How to manage moderate patellar chondropathy?

Management of Moderate Patellar Chondropathy

Begin with a structured exercise program focused on quadriceps strengthening combined with patient education, as this forms the cornerstone of conservative management for patellar chondropathy and has the strongest evidence for reducing pain and improving function. 1

Initial Conservative Management

Exercise Therapy (First-Line Treatment)

• Quadriceps strengthening exercises are the primary intervention, with evidence showing significant pain reduction (effect size 1.05) and functional improvement in knee pathology 1
• Eccentric exercises specifically reduce symptoms, increase strength, and promote healing in patellar conditions 1
• Both joint-specific strengthening and aerobic fitness training demonstrate equal efficacy over 18 months, with sustained improvements lasting 6-18 months 1
• Exercise programs do not require continuous professional supervision once properly instructed, making them practical for long-term management 1

Patient Education

• Provide structured education about the condition's nature, expected course, and activity modification strategies 1
• Education has Level 1A evidence for pain reduction and improving coping skills in knee pathology 1
• Emphasize active interventions over passive treatments to promote patient empowerment 2

Activity Modification

• Advise temporary reduction of aggravating activities (stair climbing, prolonged sitting) while maintaining overall activity levels 1
• Implement load monitoring to prevent symptom exacerbation during rehabilitation 3

Pharmacological Interventions

Pain Management Algorithm

1. Start with paracetamol (acetaminophen) up to 4,000 mg/day as the first-line oral analgesic 1, 4
2. If paracetamol is insufficient, add topical NSAIDs before considering oral NSAIDs 1
3. Oral NSAIDs or COX-2 inhibitors should be used at the lowest effective dose for the shortest duration, with proton pump inhibitor co-prescription 1
4. Avoid glucosamine and chondroitin as they lack evidence for clinically important outcomes in knee pathology 1

Adjunctive Therapies

• Deep transverse friction massage is recommended for pain reduction in patellar conditions 1
• Patellar taping can provide immediate pain relief and should be considered early to gain patient trust 2
• Corticosteroid iontophoresis is effective for patellar pain and function 1

Physical Therapy Referral

Refer to physiotherapy as a mainstay of treatment for supervised exercise prescription and manual therapy 1

• Manual therapy (manipulation and stretching) provides additional benefit when combined with exercise 1
• Physiotherapy offers added benefit even when patients are already using analgesics 1

Weight Management

• Recommend weight reduction if BMI ≥25 kg/m² to reduce joint loading 1
• Weight loss reduces the risk of symptomatic knee pathology progression, particularly in women 1

Interventions NOT Recommended

• Hyaluronic acid injections are not recommended despite some evidence, due to small effect size and unclear patient selection criteria 1
• Acupuncture lacks sufficient evidence for recommendation 1
• Lateral wedge insoles are not suggested for patellar pathology 1

Common Pitfalls to Avoid

• Do not rely solely on passive treatments (injections, modalities) without incorporating active exercise rehabilitation 2
• Avoid premature surgical referral before exhausting conservative options, as most patients improve with structured rehabilitation 1, 5
• Do not prescribe prolonged rest, as this compromises outcomes; maintain modified activity instead 5, 6
• Ensure patient compliance with ongoing rehabilitation, as non-compliance is a major factor in treatment failure 6

Monitoring and Follow-up

• Reassess pain and function at 1,3, and 6 months to evaluate treatment response 7, 3
• Expect gradual improvement over 3-6 months with consistent exercise adherence 3, 5
• Consider surgical consultation only if there is refractory pain with substantial quality of life impact despite 6+ months of comprehensive conservative management 1