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Patella Alta: Causes, Symptoms & Treatment

Patella alta describes a condition where the kneecap sits higher than normal within the knee joint, which can lead to pain, instability, and cartilage damage.

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Things worth knowing about "Patella alta"

Patella alta describes a condition where the kneecap sits higher than normal within the knee joint, which can lead to pain, instability, and cartilage damage.

What is Patella Alta?

Patella alta is an anatomical condition in which the kneecap (patella) is positioned higher than normal within the knee joint. The term originates from Latin and literally means “high kneecap.” Under normal anatomy, the kneecap glides within a groove on the thighbone (femur) called the trochlea. In patella alta, this guidance is compromised because the kneecap sits too high and does not engage properly within the trochlear groove, leading to biomechanical problems.

Causes

Patella alta can be congenital or acquired:

Congenital variation: Many individuals are born with this anatomical variant.
Elongated patellar tendon: The tendon connecting the kneecap to the shinbone is longer than normal.
Muscular imbalances: Weakness or imbalance in the thigh muscles can contribute to high kneecap positioning.
Skeletal developmental disorders: Growth-related changes during childhood and adolescence.
Spasticity: In neurological conditions such as cerebral palsy, spasticity of the rectus femoris muscle can result in patella alta.

Symptoms

Patella alta does not always cause symptoms, but when it does, the following complaints are common:

Knee pain: Particularly at the front of the knee, especially when climbing stairs, squatting, or sitting for extended periods.
Patellar instability: The kneecap is prone to dislocations (luxations) or partial dislocations (subluxations).
Patellofemoral pain syndrome: Aching pain in the area between the kneecap and the thighbone.
Cartilage damage: Abnormal stress on the joint can lead to long-term cartilage deterioration.
Swelling and effusions: Irritation within the knee joint can cause visible swelling.

Diagnosis

The diagnosis of patella alta is made through clinical examination and imaging:

Clinical Examination

The physician assesses the position of the kneecap, the range of motion of the knee, and patellar stability. A characteristic sign is the “grasshopper eye” appearance, where the kneecap engages late into the trochlear groove during knee flexion.

Imaging

Standardized lateral X-rays of the knee are used to measure patellar height. The following indices are commonly used:

Insall-Salvati Index: Ratio of the patellar tendon length to the patellar length. A value above 1.2 indicates patella alta.
Caton-Deschamps Index: Ratio of the distance from the lower patellar edge to the anterior tibial plateau, relative to the articular surface length of the patella. A value above 1.2 is considered abnormal.
MRI (Magnetic Resonance Imaging): Used to evaluate cartilage damage, tendon integrity, and soft tissue structures around the knee.

Treatment

Conservative Treatment

In mild cases without significant instability, conservative management is the first approach:

Physiotherapy: Strengthening exercises targeting the thigh muscles, particularly the vastus medialis obliquus, to improve patellar stability.
Orthoses and braces: Specialized knee braces or patellar stabilizing sleeves can help keep the kneecap in place.
Pain management: Non-steroidal anti-inflammatory drugs (NSAIDs) for acute pain relief.
Activity modification: Avoiding high-impact activities during symptomatic phases.

Surgical Treatment

Surgery may be required in cases of frequent dislocations, severe cartilage damage, or failure of conservative therapy:

Tibial tubercle transfer (TTT): The attachment point of the patellar tendon on the shinbone is moved distally (downward) to lower the kneecap position.
Patellar tendon shortening: Surgical shortening of the patellar tendon to correct the high-riding position.
MPFL reconstruction: Reconstruction of the medial patellofemoral ligament to address concurrent patellar instability.

References

Dejour H, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study. Knee Surgery, Sports Traumatology, Arthroscopy. 1994;2(1):19-26.
Insall J, Salvati E. Patella position in the normal knee joint. Radiology. 1971;101(1):101-104.
Caton JH, Deschamps G. Patella infera and patella alta. Revue de chirurgie orthopedique et traumatologique. 2014;100(4 Suppl):S181-S189.

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