What is the initial treatment for patellofemoral compartment degenerative changes that are most pronounced laterally?

Initial Treatment for Patellofemoral Compartment Degenerative Changes with Lateral Predominance

Conservative therapy, including knee-targeted exercise therapy and education, should be the initial treatment for patellofemoral compartment degenerative changes that are most pronounced laterally. 1

Core Treatment Components

1. Exercise Therapy

• Knee-targeted strengthening exercises

  • Focus on quadriceps strengthening, which has high-certainty evidence for short-term pain reduction and moderate-certainty evidence for functional improvement 1
  • Progressive loading of quadriceps in both open and closed chain exercises
  • Adjust exercise intensity based on pain severity and irritability

• Hip-and-knee-targeted exercise therapy

  • Add hip strengthening exercises, especially for patients with poor tolerance to loaded knee flexion 1
  • Modify task/load/intensity/frequency as needed based on patient response

2. Education

Education should underpin all interventions and be tailored to the patient's needs:

• Explain the nature of patellofemoral degenerative changes
• Clarify that pain doesn't necessarily correlate with damage
• Set realistic expectations about recovery timeframes
• Provide guidance on activity modification and load management
• Build confidence and reduce fear of movement 1

3. Supporting Interventions

Patellofemoral Bracing

• Patellofemoral braces help resist lateral displacement of the patella and maintain patellar alignment 1
• Select an appropriate brace:
  • For most patients: off-the-shelf neoprene brace with straps or buttresses
  • For more active individuals: brace with lateral hinge and adjustable patellar buttress 1
• Proper fitting is essential for effectiveness:
  • Measure leg circumference according to manufacturer guidelines
  • Position buttress support to resist lateral displacement
  • Align patella in center of cutout if applicable
  • Secure straps with moderate tension 1

Prefabricated Foot Orthoses

• Consider for patients who respond favorably to treatment direction tests
• Can be customized for comfort by modifying density and geometry 1
• Most beneficial in the short term to help change function 1

Clinical Assessment to Guide Treatment Selection

Objective Evaluation

• Assess muscle strength (hip and knee)
• Evaluate movement patterns of the lower extremity (e.g., single leg squat)
• Determine tissue tolerance to load through pain provocation tests
• Examine patellofemoral joint structure/function (e.g., presence of patella alta, hypermobility)
• Identify contextual factors related to symptoms (e.g., fear avoidance during functional tasks) 1

Treatment Progression

1. Start with knee-targeted exercise therapy and education
2. Add hip-targeted exercises if needed
3. Incorporate supporting interventions (bracing, orthoses) based on assessment findings
4. If favorable outcomes are not observed after a reasonable period, reassess and adjust the intervention approach 1

Common Pitfalls and Caveats

1. Overreliance on passive treatments: Exercise therapy should remain the cornerstone of treatment, with bracing and orthoses serving as adjuncts to facilitate exercise and activity.

2. Inadequate exercise dosage: Ensure sufficient intensity and progression of exercises to achieve therapeutic effect.

3. Neglecting patient education: Education is integral to treatment success and should not be overlooked.

4. Improper brace fitting: Effectiveness of patellofemoral braces depends on correct application and use 1.

5. Focusing solely on the patellofemoral joint: Consider the entire lower kinetic chain in assessment and treatment.

By implementing this comprehensive approach to conservative management, most patients with patellofemoral compartment degenerative changes can experience significant improvement in pain and function before considering more invasive interventions.