How to manage grade 3 chondromalacia of the medial patellar facet and a peripheral tear of the posterolateral bundle of the tibial attachment of the Anterior Cruciate Ligament (ACL)?

From the Guidelines

Management of grade 3 chondromalacia of the medial patellar facet and a peripheral tear of the posterolateral bundle of the ACL's tibial attachment should prioritize a comprehensive approach focusing on conservative treatment, including physical therapy and activity modification, before considering surgical options. The primary goal is to alleviate symptoms, improve function, and prevent further joint degeneration.

Conservative Management

Conservative treatment should include:

• Physical therapy focusing on quadriceps and hamstring strengthening, particularly vastus medialis obliquus exercises to improve patellar tracking, as recommended by 1
• A regimen of 3 sets of 10-15 repetitions of straight leg raises, terminal knee extensions, and mini-squats, performed daily for 6-8 weeks
• Pain management with NSAIDs such as ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks, along with ice application for 15-20 minutes every 2-3 hours during acute pain phases
• Activity modification to avoid high-impact activities, deep squatting, and prolonged sitting with bent knees

Surgical Considerations

If conservative measures fail after 3-6 months, surgical options may be considered:

• Arthroscopic debridement for the chondromalacia
• ACL repair or reconstruction depending on tear severity and patient activity level, with the consideration of immediate weight bearing as tolerated if there is a correct gait pattern and no pain, effusion, or increase in temperature when walking or shortly after walking, as suggested by 1

Rehabilitation

Postoperative rehabilitation should follow a structured program:

• Continue rehabilitation for 9–12 months, depending on the final return-to-work or play goals of the patient, as recommended by 1
• Include isometric quadriceps exercises from the first postoperative week, progressing to concentric and eccentric exercises as tolerated
• Incorporate neuromuscular training to optimize self-reported outcome measurements and prevent reinjuries, as emphasized by 1

Return to Play

Criteria for return to play should include an extensive test battery assessing quantity and quality of movement, with a recommended Limb Symmetry Index (LSI) of >90%, and consideration of an LSI of 100% for pivoting/contact sports, as suggested by 1

From the Research

Managing Grade 3 Chondromalacia and ACL Injury

To manage grade 3 chondromalacia of the medial patellar facet and a peripheral tear of the posterolateral bundle of the tibial attachment of the Anterior Cruciate Ligament (ACL), consider the following approaches:

• For grade 3 chondromalacia, patellar tendon transfer is recommended in adolescents and athletes, as it achieved a 60% satisfactory result in a study 2.
• In adults over twenty years of age with grade 3 changes, patellectomy is the treatment of choice, with 77% satisfactory results 2.
• For partial tears of the ACL, conservative treatment is optional for cases without instability, with a focus on motor rehabilitation 3, 4.
• Surgical treatment for ACL tears is a challenge and requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle 3.
• Osteochondral autografts (OAT) can be a good alternative to treat high-grade patellar chondral defects, especially among young patients, with good and excellent results regarding symptoms and activity levels 5.

Treatment Considerations

When deciding on a treatment approach, consider the following factors:

• The extent of the ACL injury and the activity level of the patient 4.
• The presence of concomitant injuries, such as meniscus and/or cartilage damage 6.
• Patient-specific factors, such as age and overall health 6.
• The results of imaging examinations, such as magnetic resonance imaging (MRI), and arthroscopic appearance 3, 5.