Patella Ligament Surgery - Worth it?

Hey everyone,

Long story short: does anyone have any experience with patellar ligament “tightening” for the sake of alignment? What are the risks / benefits?


Long form: So in HS I had a bad dislocation of my kneecap. At the time I was slated to play college sports. So my dr thought it best to skip surgery, shorten rest time, and go straight to PT. In my recollection, he warned me this may mean more knee pain and potentially a loose patella later in life and 17 year old me (+ scholarship calculating parents) decided that was a fair trade. Well, that day has come.

There’s always been a little big of nagging pain in my knee especially after a long training block, but after completing an Everesting in June, where the last few laps were at about 45 rpms (because of dying on the bike, not choice), my knee really hurts if I push hard on the pedals. My sprint power has dropped in half or more, my hill climbing has suffered, it’s not good. My riding volume has dropped from 9-10 hrs / week to 1-3 hrs. I finally decided to go back to the doctor and have it checked out. Lo and behold there is a fair amount of misalignment in my knee cap. The doctor said that he might go in and realign the kneecap. That “could” fix things and relieve the pain but it might not. We could also just go to PT again and try and fix misalignment that way. More or less left it to me.

Has anyone had experience with this or other knee surgeries? I’m somewhat paranoid to make things worse. After all, I can still ride today, though no where near where I want to be. It hurts and I can’t win town line sprints anymore, but if the surgery goes poorly and took me off the bike in a more serious way, I’d be devastated.

I haven’t looked much into this specific surgery, but I’m curious what cyclists opinions are. My doctor is not a cyclist, though he is the top rated knee doctor in my area and one of the best in the country.

Thoughts, opinions, and experiences are appreciated and again, I’m mulling this over and making a personal choice in conjunction with my doctor. I won’t consider anything said here as professional medical advice nor should anyone else.

Hmmmm…I would proceed pretty cautiously. 25 years ago, I had the opposite surgery (lateral release, where they slice the ligament lengthwise).

Worst mistake of my cycling career…as my rehab continued to go to schitt, I envetually went to Andy Pruitt and the ortho doc he was working with at the time (can’t remember his name). They said they had not done a lateral release on a cyclist in 12 years (and this was 25 years ago!)

I would find a really good orthopedic surgeon with a history of working on athletes, and hopefully specifically cyclists, before making any final decisions.

I too have had quite a few knee surgeries. Meniscus tear repair. Lateral release, Patellar dislocation, then Patellar groove deepening(to help stop dislocation. Unicompartmental surgery.
My right kneecap xray looks just like yours. The lateral release op was supposed to allow the kneecap to move into the right alignment, It was not that effective and caused a fair amount of scar tissue.
My left kneecap dislocated when I trod on a rock while running.It caused mild damage to the cartilage and I had an arthroscopy. The surgeon deepened the Patellar groove, and told me mine was very shallow, and that made it easy for the kneecap to dislocate.
This was successful and did not have any after effects.
Cycling and running strengthen the outside muscles of your quads, and there is often a muscle imbalance between the outside and inside thigh muscles. Particularly the vastus medialis ,which only works fully when you straighten your leg fully, which you dont do in cycling and running.
Therefore you have to spend valuable time working on strengthening these.
A good sports physio will show you the right excersises and give you a program to do.
If you injure your knee, the vastus M shuts off and you are even more vulnerable to the kneecap tracking incorrectly.
this is my experience.
Make sure you get really good advice ,and don’t opt for surgery unless the strengthening and physio etc doesn’t work for you.
Hope it goes well!
PS I consulted Professor David Barrett who is an internationally renowned knee surgeon.
He did my successful surgeries.

Based on history and xrays the likely original injury was a patella dislocation. Initial treatment is typically non op with about a 50/50 chance of surgery. The ligament in question is the medial patellofemoral ligament or mpfl. Yours does not work hence why The patella is lateralized. The problem long term is either instability where the patella can repeatedly dislocate or development of cartilage wear and arthritis leading to pain. Unfortunately I’ve seen several patients with similar issues present years after initial injury. Options become quite limited.

If the option is tightening meaning they plan on just putting some suture in and trying to tighten the medial side you should find a different surgeon. Realistically depending on cartilage you may need a reconstruction of the ligament and possibly a realignment of the tubercle where your patella attaches. I obviously can’t make official recs but this is the common situation.

Based on X-ray if this is not addressed early arthritis is a likely scenario.

Below is my n=1 on knee surgery.

Following multiple dislocations of both knees, in my early teens I had lateral ligament release and medial ligament tightening done on both of my knees.

I wasn’t a cyclist at the time, and was dislocating my knees regularly doing ball sports. Basically anything that required lateral movement can cause a dislocation for me. The surgery, as it was presented to me was to reduce the chances of dislocation moving forward.

Fast forward 15 years to around age 30 and I have subsequently had microfracture surgery on my right knee to attempt to get some cartilage growing in there as well as removing from free bodies I had floating around in there. Both of my knees were basically bone on and bone and I had moderate knee pain from time to time. At the time of the microfracture surgery (8 years ago at this point) I was told eventually the pain would become severe enough that I’d need both knees replaced

I became a more serious cyclist in the meantime and have spent a fair amount of time balancing out my knee motion, etc. I still have knee pain, but only in more specific scenarios. I can’t really kneel down or squat, and I still can’t play ball sports that require lateral movement because I can still pretty easily mess up my knees

All that said - no real issues on the bike for me.

