. Petri et al. [20] showed a mean Kujala score of the conservative vs operative treatment group of 78.6 vs 80.3 after 6 months (p = 0.8), 79.9 vs 88.9 after 12 months (p = 0.2), and 81.3 vs 87.5 after 24 months (p = 0.3). The re-dislocation rate after 24 months was 37.5% in the conservative group and 16.7% in the operative group (p = 0.4).

Discussion

According to the main findings of the present systematic review of level I evidence, surgical management is associated with a lower rate of re-dislocation; however, whether surgery promotes greater functional outcomes than conservative management is still unclear. The use of a knee brace with a limited range of motion, stretching and neuromuscular exercises are the most commonly recommended methodologies of physiotherapy. In cases of primary patellar dislocation associated with large displaced osteochondral fractures (> 5 mm) or chondral shear fragments and/or complete VMO avulsion of the patellar insertion site, surgery is indicated [43]. However, the management of the patients who experienced traumatic patellar dislocation with no evidence of osteochondral injuries or intraarticular loose bodies is still controversial [17, 44, 45].

Straume‑Næsheim et al. [41] compared MPFL-R surgery with active rehabilitation in patients with recurrent patellofemoral instability. Patients with recurrent patellar dislocations have a six times greater risk of persistent patellar instability if treated with active rehabilitation alone, compared to active rehabilitation combined with MPFL-R, even in the absence of significant anatomical risk factors.

Data from the included studies suggest that the rate of recurrence might not be directly associated with joint function [41]. Long-term subjective and functional results of conservatively managed patients following patellar dislocation are for the most part satisfactory [46]. Lampros et al. [47] report that studies with objective measures combined with psychological readiness and a comprehensive understanding of the individual's specific tasks should be considered when assessing the ability to safely and successfully return to sport and, to a lesser extent, to daily life. Therefore, the level of functional demand is discussed to reflect on rehabilitation when working with non-operative and operative management of patellar instability.

The present study compared investigations in which the only therapeutic interventions were exercises. Smith et al. [40] compared the functional result of muscle strengthening of the vastus medialis obliquus with a general strengthening of the quadriceps muscle. The statistical difference in the Lysholm knee score and in the Tegner score between the groups at 12 months of intervention was not clinically relevant: isolated muscle training provided the same result as what obtained exercising the whole quadriceps. Although strengthening the quadriceps muscle and vastus medialis obliquus is the primary and main treatment advocated by many authors, the production of force in the knee extensors, hip abductors and hip extensor musculature is also an important target for rehabilitation [48], in addition to soft tissue flexibility [49]. Rood et al. [21] compared function using the Lysholm knee score and the rate of dislocation by performing two types of conservative intervention: taping and immobilization. They evaluated the outcomes of this regimen at 6 and 12 weeks, 1 year and 5 years. Taping resulted in higher values in terms of knee function compared to plaster immobilization, both in the short- and medium-term, with no difference in re-dislocation rate. Also, taping produced less muscular hypotrophy. Controlled mobilizations can be performed in the post-injury period to avoid loss of mobility and, in the future, muscle atrophy. Most of the surgeons recommend weight-bearing to tolerance and a knee brace during the first four weeks, with a range of motion from full extension to 30° of flexion during the first 15 days and up to 60° of flexion for an additional 15 days [50]. This study was corroborated by the use of a stabilizing and restrictive brace for 4 weeks after traumatic patellar dislocation for the first time, not resulting in a reduction in re-dislocations compared to the use of a brace without neoprene. Knee immobilization was associated with quadriceps muscle atrophy, more restricted knee ROM and worse functional outcomes in the first 6 months after injury [42]. In summary, although some studies have already addressed this issue, there is still no consensus on the ideal conservative treatment for primary patellar dislocation. Exercises to strengthen the quadriceps (including vastus medialis) and hip muscles; gain/maintenance of knee flexibility (hamstring stretching); use of braces with controlled free motion seem to be equivalent [38]. Surgical intervention is an appropriate option if patients continue to experience recurrent patellar dislocations and remain symptomatic, and conservative treatment options have been exhausted [51].

Some points are important to consider in this systematic review. The different methods used between the studies and the lack of randomised controlled trials represent important limitations of the present study. The criteria to diagnose instability and dislocation were not always clear in all studies, with different criteria used. Consequently, the different treatments used, whether surgical or conservative, influence the non-standardization of results and their heterogeneity. This also contributed to the fact that it was not possible to perform a meta-analysis. Follow-up studies may be more reliable for assessing instability and function. Postoperative rehabilitation was not the objective of our study and would need to be better described, as it is also part of the success of surgical treatment. Studies with better methodological controls and larger samples are important for greater study validity.

