What is the treatment for focal grade 3 to 4 chondromalacia?

Treatment of Focal Grade 3 to 4 Chondromalacia

For focal grade 3 to 4 chondromalacia, a structured rehabilitation program should be the first-line treatment, with surgical interventions reserved for cases that fail to respond to conservative management after 3 months.

Conservative Management (First-Line Treatment)

Exercise Therapy

• Implement a structured 6-12 week physiotherapist-led rehabilitation program 1:

  • Frequency: At least 3 times per week
  • Duration: Minimum 30 minutes per session
  • Components:
    • Quadriceps strengthening exercises (particularly closed kinetic chain exercises)
    • Core strengthening
    • Hip girdle muscle strengthening
    • Range of motion/stretching exercises
    • Aerobic activity

• Closed kinetic chain exercises (semi-squat exercises) are more effective than open kinetic chain exercises (straight leg raises) for chondromalacia 2

  • These exercises show better outcomes in:
    • Reducing Q angle
    • Decreasing crepitation
    • Increasing quadriceps strength
    • Increasing thigh circumference

Pain Management

• First-line analgesic: Paracetamol (up to 4g/day) 1
• Second-line: Short-term NSAIDs if paracetamol is insufficient 1
• Opioids should only be used when other options are contraindicated, ineffective, or poorly tolerated 1

Activity Modification

• Implement pacing strategies ("small amounts often") 3
• Avoid activities that exacerbate symptoms
• Use appropriate and comfortable footwear 3

Advanced Conservative Options (If Initial Treatment Inadequate)

Intra-articular Injections

• Consider hyaluronic acid injections for persistent symptoms 4
  • Precautions:
    • Remove joint effusion before injection if present
    • Use proper aseptic technique
    • Avoid overloading the treated joint immediately after injection
    • Examine patients for signs of acute inflammation before administration

Prolotherapy

• Consider for patients who fail to respond to exercise therapy
• Has shown significant improvements in pain levels, stiffness, crepitus, and physical function in chondromalacia patients 5
  • 85% of patients reported >75% sustained improvement in symptoms
  • Reduced need for pain medication
  • Only 3 of 16 knees still required surgery after prolotherapy

Surgical Management (For Failed Conservative Treatment)

Indications for Surgery

• Persistent symptoms despite 3 months of appropriate conservative management 1
• Significant functional limitations
• Failure to respond to non-surgical interventions

Surgical Options Based on Lesion Size and Characteristics

1. Microfracture

   • Indicated for focal, contained lesions <4 cm² 3
   • Procedure:
     • Debridement of friable cartilage
     • Creation of perpendicular holes (3-4mm deep, spaced 3-4mm apart) in subchondral bone
     • Allows marrow cells to form new fibrocartilage

2. Mosaicplasty

   • Indicated for focal, full-thickness lesions <3 cm² in patients <45 years without osteoarthritis 1
   • Advantages:
     • No need for second procedure
     • Replacement with hyaline cartilage
     • Immediate or near-immediate weight bearing after surgery

3. Osteochondral Allograft Transplantation (OAT)

   • Appropriate for larger defects (>2.5 cm²) or substantial loss of subchondral bone 1
   • Best for patients ≤50 years with no evidence of osteoarthritis

Monitoring and Follow-up

• Assess treatment response after 3 months of conservative management 1
• Regular follow-up (at least annually) to monitor:
  • Pain levels
  • Functional improvement
  • Development of early osteoarthritis
  • Quality of life

Common Pitfalls to Avoid

• Premature surgical intervention before completing a full 3-month conservative management program 1
• Inadequate physiotherapy or poor exercise technique
• Overlooking biopsychosocial factors affecting recovery
• Relying solely on imaging for treatment decisions rather than clinical symptoms and examination findings 1

Treatment Algorithm

1. Start with 6-12 week structured rehabilitation program
2. If inadequate response, add advanced conservative options (injections, prolotherapy)
3. If still inadequate after 3 months, consider surgical intervention based on lesion characteristics
4. Continue monitoring and adjust treatment plan based on response