What is the treatment for Chondromalacia?

Treatment for Chondromalacia Patellae

The most effective treatment for chondromalacia patellae is a conservative approach focused on closed kinetic chain exercises (semi-squat exercises) rather than open kinetic chain exercises, as these have been shown to significantly reduce pain, improve quadriceps strength, and decrease Q-angle and crepitation. 1

Understanding Chondromalacia Patellae

Chondromalacia patellae refers to softening of the articular cartilage on the posterior surface of the patella. It can progress to fibrillation, fissuring, and erosion of the cartilage 2. This condition is one of the most common causes of knee pain in young people, particularly athletes.

Clinical Presentation

• Pain in the anterior knee, especially during activities like running, stair climbing (particularly ascending stairs)
• Catching or locking sensation in the knee
• Crepitation during knee movement
• Pain worsens with prolonged sitting ("theater sign")

Treatment Algorithm

First-Line Treatment: Conservative Management

1. Exercise Therapy (Most Important Component)

   • Closed Kinetic Chain Exercises (preferred approach):

     • Semi-squat exercises starting with 20 repetitions twice daily, increasing by 5 exercises every 2 days 1
     • These exercises have shown superior outcomes compared to open kinetic chain exercises, with significant improvements in:
       • Q-angle reduction
       • Decreased crepitation
       • Increased quadriceps strength
       • Increased thigh circumference

   • Quadriceps Strengthening:

     • Focus on VMO (vastus medialis obliquus) strengthening to improve patellar tracking

2. Physical Modalities

   • Ice application after exercise to reduce inflammation
   • Short-wave therapy may provide symptomatic relief 3

3. Pain Management

   • NSAIDs for pain and inflammation if not contraindicated 4
   • Acetaminophen (≤4g/day) as an alternative for those with contraindications to NSAIDs 4
   • For patients with increased GI risk (age ≥60, history of peptic ulcer disease, concurrent corticosteroids), consider:
     • Topical NSAIDs
     • Acetaminophen
     • Oral NSAIDs with gastroprotective agents 4

4. Activity Modification

   • Temporary reduction in high-impact activities (running, jumping)
   • Avoidance of prolonged sitting with knees flexed
   • Cross-training with low-impact activities (swimming, cycling)

Second-Line Treatments

If first-line treatments fail after 4-6 weeks:

1. Biomechanical Correction

   • Orthotics for those with foot pronation
   • Patellar taping or bracing to improve patellar tracking

2. Advanced Physical Therapy

   • Manual therapy techniques
   • Proprioceptive training
   • Gait retraining

Surgical Options (Reserved for Refractory Cases)

For patients who fail conservative management (approximately 18% of cases) 5:

1. Arthroscopic Interventions
   • Debridement of damaged cartilage
   • For focal chondral defects <4 cm², microfracture technique may be considered 4
     • This involves creating small holes in the subchondral bone to allow marrow cells to form fibrocartilage

Important Considerations

• Conservative management has shown an 82% success rate in athletes with chondromalacia patellae, with only 8% requiring surgical intervention 5
• Hamstring and quadriceps flexibility should be assessed and addressed as part of treatment 6
• The inferior pole of the patella is often the most tender site to palpation 6
• Polypharmacy should be avoided in the conservative treatment of chondromalacia patellae 3

Monitoring and Follow-up

• Reassess pain levels, quadriceps strength, and functional abilities every 1-2 weeks during initial treatment
• If no improvement after 6-8 weeks of consistent conservative therapy, consider referral for orthopedic evaluation
• For athletes, a gradual return-to-sport protocol should be implemented once pain has subsided and strength has improved

By following this structured approach to treating chondromalacia patellae, most patients can expect significant improvement in symptoms and function without requiring surgical intervention.