Conservative interventions were often biased, lacking in description or not reporting exactly the type, duration and structure of the physical sessions, which limit translation into the clinical practice. Further high-quality investigations are strongly required to establish the proper indications and efficacy of a structured rehabilitation program.

Conclusion

Conservative treatment resulted in higher rates of recurrence of patellar dislocation compared to surgery. When comparing conservative treatments, the exercises were not well described, but exercises for the entire lower limb have effects similar to those concentrating on specific muscles, and the use of braces with controlled motion in the post-injury period is better than immobilization. For future interventions, it is important to consider conservative management before surgical treatment, when current active rehabilitation programs should be the basis of physical therapy intervention. However, it is essential to assess the level of functional demand of patients to tailor the treatment most appropriate to them.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

Mesh:

Medical Subject Headings

TT:

Tibial tubercle

TG:

Trochlear groove

PRISMA:

Preferred Reporting Items For Systematic Reviews And Meta-Analyses

PISS:

Patellar Instability Severity Score

BHS:

Beighton Hypermobility Score

PROMS:

Patient Reported Outcome Measures

KOOS:

Knee Injury And Osteoarthritis Outcome Score

VMO:

Vastus Medialis Oblique

VAS:

Visual Analog Scale

N/A:

Not applicable

RCT:

Randomized controlled trials

References

  1. Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI. Patellar Instability. StatPearls; 2022.

  2. Duthon VB. Acute traumatic patellar dislocation. Orthopaed Traumatol Surg Res. 2015;101(1 Suppl):S59-67.

    Article  CAS  Google Scholar 

  3. Bulgheroni E, Vasso M, Losco M, Di Giacomo G, Benigni G, Bertoldi L, et al. Management of the first patellar dislocation: a narrative review. Joints. 2019;7(3):107–14.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Rosa SB, Ewen PM, Doma K, Ferrer JFL, Grant A. Dynamic evaluation of patellofemoral instability: a clinical reality or just a research field? A Literature review. Orthopaed Surg. 2019;11(6):932–42.

    Article  Google Scholar 

  5. Fucentese SF. Patellofemoral instability. Der Orthopade. 2018;47(1):77–86.

    Article  CAS  PubMed  Google Scholar 

  6. Pascual-Leone N, Ellis HB, Green DW. Patellar instability: Will my patella dislocate again? Curr Opin Pediatr. 2022;34(1):76–81.

    Article  PubMed  Google Scholar 

  7. Weltsch D, Chan CT, Mistovich RJ, Urwin JW, Gajewski CR, Fabricant PD, et al. Predicting risk of recurrent patellofemoral instability with measurements of extensor mechanism containment. Am J Sports Med. 2021;49(3):706–12.

    Article  PubMed  Google Scholar 

  8. Christensen TC, Sanders TL, Pareek A, Mohan R, Dahm DL, Krych AJ. Risk factors and time to recurrent ipsilateral and contralateral patellar dislocations. Am J Sports Med. 2017;45(9):2105–10.

    Article  PubMed  Google Scholar 

  9. Migliorini F, Maffulli N, Vaishya R. Patellofemoral instability: current status and future perspectives. J Orthop. 2022;36:49–50.

    Article  PubMed  Google Scholar 

  10. Jain NP, Khan N, Fithian DC. A treatment algorithm for primary patellar dislocations. Sports Health. 2011;3(2):170–4.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Tsai CH, Hsu CJ, Hung CH, Hsu HC. Primary traumatic patellar dislocation. J Orthop Surg Res. 2012;7:21.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Atkin DM, Fithian DC, Marangi KS, Lou SM, Dobson BE, Mendelsohn C. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. Am J Sports Med. 2000;28(4):472–9.

    Article  CAS  PubMed  Google Scholar 

  13. Fithian DC, Paxton EW, Lou Stone M, Silva P, Davis DK, Elias DA, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med. 2004;32(5):1114–21.

    Article  PubMed  Google Scholar 

  14. Waterman BR, Belmont PJ, Owens BD. Patellar dislocation in the United States: role of sex, age, race, and athletic participation. J Knee Surg. 2012;25(1):51–8.

    Article  PubMed  Google Scholar 

  15. Sillanpää P, Mattila VM, Iivonen T, Visuri T, Pihlajamäki H. Incidence and risk factors of acute traumatic primary patellar dislocation. Med Sci Sports Exerc. 2008;40(4):606–11.

    Article  PubMed  Google Scholar 

  16. Parikh SN, Veerkamp M, Redler LH, Schlechter J, Williams BA, Yaniv M, et al. Patellar instability in young athletes. Clin Sports Med. 2022;41(4):627–51.

