What is the recommended treatment for a 68-year-old male with mild to moderate arthrosis of the patellofemoral joint?

Treatment for Mild to Moderate Patellofemoral Joint Arthrosis in a 68-Year-Old Male

The recommended first-line treatment for mild to moderate patellofemoral joint arthrosis in a 68-year-old male includes a regular exercise program focusing on quadriceps strengthening, weight management if overweight, and topical or oral NSAIDs for pain relief. 1

Non-Pharmacological Interventions

Exercise Therapy

• Quadriceps strengthening exercises - Strong evidence supports this as a primary intervention 1

  • Improves pain and function with effect sizes of 1.05 compared to control groups
  • Can be performed with or without regular professional supervision
  • Should be performed regularly and consistently

• Patellofemoral-specific exercises

  • Conditional recommendation for patellofemoral bracing to improve joint mechanics 1
  • Balance exercises to improve lower extremity control 1
  • Tai chi has strong evidence supporting its use for knee OA 1

Assistive Devices

• Walking cane - Strong recommendation for use in the contralateral hand 1
• Patellofemoral bracing - Conditional recommendation to improve tracking and reduce pain 1

Weight Management

• If the patient is overweight or obese, weight loss is strongly recommended 1
• Even modest weight loss can significantly reduce symptoms and improve function

Self-Management Programs

• Patient education - Strong recommendation 1
  • Understanding the condition
  • Activity modification strategies
  • Pain management techniques
  • Realistic expectations about recovery

Pharmacological Interventions

Topical Treatments

• Topical NSAIDs - Strong recommendation for knee OA 1

  • First choice for patients with limited disease
  • Lower systemic side effect profile compared to oral NSAIDs
  • Apply to affected area 3-4 times daily

• Topical capsaicin - Conditional recommendation for knee OA 1

  • Can be used as an alternative or adjunct to NSAIDs

Oral Medications

• Oral NSAIDs - Strong recommendation 1, 2

  • Ibuprofen: 1200-3200 mg daily (400 mg, 600 mg, or 800 mg TID or QID) 2
  • Use lowest effective dose for shortest duration
  • Take with meals to reduce GI side effects
  • Consider cardiovascular and renal risk factors in this age group

• Acetaminophen - Conditional recommendation 1

  • Less effective than NSAIDs but better safety profile
  • Can be used if NSAIDs are contraindicated

• Duloxetine - Conditional recommendation 1

  • May be considered for pain management if other options fail

Intra-articular Injections

• Intra-articular glucocorticoid injections - Strong recommendation 1
  • Effective for short-term pain relief
  • Can be repeated if beneficial, typically no more than 3-4 times per year

Treatment Algorithm

1. Initial approach:

   • Begin with quadriceps strengthening exercises
   • Implement weight loss if BMI > 25
   • Consider patellofemoral bracing
   • Use topical NSAIDs as first-line pain management

2. If inadequate response after 4-6 weeks:

   • Add oral NSAIDs if no contraindications
   • Consider intra-articular glucocorticoid injection
   • Intensify exercise program with professional supervision

3. For persistent symptoms despite 6 months of conservative treatment:

   • Consider referral to orthopedic specialist to evaluate for surgical options 3
   • Surgical options may include lateral retinacular release, tibial tubercle osteotomy, or patellofemoral arthroplasty in selected cases

Common Pitfalls and Caveats

• Overreliance on medications - Exercise therapy should remain the cornerstone of treatment
• Inadequate exercise intensity - Exercises must be sufficiently challenging to strengthen quadriceps
• Premature consideration of surgery - Conservative management should be tried for at least 6 months 3
• Neglecting weight management - Weight loss can significantly reduce joint stress
• Inappropriate use of opioids - Should be avoided due to limited evidence and risk of dependence

Monitoring and Follow-up

• Reassess pain and function every 4-6 weeks
• Adjust treatment plan based on response
• Monitor for medication side effects, particularly in this age group
• Evaluate exercise technique and compliance regularly

By implementing this comprehensive approach focusing on exercise, weight management if needed, and appropriate pain control, most patients with mild to moderate patellofemoral arthrosis can achieve significant symptom relief and improved function.