by Mitch Hauschildt, MA, ATC, CSCS
Patellofemoral knee pain is a large part of what I treat on a regular basis, as it is anyone who performs rehab on patients. I see this pain with my active athletes as well as young people who have poor motor control and biomechanics and the general adult population who have become a bit deconditioned over time. It’s common, but usually relatively easy to fix with therapy, when it is treated correctly.
Before we get to the lateral release, let’s first understand patellofemoral pain. Traditional thought is that in people with this type of knee pain, the muscles of the lateral side of the knee (Vastus Lateralis) are stronger and they are over powering the muscles of the inside of the knee (VMO). When this muscle imbalance happens, it pulls the patella laterally and that causes pain. Or, that’s what we thought was happening.
We now know that patellofemoral knee pain is much more about what is going on at the foot and the hip than it is the VMO or any other quad muscle. If the foot collapses (pronation) or the hip can’t control the position of the knee (valgus collapse), then the femur moves medially, causing pain. So, instead of the patella tracking laterally, it is much more about the femur tracking medially.
If we go back to the traditional thought on the cause of Patellofemoral pain, then the lateral release makes sense. As a quick overview of a lateral release, it is a surgical procedure where they basically go in and cut part of the lateral retinaculum, which attaches the lateral muscles of the quad onto the patellar tendon. When then clip it, in theory, it doesn’t pull as hard and the patella is able to track more medially.
The lateral release is becoming less and less common with surgeons because there have been so many advances with conservative options for these patients, but we do still see them from certain physicians from time to time.
There are several reasons why I dislike this procedure so much:
- It is very painful for the patient. I’m not exactly sure why, but I have had athletes with much larger reconstructive procedures done in the knee who have less pain that lateral release patients do.
- They bleed. A lot. When they clip the retinaculum, it will bleed and bleed and bleed. It isn’t an external bleeding that you can see. Rather, it bleeds into the knee joint and causes a lot of swelling. Patients who have lateral releases tend to swell for days and weeks after surgery. It is a constant battle to keep their effusion under control.
- Except under certain circumstances, the lateral release can usually be avoided. A good clinician should be able to fix most cases of patellofemoral pain. It may take some good exercises, some soft tissue work, motor pattern retraining and maybe even some orthotics, but if you are persistent, it can get better. Unfortunately, some surgeons aren’t as interested in working through conservative treatment. The problem is, once you cut, that knee is never the same.
- It oftentimes doesn’t work. I can’t tell you how many people I have seen over the years that had a lateral release and still have knee pain. It doesn’t help because the surgery isn’t actually treating the real cause of the pain. The root cause is at the foot and/or hip. Cutting the lateral retinaculum isn’t solving anything. And, if you have a severe biomechanical issue where you feel that you have no choice but to do a lateral release, the success rate is much higher if you perform one of the various procedures to tighten down the medial side of the knee. While I still don’t like that option, patients do much better with a combination procedure than they do an isolated lateral release.
Overall, I have to say that a lateral release is likely my least favorite surgery to see happen to someone. I know I’m biased, but I want to fix these patients with therapy and exercise. If you are a clinician, take a moment and educate people on this procedure if they are considering it to make sure they fully understand the risks and rewards of the lateral release.
I can’t agree with you more Mitch, thank you! We should all be educating our patients and clients on the true benefit of prevention and how we can work with the body to improve such mechanical issues.
As an early intervention Physical Therapist I believe it starts with good positioning and movement patterns from childhood, but it’s NEVER too late to start!
Thank you again Mitch!
I had surgery last Thursday on my left knee. I had chondroplasty of patella and a lateral release done. I am 39 and have had total knee cap dislocations since I was 13 years old. Jan 23, my cartilage started rubbing off the back of my knee cap from rubbing against my leg bones. This article makes sense and is something I am very concerned about since the x-rays showed the “notch or grove” for my knee cap to sit in is not centered. The two leg bones do not attach correctly. I have been going to a chiropractor to keep my legs aligned. The 1st OS I went to suggested a knee replacement. I got a 2nd opinion and went with his since I would be out of work less time. I am wondering if my knee cap will dislocate more often now after the lateral release. I am not eager to find out though. I was told what I had was a birth defect in both knees…. diagnosis at 39 years old.
There are a lot of factors consider here. First, you are very young for a total joint. Put that off as long as humanly possible. The lateral release is better than a total joint. If you are a chronic dislocator, I would have preferred that you have therapy to improve your foot and hip control. If that fails and you have stretched the tissue so much that it won’t stay where it needs to, then I would have preferred that they performed a medial reconstruction to go along with the lateral release to tighten everything up. But, I don’t know all of the factors involved, so I want to be fair to the surgeon. You still need to work on foot and hip stability, strength and control.
I feel as you have described me to a a T. I had the lateral release done when I was 30. My knee has not slipped out of place since. I can still tell when I have over done my knee and will try to rest it. I still have pain (probably some arthritis) and a lot of snap, crackle, pop, but no more randomly falling on my face. Best of luck.
I’m very curious to know if you’ve improved since this comment?
I am 40 and have had luxating patellas since I was around 14. I had a lateral release while having a clean out 5 months ago and am in WORSE pain than I was before the surgery! I’m now feeling as though my foot and ankle don’t align like they used to.
Add me to your list of “it often doesn’t work” patients. I am one of those early patients who was indiscriminately subjected to a lateral releases in both knees in the mid- 80s (as a teen, to solve patella tracking problems causing pain), and for the past thirty years have struggled with weak / unstable / painful knees / swelling / repeated rounds of PT and NSAIDs / injections / etc.. Dozens of orthopedic doctors have told me there isn’t anything I can do about the knees, but the recent onset of hip pain and stiffness led to the discovery that I have hip impingement – which may have been the source of the knee pain way back then (body mechanics). Nice to know I wasn’t being completely unreasonable with my dissatisfaction over the knee surgeries… Currently in a round of acupuncture to try and relieve chronic swelling in one knee.
I had lateral release surgery 7/17/2020 I was on the first 2 weeks but I was doing therapy at home trying to bending my knee I was rocking it and I felt like a Little pop than my knee feels like it gets stuck. If this normal? I got worse I’m scared to feel that pain again. It’s happens to me 4 times. If anyone has any info I’d greatly appreciate it. Not sure if it’s me being scared or what?? But now it’s so weak. I just had an MRI done a few days ago and he said nothing tore and I have swelling behind and around my knee cap. I’m so scared and I just want to walk again. Please help, thanks.
LR should be banned. For those who had this life destroying surgery, the only savage option is LPFL reconstruction and there are only a handful of surgeons who has sufficient experience.