    Article  PubMed  Google Scholar 

  17. Rund JM, Hinckel BB, Sherman SL. Acute patellofemoral dislocation: controversial decision-making. Curr Rev Musculoskelet Med. 2021;14(1):82–7.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Stefancin JJ, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat Res. 2007;455:93–101.

    Article  PubMed  Google Scholar 

  19. Van Gemert JP, De Vree LM, Hessels RAPA, Gaakeer MI. Patellar dislocation: cylinder cast, splint or brace? An evidence-based review of the literature. Int J Emerg Med. 2012;5(1):45.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Petri M, Liodakis E, Hofmeister M, Despang FJ, Maier M, Balcarek P, et al. Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial. Arch Orthop Trauma Surg. 2013;133(2):209–13.

    Article  CAS  PubMed  Google Scholar 

  21. Rood A, Boons H, Ploegmakers J, Van Der Stappen W, Koëter S. Tape versus cast for non-operative treatment of primary patellar dislocation: a randomized controlled trial. Arch Orthop Trauma Surg. 2012;132(8):1199–203.

    Article  PubMed  Google Scholar 

  22. Armstrong BM, Hall M, Crawfurd E, Smith TO. A feasibility study for a pragmatic randomised controlled trial comparing cast immobilisation versus no immobilisation for patients following first-time patellar dislocation. Knee. 2012;19(5):696–702.

    Article  PubMed  Google Scholar 

  23. Brightwell BD, Stone A, Li X, Hardy P, Thompson K, Noehren B, et al. Blood flow Restriction training After patellar INStability (BRAINS Trial). Trials. 2022;23(1):88.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Popkin CA, Bayomy AF, Trupia EP, Chan CM, Redler LH. Patellar instability in the skeletally immature. Curr Rev Musculoskelet Med. 2018;11(2):172–81.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Krych AJ, O’Malley MP, Johnson NR, Mohan R, Hewett TE, Stuart MJ, et al. Functional testing and return to sport following stabilization surgery for recurrent lateral patellar instability in competitive athletes. Knee Surg Sports Traumatol. 2018;26(3):711–8.

    Article  Google Scholar 

  26. Liebensteiner M, Keiler A, El Attal R, Balcarek P, Dirisamer F, Giesinger J, et al. Conservative versus tailored surgical treatment in patients with first time lateral patella dislocation: a randomized-controlled trial. J Orthop Surg Res. 2021;16(1):378.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Vetrano M, Oliva F, Bisicchia S, Bossa M, De Carli A, Di Lorenzo L, et al. I.S.Mu.L.T. first-time patellar dislocation guidelines. Muscles Ligaments Tendons J. 2017;7(1):1–10.

  28. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372: n71.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7): e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009)—Centre for Evidence-Based Medicine (CEBM), University of Oxford [Internet]. [citado 3 de janeiro de 2023]. Disponível em: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009.

  31. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–21.

    Article  PubMed  Google Scholar 

  33. Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C. There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials. J Clin Epidemiol. 2010;63(8):920–5.

    Article  PubMed  Google Scholar 

  34. Neal BS, Bartholomew C, Barton CJ, Morrissey D, Lack SD. Six treatments have positive effects at 3 months for people with patellofemoral pain: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2022;52(11):750–68.

    Article  PubMed  Google Scholar 

  35. Ahmad MA, Mohamad MS, Yusof A. Effects of low-level and high-intensity laser therapy as adjunctive to rehabilitation exercise on pain, stiffness and function in knee osteoarthritis: a systematic review and meta-analysis. Physiotherapy. 2022;114:85–95.

    Article  PubMed  Google Scholar 

  36. Thomas DT, Shruthi R, Prabhakar AJ, Dineshbhai PV, Eapen C. Hip abductor strengthening in patients diagnosed with knee osteoarthritis—a systematic review and meta-analysis. BMC Musculoskelet Disord. 2022;23(1):622.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Yamato TP, Maher C, Koes B, Moseley A. The PEDro scale had acceptably high convergent validity, construct validity, and interrater reliability in evaluating methodological quality of pharmaceutical trials. J Clin Epidemiol. 2017;86:176–81.

    Article  PubMed  Google Scholar 

  38. Camanho GL, Viegas A de C, Bitar AC, Demange MK, Hernandez AJ. Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella. Arthroscopy. 2009;25(6):620–5.

  39. Bitar AC, Demange MK, D’Elia CO, Camanho GL. Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med. 2012;40(1):114–22.

    Article  PubMed  Google Scholar 

  40. Smith TO, Chester R, Cross J, Hunt N, Clark A, Donell ST. Rehabilitation following first-time patellar dislocation: a randomised controlled trial of purported vastus medialis obliquus muscle versus general quadriceps strengthening exercises. Knee. 2015;22(4):313–20.

