What is the treatment for Grade II/III chondromalacia involving the medial patellar facet and patellar ridge?

Treatment for Grade II/III Chondromalacia of the Medial Patellar Facet and Patellar Ridge

Conservative management should be the first-line treatment for Grade II/III chondromalacia patellae, with a focus on quadriceps strengthening exercises, particularly closed kinetic chain exercises like semi-squats which are more effective than open kinetic chain exercises. 1

First-Line Conservative Management

Exercise Therapy

• Quadriceps strengthening exercises:
  • Semi-squat exercises (closed kinetic chain) are superior to straight leg raises (open kinetic chain) for:
    • Reducing Q angle
    • Decreasing crepitation
    • Increasing quadriceps strength
    • Increasing thigh circumference 1
  • Include walking, strengthening exercises, and neuromuscular training 2
  • Aquatic exercises may be beneficial for patients who are aerobically deconditioned 3

Patellar Taping

• Medial patellar taping provides short-term relief of pain and improved function 3, 2
• More effective when compared to no taping (rather than sham taping) 3

Weight Management

• For overweight patients, weight loss is strongly recommended 3, 2
• Should include structured approach with regular self-monitoring and increased physical activity 2

Second-Line Management

Pharmacological Treatment

• Topical NSAIDs: First-line pharmacological treatment due to lower systemic absorption and fewer adverse effects 2
• Oral NSAIDs: Second-line when topical treatments are insufficient 2
• Acetaminophen: For mild to moderate pain (up to 4g/day) 3, 2

Bracing Options

• Patellofemoral bracing is conditionally recommended 2
• Consider a brace with valgus-directing force for medial compartment involvement, though evidence is inconclusive 3

Surgical Options (for refractory cases)

Surgical intervention should be considered only after failure of conservative management:

1. For Grade II/III chondromalacia:

   • Lateral release may be beneficial for Grade II to IV chondromalacia 4
   • Patellar tendon transfer is recommended for younger patients (under 20) with Grade I-III changes 5

2. For more advanced cases (Grade IV):

   • Cartilage excision and drilling may be appropriate for adults over 20 with Grade I-II changes 5
   • Patellectomy should be reserved for severe cases (Grade IV) or after failed previous operations 5

Treatment Algorithm

1. Initial 6-8 weeks:

   • Daily quadriceps strengthening with emphasis on closed kinetic chain exercises
   • Medial patellar taping
   • Weight management if applicable
   • Topical NSAIDs for pain control

2. If inadequate response after 8 weeks:

   • Add oral NSAIDs
   • Consider patellofemoral bracing
   • Intensify physical therapy with supervised exercise

3. If persistent symptoms after 3-6 months of conservative care:

   • Orthopedic referral for surgical evaluation
   • Consider lateral release, especially if positive patellar inhibition test 4

Monitoring and Follow-up

• Regular assessment of pain control and function
• Adjust treatment plan based on response
• Consider specialist referral if there is established functional limitation and severe refractory pain despite conservative management 2

Common Pitfalls to Avoid

• Relying solely on open kinetic chain exercises (straight leg raises), which are less effective than closed kinetic chain exercises (semi-squats) 1
• Rushing to surgical intervention before adequate trial of conservative management (at least 3-6 months)
• Using lateral heel wedges, which are not recommended for medial compartment OA 3
• Neglecting quadriceps strengthening, which is the cornerstone of conservative management

The success rate of comprehensive conservative management for chondromalacia patellae has been reported as high as 82%, with only 18% requiring surgical intervention 6, emphasizing the importance of thorough non-surgical approaches before considering surgery.