Summary Lateral patellar compression syndrome is the improper tracking of the patella in the trochlear groove generally caused by a tight lateral retinaculum. Diagnosis is made clinically with pain with compression of the patella and moderate lateral facet tenderness and sunrise knee radiographs will often show patellar tilt in the lateral direction. Treatment is nonoperative with physical therapy focusing on quadriceps stretching and strengthening. Operative lateral retinaculum release is indicated in refractory cases. Etiology Mechanism Caused by tight lateral retinaculum leads to excessive lateral tilt without excessive patellar mobility Associated conditions Miserable Triad is a term coined for anatomic characteristics that lead to an increased Q angle and an exacerbation of patellofemoral dysplasia. They include: femoral anteversion genu valgum external tibial torsion / pronated feet Presentation Presentation pain with stair climbing theatre sign (pain with sitting for long periods of time) Physical exam pain with compression of patella and moderate lateral facet tenderness inability to evert the lateral edge of the patella Imaging Radiographs patellar tilt in lateral direction Treatment Nonoperative NSAIDS, activity modification, and therapy indications mainstay of treatment and should be done for extensive period of time technique therapy should emphasize vastus medialis strengthening and closed chain short arc quadriceps exercises Operative arthroscopic lateral release indications objective evidence of lateral tilting (neutral or negative tilt) pain refractory to extensive rehabilitation inability to evert the lateral edge of the patella ideal candidate has no symptoms of instability medial patellar glide of less than one quadrant lateral patellar glide of less than three quadrants patellar realignment surgery Maquet (tubercle anteriorization) indicated only for distal pole lesions only elevate 1 cm or else risk of skin necrosis Elmslie-Trillat (medialization) indicated only for instability with lateral translation (not isolated lateral tilt) avoid if medial patellar facet arthrosis Fulkerson alignment surgery (tubercle anteriorization and medialization) indications (controversial) lateral and distal pole lesions increased Q angle contraindications superior medial arthrosis (scope before you perform the surgery) skeletal immaturity Techniques Arthroscopic lateral release technique viewing through superior portal will show medial facet does not articulate with trochlea at 40 degrees of knee flexion be sure adequate hemostasis is obtained postoperatively the patella should be able to be passively tilted 80° complications persistent or worsened pain patellar instability with medial translation