If you suffer from patellar pain, chances are excellent that you will get better with a solid non-operative treatment. This is particularly true if your pain is due to patella malalignment. Appropriate physical therapy (PT) is a critical part of such treatment.

The key point here is that not all PT regimens are equivalent. An exercise bicycle, funny pads on your skin, and heat packs do not constitute an adequate PT program - at least not in my opinion.

A knowledgeable therapist will try taping to pull the malaligned kneecap back towards where it should be, assuming the kneecap is tilted (this is often the case in adults with chronic patellar pain). The premise of this approach is that by pulling on the skin the kneecap will be moved ever so slightly. This little displacement is enough to relieve some of the pressure on the kneecap and therefore the pain.

To convince yourself of this push the tip of your right index finger into the palm of your left hand. If you push hard it will hurt. Back off just a little though and the pain will disappear even if to an outside observer the displacement of your finger has been minimal.

Stretching

The lateral retinaculum, ilio-tibial band and hamstrings are often tight, and an appropriate stretching program needs to be instituted.

If you suffer from chronic pain, the therapist may be able to provide you with a TENS unit. This hangs on your belt like a beeper and is connected to your knee by external wires. It blocks pain signals through electrical impulses.

Through ultrasound and various creams, the therapist can also work on calming the irritation of the skin and of the tissues beneath it.

Although there are many PT regimens for patellar pain, the key is the personal attention of the therapist.

Timing

How long does one place a patient on a physical therapy program before proposing surgery? There is no definitive answer to this question. In my opinion, the severity of the pathology plays a role. For example, some patients may have no more than mild tilt of their patella that is easily reducible (i.e. the examiner can easily lift the lateral border of the patella to make the patella horizontal). In others, the patella is severely tilted and subluxed ("hanging off the lateral condyle") and cannot be manually corrected. In the former case I would expect a non-operative regimen to be successful. In the latter, I might, in very select cases, bypass physical therapy and propose surgery. The duration of symptoms and prior treatments also have to be considered. A patient with one week of pain following an initiation to in-line skating and someone with long-standing symptoms who has already been through many treatment regimens will be seen in a very different light. Each case must be individualized.

On average, I start with a regimen of three times a week for four weeks. As a rule, I like to see progress with the non-operative regimen in order to justify persevering with physical therapy after the initial sessions have been completed. If there is no progress, a judgment has to be passed as to whether the patient is non-compliant or whether the pathology is beyond non-operative treatment.