Initial Treatment for Chondromalacia Patellae
Begin with a structured exercise therapy program focused on progressive quadriceps strengthening, particularly using closed kinetic chain exercises like semi-squats, combined with patient education and patellar taping for immediate symptom relief. 1
First-Line Treatment: Exercise Therapy
Quadriceps strengthening is the cornerstone of initial management, with high certainty evidence demonstrating short-term pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19). 1
Exercise Protocol Specifics
Prioritize closed kinetic chain exercises (semi-squats) over open kinetic chain exercises (straight leg raises), as semi-squats demonstrate superior outcomes including reduced Q angle, decreased crepitation, increased quadriceps strength, and improved thigh circumference compared to straight leg raises. 2
Start with 20 exercises twice daily, increasing by 5 repetitions every 2 days over a minimum 3-week period, as this progressive loading protocol has demonstrated effectiveness. 2
Include both hip-and-knee-targeted exercises, modifying task intensity, load, and frequency based on individual pain response. 1
Expect recovery to take several months, not weeks—patients must understand this timeline to maintain compliance and avoid premature discontinuation of therapy. 1
Immediate Adjunctive Interventions
Patellar Taping
- Apply medially directed patellar taping for short-term pain relief and improved function (Grade B recommendation), which provides immediate symptomatic benefit while exercise therapy takes effect. 1
Patient Education
Education is not optional—it must underpin all interventions and should specifically address: 1
- Clear explanation of the diagnosis and realistic recovery timeline
- Guidance on activity modification and load management
- Critical reassurance that pain does not equal tissue damage—this reduces fear-avoidance behavior
- Building confidence and reducing kinesiophobia (fear of movement)
Secondary Supportive Measures
Foot Orthoses
- Consider prefabricated foot orthoses for patients who respond favorably to treatment direction tests, though this is not first-line for all patients. 1
Patellofemoral Bracing
- Patellofemoral braces may provide subjective improvements by resisting lateral patellar displacement, particularly useful during the initial treatment phase. 1
Range of Motion Work
- Flexibility and range-of-motion exercises are optional additions to address specific impairments (Level V evidence, Grade C recommendation). 1
Critical Pitfalls to Avoid
Do not use lateral heel wedges—they have limited evidence for effectiveness and may actually worsen symptoms. 1
Avoid complete rest or immobilization—relative rest is appropriate (avoiding activities that significantly worsen pain), but complete cessation of activity leads to quadriceps atrophy and deconditioning. 3
Conservative Management Success Rate
Conservative management succeeds in approximately 82% of patients when properly implemented, with only 8-18% ultimately requiring surgical intervention after adequate conservative trial. 4 This high success rate reinforces the importance of exhausting conservative options before considering surgery.
When to Reassess
If patients fail to show improvement after 6 months of appropriate conservative management, reassessment is warranted, though this represents a minority of cases. 5 The key is ensuring the conservative program was truly "appropriate"—meaning progressive exercise therapy was performed consistently with proper technique and adequate duration.