Management of Chondromalacia Patella
Conservative management with quadriceps strengthening exercises, specifically closed kinetic chain exercises (semi-squats), should be the first-line treatment for chondromalacia patella, with arthroscopic intervention reserved only for patients who fail to respond after 6 months of conservative therapy. 1, 2
Initial Conservative Management (First 6 Months)
Conservative treatment is highly effective, with success rates of 82% in athletes and should be attempted before any surgical consideration. 2
Exercise Prescription
- Closed kinetic chain exercises (semi-squats) are superior to open kinetic chain exercises (straight leg raises) for treating chondromalacia patella. 1
- Start with 20 semi-squat exercises twice daily, increasing by 5 repetitions every 2 days over a 3-week period. 1
- Semi-squat exercises produce significantly greater improvements in Q angle reduction, decreased crepitation, increased quadriceps strength, and increased thigh circumference compared to straight leg raises. 1
Adjunctive Conservative Measures
- NSAIDs for pain and inflammation control are recommended as part of initial management. 3
- Perineural Injection Treatment (PIT) with dextrose combined with home physical therapy demonstrates superior outcomes compared to physical therapy alone, with significant improvements in pain (7.3 vs 3.2 points), stiffness (3 vs 1.6 points), and functional capacity (23.2 vs 11.1 points) at 6 months. 4
- Diagnostic intra-articular anesthetic and steroid injections can serve both diagnostic and therapeutic purposes. 3
Classification and Prognostic Assessment
Use the Outerbridge Classification to grade severity and guide treatment decisions: 5
- Grade 0: Normal cartilage
- Grade 1: Cartilage softening and swelling
- Grade 2: Fragmentation and fissuring <1.5 cm diameter
- Grade 3: Fragmentation and fissuring >1.5 cm diameter
- Grade 4: Complete cartilage loss with exposed subchondral bone
Surgical Management (After Failed Conservative Treatment)
Arthroscopic intervention should only be considered after 6 months of failed conservative management. 6, 2, 7
Surgical Options Based on Lesion Size
For lesions <2 cm²:
- Arthroscopic lavage produces early remission in all patient groups. 6
- Arthroscopic shaving (chondroplasty) offers particular advantage in post-traumatic cases, with 78% patient satisfaction at 40-month follow-up. 6, 7
- Microfracture for contained, full-thickness defects in patients with minimal osteoarthritis (Tönnis grade ≤1). 8
For lesions 2-6 cm²:
- Microfracture remains first-line for acetabular lesions. 8
- Mosaicplasty or single-plug osteochondral allograft for femoral head lesions. 8
For lesions >6 cm²:
- Consider conversion to total hip arthroplasty in appropriate candidates. 8
Specific Surgical Techniques by Etiology
- Post-traumatic chondromalacia: Shaving provides particular benefit. 6
- Maltracking patellae: Lateral release plus shaving and lavage is beneficial. 6
- Unstable patellae: Lateral release produces good results in only 25% of patients, requiring more comprehensive surgical planning. 6
Critical Pitfalls to Avoid
- Do not recommend stem cell injections for cartilage regeneration, as the American College of Rheumatology/Arthritis Foundation explicitly advises against this due to lack of standardization and low-quality evidence. 5, 3
- Do not proceed to surgery prematurely—only 8% of patients ultimately require surgical intervention after adequate conservative trial. 2
- Do not use open kinetic chain exercises (straight leg raises) as primary therapy when closed kinetic chain exercises are available and proven superior. 1
Long-Term Monitoring
- Regular monitoring is essential as chondromalacia may progress to osteoarthritis if not properly managed. 5
- Continue surveillance for symptom recurrence or progression even after successful initial treatment. 3
- Arthroscopic chondroplasty results show 49% excellent-to-good outcomes at 40-month follow-up, indicating the need for ongoing assessment. 7