On an unrelated to knees note - I’m pretty loosely put together from a joint perspective and can pop my shoulders out pretty easily to this day, and basically every cycling crash I’ve ever had has been followed by me popping a shoulder back in and then assessing everything else. In some senses I think this has saved me from a collarbone breaking in a couple of instances since the shoulder joint coming apart is sort of an extra shock absorber. Purely theory and not based on anything other than my own guesswork of course

I think you need to do more research on what surgery is going to be performed. The patellar tendon is notoriously strong and any of those shenanigans at the medial and lateral aspect of the patella provide very little effect. Is your physician suggesting a high tibial is osteotomy- cutting and moving the tibial tubercle?

Something else to consider is that your right knee alignment is the way you are. Perhaps you just need rehab and aligning the patella in the groove won’t make a difference because that’s not how you were born. Radiological pictures can’t say that your patella is causing pain. If you experience significant periods of no pain both on and off the bike it’s likely that rehab is your best bet. Radiographs can’t, and never have shown pain. We assume we should be equal and aligned bilaterally, but that is almost never the case.

I would STRONGLY implore you to find a sports medicine doctor and get his/her opinion, rather than just the opinion of an orthopedist.

Sports medicine is a rarely specialty in the U.S., but you can normally find one attached to a university that has a full slate of athletic teams. Living in Chicago, I was able to find one at UIC, and had to wait 8 weeks for an appointment but it changed my life (story below)…

I am currently 46, but in my mid-twenties I had such terrible pain under my patella that I couldn’t run or bike without resting for at least two days in between sessions. As an aspiring triathlete, I was incredibly frustrated, angry and almost desperate.

I played (American) football and basketball in high school, and was decent enough that I was given a scholarship to play football in college. While I never sustained a catastrophic knee injury (ACL, etc.), the wear and tear of that sport definitely caused me some knee trouble from time to time.

So in my post-collegiate attempt to transition to “easier” and “gentler” endurance sports, I was incredibly surprised to have to deal with worse knee issues than I did playing football.

Well, being the good old American football player, I did what American football players do - I went to visit and orthopedic surgeon to look at my knees. He examined them and found that my lateral stability was good, but then he listened to them and heard a popping and grinding noise (which persists to this day…it grosses my daughter out) - his diagnosis was that my knees had likely sustained so much wear and tear from football/basketball that the cartilage had been damaged to the point that it was jagged and over time was wearing out the underside of my kneecap. His recommendation was, 1) that he go in and clean up the loose cartilage that was causing the noise and damaging the patella, and; 2) remove the patella/kneecap and smooth it out to repair it. He literally wanted to sand it down. He wanted to do this for both knees. Full recovery from each surgery would take 8-9 months, or I could do them both at the same time and be in a wheelchair for 2+ months before being able to walk with assistance.

Long story longer…

While contemplating this, I happened to be on business trip and grabbed a Runner’s World magazine for the flight. In that issue of that magazine (which I should have kept and framed) there was a story about a female runner who had been through multiple surgeries to correct her knee pain, and each time she rehabbed she would find that the pain would return. Devastating. The story continued to say she finally sought out a sports medicine doctor and that doctor told her the problem wasn’t her knees, it was her hips being out of alignment that was cascading her injuries. She had spent all this time on surgeries and rehab, and never solved the actual problem.

I immediately searched for a sports medicine doctor, found one, waited 8 weeks for my appointment and had a similar experience. He didn’t even look at my knees… he watched me walk down the hall of his facility in socks and told me the problem wasn’t my knees, it was my feet. My high-arches, combined with a relatively rare type of footfall (supination) was torquing my knees slightly with every stride/pedal stroke. That torquing was causing the pain by over-tightening the tendons in my knees - the over-tightening was causing the grinding and damage…and while the damage was real and permanent and could only be fixed with surgery, he told me he could eliminate the pain with a new pair of shoes, insoles, some PT and foam rolling. 6 weeks later I was running and riding pain free. I still am, and that was 20 years ago.

I tell this story often to try and save others from the fate I almost suffered - because it was truly life changing.

Now the reality might be that you have a condition that only surgery can correct. That may be the case.

But my opinion on orthopedic surgeons can be summed up the following way: when you are a hammer, every problem looks like a nail

Meaning, surgeons solve problems through surgery. It’s not their fault, it’s how they were trained.

I truly wish you good luck and caveat all this by saying I am not a medical professional. But if you have only seen a PT or an orthopedic, I would desperately seek out a sports medicine doctor and solicit their opinion. Surgery may be the only option, but if you can fix your problem without it, it will be well, well, worth the effort.

I wish you the good luck that I had🤘

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Glad to hear your story had a good ending. Food for thought for us all. And I probably too could have avoided some of my surgeries if I had had he opportunity to see a sports medicine doctor. When i was running 90 miles /week in my early 20s womens’ endurance running was relatively new ,and Triathlon was waiting to be conceived!
I had knock knees as a kid, and my parents thought about getting my legs straightened. Relieved they didn’t.
Years later I found a good sports physio, who assessed me and found my glut mediuses were very weak, and this malfunction + the Q angle with knock knees led to pelvis instability ,pronation and other nasties. I still managed 25 years of a great running career ,with very few injuries, and many wins in road running ,Fell and xc. Sadly ,I don’t love cycling quite as much, but I can still compete at a high level, whereas I’m rather a slow runner now :rofl:

This is good advice. I would also suggest that most good surgeons - very obviously catastrophic injuries aside - will say surgery should usually be a last resort*, is never guaranteed, and that the correct conservative therapies can keep you off the operating table.

*I’m informed that for certain chronic injuries, in competitive athletes, surgery can sometimes lead to a quicker return to high level performance.

It is also always worth consulting a very good physio, with knowledge of your specific sport and injury. A good one will say honestly if they think they can help you, and give a very rough timescale.