What is the initial treatment for Chondromalacia (cartilage softening)?

Initial Treatment for Chondromalacia Patella

The initial treatment for chondromalacia patella should focus on conservative management with physical therapy, particularly closed kinetic chain exercises like semi-squats, which are more effective than open kinetic chain exercises in improving symptoms and function. 1

Understanding Chondromalacia Patella

Chondromalacia patella refers to the softening of articular cartilage on the posterior surface of the patella, which may eventually lead to fibrillation, fissuring, and erosion 2. It is one of the most common causes of knee pain in young people and can be classified using several systems:

• Outerbridge Classification:
  • Grade 0: Normal cartilage
  • Grade 1: Cartilage softening and swelling
  • Grade 2: Fragmentation and fissuring involving area <1.5 cm in diameter
  • Grade 3: Fragmentation and fissuring involving area >1.5 cm in diameter
  • Grade 4: Loss of cartilage and exposed subchondral bone 3

Conservative Management Approach

First-Line Treatment Options

• Physical Therapy: The cornerstone of initial treatment with a success rate of 82% in athletes 4

  • Closed Kinetic Chain Exercises (e.g., semi-squats) are superior to open kinetic chain exercises in:
    • Reducing Q angle
    • Decreasing crepitation
    • Increasing quadriceps strength
    • Increasing thigh circumference 1

• Activity Modification: Reducing activities that aggravate symptoms while maintaining overall fitness 4

• Pain Management:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation control 4
  • Ice application after activity to reduce inflammation 4

Progressive Treatment Options

• Perineural Injection Treatment (PIT): When combined with physical therapy, PIT has shown superior outcomes compared to physical therapy alone in:
  • Pain reduction
  • Decreased stiffness
  • Improved functional capacity 5

Treatment Algorithm

1. Initial 6-week trial of conservative management:

   • Closed kinetic chain exercises (semi-squats) starting with 20 exercises twice daily, increasing by 5 exercises every 2 days 1
   • Activity modification to avoid aggravating activities 4
   • Ice application after exercise 4

2. If inadequate improvement after 6 weeks:

   • Consider adding Perineural Injection Treatment (PIT) while continuing physical therapy 5

3. For persistent symptoms after 6 months of conservative management:

   • Consider arthroscopic evaluation and potential surgical intervention 6
   • Arthroscopic options include lavage, shaving, and lateral release depending on the underlying pathology 6

Important Considerations

• Arthroscopic surgery should only be considered after failure of an adequate trial of conservative management, with only about 18% of patients requiring surgical intervention 4

• Different arthroscopic approaches may be more effective depending on the etiology:

  • Lavage produces early remission in all groups
  • Shaving offers particular advantage in post-traumatic cases
  • Lateral release plus shaving benefits patients with maltracking patellae 6

• Stem cell injections are not currently recommended for cartilage regeneration in osteoarthritis according to American College of Rheumatology/Arthritis Foundation guidelines due to concerns regarding heterogeneity and lack of standardization 7

• Long-term monitoring is important as chondromalacia may progress to osteoarthritis if not properly managed 3