    Article  CAS  PubMed  Google Scholar 

  41. Straume-Næsheim TM, Randsborg PH, Mikaelsen JR, Årøen A. Medial patellofemoral ligament reconstruction is superior to active rehabilitation in protecting against further patella dislocations. Knee Surg Sports Traumatol Arthrosc. 2022;30(10):3428–37.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Honkonen EE, Sillanpää PJ, Reito A, Mäenpää H, Mattila VM. A randomized controlled trial comparing a patella-stabilizing, motion-restricting knee brace versus a neoprene nonhinged knee brace after a first-time traumatic patellar dislocation. Am J Sports Med. 2022;50(7):1867–75.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Khormaee S, Kramer DE, Yen YM, Heyworth BE. Evaluation and management of patellar instability in pediatric and adolescent athletes. Sports Health. 2014. https://doi.org/10.1177/1941738114543073.7(2):115-23.

    Article  Google Scholar 

  44. Shubin Stein BE, Gruber S, Brady JM. MPFL in first-time dislocators. Curr Rev Musculoskelet Med. 2018;11(2):182–7.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Moiz M, Smith N, Smith TO, Chawla A, Thompson P, Metcalfe A. Clinical outcomes after the nonoperative management of lateral patellar dislocations: a systematic review. Orthop J Sports Med. 2018;6(6):2325967118766275.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Palmu S, Kallio PE, Donell ST, Helenius I, Nietosvaara Y. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg. 2008;90(3):463–70.

    Article  PubMed  Google Scholar 

  47. Lampros RE, Tanaka MJ. Return to play considerations after patellar instability. Curr Rev Musculoskelet Med. 2022;6:66.

    Google Scholar 

  48. Fisher B, Nyland J, Brand E, Curtin B. Medial patellofemoral ligament reconstruction for recurrent patellar dislocation: a systematic review including rehabilitation and return-to-sports efficacy. Arthroscopy. 2010;26(10):1384–94.

    Article  PubMed  Google Scholar 

  49. Saper MG, Fantozzi P, Bompadre V, Racicot M, Schmale GA. Return-to-sport testing after medial patellofemoral ligament reconstruction in adolescent athletes. Orthop J Sports Med. 2019;7(3):2325967119828953.

    Article  PubMed  PubMed Central  Google Scholar 

  50. D’Ambrosi R, Migliorini F, Cerciello S, Guerra G, Corona K, Mangiavini L, et al. Management of the first episode of traumatic patellar dislocation: an international survey. Knee Surg Sports Traumatol Arthrosc. 2022;6:66.

    Google Scholar 

  51. Vandenberg CD, Sarkisova N, Pace JL, Rhodes J, Perea SH, Green DW. Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society. J Child Orthopaed. 2021;15(6):571–6. https://doi.org/10.1302/1863-254815210084.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Open Access funding enabled and organized by Projekt DEAL. No external source of funding was used.

Author information

Authors and Affiliations

  1. Department of Physiotherapy, University of the State of Santa Catarina, Florianópolis, SC, Brazil

    Gustavo Wickert Flores, Deise Ferreira de Oliveira, Luciana Sayuri Sanada & Rodrigo Okubo

  2. Physiotherapy Department, University of South of Santa Catarina (Unisul), Florianópolis, SC, Brazil

    Ana Paula Silveira Ramos

  3. Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany

    Filippo Migliorini

  4. Department of Medicine, Surgery and Dentistry, University of Salerno, 84081, Baronissi, SA, Italy

    Filippo Migliorini & Nicola Maffulli

  5. School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB, England, UK

    Nicola Maffulli

  6. Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, E1 4DG, England, UK

    Nicola Maffulli

  7. Department of Orthopaedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy

    Filippo Migliorini

Authors
  1. Gustavo Wickert Flores
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deise Ferreira de Oliveira
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ana Paula Silveira Ramos
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Luciana Sayuri Sanada
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Filippo Migliorini
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Nicola Maffulli
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rodrigo Okubo
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

RO did conceptualization, writing, revision; FM done revision; GWF wrote the article; DFO and LSS supervised the study; APSR and NM revised the study. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Filippo Migliorini.

Ethics declarations

Ethics approval and consent to participate

'Not applicable' for that section.

Consent for publication

'Not applicable' for that section.

Competing interests

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Flores, G.W., de Oliveira, D.F., Ramos, A.P.S. et al. Conservative management following patellar dislocation: a level I systematic review. J Orthop Surg Res 18, 393 (2023). https://doi.org/10.1186/s13018-023-03867-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13018-023-03867-6

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X