What is the recommended treatment for a 72-year-old male with early hypertrophic changes of the posterior superior margin of the patella, presenting with pain and instability in the left knee?

Treatment for Early Hypertrophic Changes of the Posterior Superior Patella with Pain and Instability

Start with knee-targeted exercise therapy combined with education as your primary treatment—this is the foundation of management for patellofemoral pathology in this patient. 1

Initial Conservative Management Framework

Exercise Therapy (Primary Treatment)

• Implement knee-targeted strengthening exercises immediately, focusing on quadriceps strengthening with both open and closed chain exercises 1, 2
• Progress load intensity based on pain response and tissue tolerance 1
• Consider adding hip-and-knee-targeted exercise therapy if the patient demonstrates poor tolerance to loaded knee flexion or shows hip muscle weakness on examination 1
• Eccentric strengthening exercises specifically reduce symptoms, increase strength, and promote tissue healing by stimulating collagen production 3, 2

Pain Management

• Use paracetamol (acetaminophen) as first-line oral analgesic for this 72-year-old patient, as it is the preferred long-term option given his age and likely comorbidities 1
• Add topical NSAIDs for additional pain relief—these eliminate gastrointestinal hemorrhage risk compared to oral NSAIDs, which is particularly important in elderly patients 1, 2
• Apply cryotherapy (ice through wet towel for 10-minute periods) for acute pain episodes 3, 2

Education Component

• Explain that pain does not correlate with structural damage—the radiographic findings show only early changes 1, 2
• Address any fear avoidance behaviors, particularly regarding instability symptoms 1
• Set realistic expectations: most patients with appropriate conservative treatment show significant improvement within 3-6 months 3
• Emphasize that this represents chronic degenerative change rather than acute inflammation 2

Supporting Interventions Based on Examination Findings

If Weakness is Present

• Objectively assess hip and knee muscle strength 1
• Evaluate movement patterns during single-leg squat 1
• Prioritize hip strengthening if poor tolerance to loaded knee flexion exists 1

If Mechanical Factors Contribute

• Consider prefabricated foot orthoses if treatment direction tests are favorable (have patient squat with/without orthoses to assess immediate response) 1
• These provide short-term benefit and can be customized for comfort 1
• Medially directed patellar taping may provide short-term pain relief and improved function 2

Manual Therapy Adjunct

• Deep transverse friction massage reduces pain and provides additional benefit when combined with exercise 3, 2

What NOT to Do

Avoid Arthroscopic Surgery

• Do not refer for arthroscopic debridement—there is strong evidence against arthroscopic surgery for degenerative knee disease in patients over 35 years old 1
• Arthroscopy provides no sustained benefit beyond 3 months and does not improve long-term pain or function compared to conservative management 1
• The patient's age (72), degenerative findings, and absence of acute trauma make him a poor surgical candidate 1

Avoid Corticosteroid Injections

• Never inject corticosteroids into tendon substance—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 3
• Intra-articular corticosteroid injection may be considered only if there is joint effusion (which this patient does not have) 1

Avoid Complete Rest

• Do not immobilize—this causes muscular atrophy and deconditioning 3, 2
• Instead, implement relative rest by reducing activities that reproduce pain while maintaining general activity 3, 2

Clinical Pitfalls to Avoid

• The "instability" symptom requires careful evaluation—assess for true mechanical instability versus subjective instability from pain/weakness 1
• The posterior superior patellar location is unusual for typical patellar tendinopathy (which affects inferior pole), so ensure symptoms correlate with imaging findings 3
• If multiple tendons become symptomatic, evaluate for underlying rheumatic disease 3

When to Escalate Treatment

• Reassess at 3 months—if no improvement with comprehensive conservative management, consider advanced imaging (MRI) to evaluate for other pathology 2
• Surgery should only be considered after 3-6 months of failed conservative therapy, and only if pain significantly affects quality of life 3, 2, 4
• Given the patient's age and early radiographic changes, surgical intervention would be exceptionally rare and reserved for refractory cases 1, 4

Expected Outcome

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 3
• Conservative management (exercise therapy, pain management, education) has good long-term outcomes and avoids surgical risks 1