What is the initial treatment for Chondromalacia patella?

Initial Treatment for Chondromalacia Patellae

The initial treatment for chondromalacia patellae should focus on quadriceps strengthening exercises, particularly closed kinetic chain exercises such as semi-squats, which have demonstrated superior outcomes compared to open kinetic chain exercises. 1, 2

Understanding Chondromalacia Patellae

Chondromalacia patellae is a condition characterized by:

• Softening and deterioration of the cartilage on the posterior surface of the patella 3
• Activity-related anterior knee pain that worsens with stairs and prolonged sitting 1
• Pain often exacerbated by activities that increase patellofemoral joint loading 1

Conservative Management Algorithm

First-Line Treatment: Exercise Therapy

1. Knee-targeted exercise therapy

   • Demonstrated high certainty evidence for short-term pain reduction (SMD 1.16,95% CI 0.66,1.66) 1
   • Moderate certainty evidence for short-term function improvement (SMD 1.19,95% CI 0.51,1.88) 1
   • Focus on progressive quadriceps strengthening in both open and closed chain exercises 1

2. Closed kinetic chain exercises (semi-squats)

   • More effective than straight leg raises (open kinetic chain) 2
   • Demonstrated greater improvements in:
     • Q-angle reduction
     • Decreased crepitation
     • Increased quadriceps strength
     • Increased thigh circumference 2

3. Hip-and-knee-targeted exercise therapy

   • Consider adding hip exercises when patients have poor tolerance to loaded knee flexion 1
   • Modify task/load/intensity/frequency based on pain response 1

Supporting Interventions

1. Patellar taping

   • Recommended for short-term relief of pain and improved function (Grade B recommendation) 1
   • Medial taping shows statistically significant and possibly clinically important effects on pain reduction 1
   • Most effective when compared to no taping rather than sham taping 1

2. Prefabricated foot orthoses

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

3. Patellofemoral braces

   • May help resist lateral displacement of the patella 1
   • Patients often report subjective improvements in pain and disability 1
   • Note that subjective benefits often exceed objective findings 1

Education

Education should underpin all interventions and include:

• Explanation of the diagnosis and expected recovery timeline 1
• Guidance on managing activity and load modification 1
• Reassurance that pain does not necessarily correlate with damage 1
• Building confidence and reducing fear of movement 1

Important Clinical Considerations

• Conservative management has shown an 82% success rate in athletes with symptomatic patellofemoral syndromes 4
• Only 8% of patients in one study required surgical intervention after comprehensive conservative management 4
• Avoid lateral heel wedges as they have limited evidence for effectiveness and may worsen symptoms 1
• Range-of-motion and flexibility exercises are an option to address impairments (Level V evidence, Grade C recommendation) 1

Treatment Duration and Follow-up

• Patients should be informed that recovery may take several months 1
• Exercise therapy should be continued for at least 3-4 weeks with progressive increases in intensity 2
• Consider reassessment at weekly intervals to monitor progress and adjust interventions 2

When to Consider Surgical Intervention

Surgery should only be considered after failure of a comprehensive conservative management program, which is reported in only about 18% of cases 4. Surgical options include arthroscopic lavage, shaving, and lateral release, but these should be reserved for persistent cases unresponsive to conservative care 5.