This week’s Ask Dr. Geier column addresses a problem that is not all that unusual – patellar dislocations – but it is somewhat unusual to be discussing surgery for a patellar dislocation for such a young athlete.
Worried in Manitowoc, Wisconsin, asks:
My 13-year-old daughter had dislocated the patella of her right knee almost two years ago. Because she had torn some tissue, her doctor chose to do surgery to repair the tissue. A year after that, she dislocated the left knee and again had surgery. In October of this year she had the same thing happen to the right knee, again stretching the tissue.
She rehabbed for a month. Everything looked good with both knees. With the ok from her doctor, she returned, wearing braces on both knees, to basketball. About a month into the season, her right knee gave out again, and the doctor said she had stretched the repair further. He feels the best option for her would be to surgically repair the tissue. She is still growing so he can’t do any reconstruction at this time. Her dad does not want her to have the surgery. He thinks we should just rehab and keep her out of sports. I feel if we don’t have the surgery it will most likely happen again. She is always going to naturally want to be active, and even if we keep her out of organized sports, her personality and energy would be hard to harness.
What would be your recommendation?
Patellar dislocations can be very tricky, especially in young athletes. In general, I think that physical therapy to rehabilitate the knee and lower extremity of a young athlete with a first-time dislocation is the first line of treatment. Strengthening muscles around the knee and hip and working on lower extremity mechanics can be very helpful. Occasionally taping or bracing while the athlete plays can be helpful as well.
Surgery for a patellar dislocation
If surgery is needed, there are many different procedures that can be performed depending on specific issues with different patients. Generally, patients who are not done growing can only receive procedures that involve the soft tissue structures. The surgeries involve releasing the tight ligaments on the outside of the patella and tightening the ligaments on the inside of the kneecap. Procedures to move the tibial tuberosity (the part of the bone where the patella tendon attaches) usually are reserved for skeletally immature athletes.
Choosing rehab vs. surgery for a patellar dislocation
The decision to choose surgery is always a difficult one, whether it’s for a first surgery or a revision operation. I like to tell patients and their families that often surgery can be done at any time but it is often a good idea to exhaust all nonsurgical possibilities first. If the patient fully rehabs aggressively, there is a chance that he or she will get better and be able to play without difficulty after 4-12 weeks of work with a physical therapist. The worst that could happen is that he or she does not get back to sports and isn’t much better. At that point surgery is an easier decision. Once someone decides to go through with surgery, that bridge is burned, so to speak. Often a second surgery, if recurrent dislocations occur after the first surgery, involves a larger operation with a longer rehabilitation. On the other hand, trying to hold a young athlete out of sports can be very difficult, as it is often a very important part of his or her life.