What is the recommended treatment for a patient with mild-to-moderate chondromalacia (cartilage softening) involving the right hip?

Treatment of Mild-to-Moderate Chondromalacia of the Right Hip

For mild-to-moderate chondromalacia of the hip, initiate physical therapy as first-line treatment, combined with oral NSAIDs (when not contraindicated), and consider acetaminophen for pain control. 1

Initial Conservative Management Algorithm

First-Line Therapy (Start Here)

• Physical therapy is the cornerstone intervention with high-quality evidence supporting its use specifically for mild-to-moderate symptomatic hip pathology 1
• Oral NSAIDs at the lowest effective dose represent the strongest recommendation (high quality evidence, strong strength) when not contraindicated 1
• Acetaminophen up to 4g/day may be added as the preferred long-term oral analgesic for mild-moderate pain due to its safety profile 1

Second-Line Options if Initial Therapy Inadequate

• Intra-articular corticosteroid injection (guided by ultrasound or fluoroscopy) can be considered with moderate strength recommendation for symptomatic relief 1
• This provides both diagnostic confirmation and therapeutic benefit 2, 3

What NOT to Do

• Do not use intra-articular hyaluronic acid - this has high quality evidence with strong recommendation AGAINST its use in hip pathology 1
• Avoid opioids - consensus evidence recommends against their use for symptomatic hip osteoarthritis 1

Surgical Considerations for Focal Chondral Defects

If conservative management fails after adequate trial (typically 3-6 months) and imaging confirms focal cartilage damage:

Joint-Preserving Surgery (Age ≤50 years preferred)

• Microfracture is indicated for contained lesions <4 cm² with minimal osteoarthritis (Tönnis grade ≤1) 1, 4
• The procedure involves debridement of friable cartilage, creating perpendicular edges, then using an awl to create 3-4mm deep holes spaced 3-4mm apart in subchondral bone to stimulate fibrocartilage formation 1
• For lesions 2-6 cm²: microfracture remains first-line for acetabular lesions; consider mosaicplasty or single-plug osteochondral allograft for femoral head lesions 4
• For lesions >6 cm²: conversion to total hip arthroplasty should be considered in appropriate candidates 4

Classification Guides Treatment Decisions

The Outerbridge Classification system stratifies severity 1, 4:

• Grade 1: Cartilage softening and swelling - conservative management
• Grade 2: Fragmentation/fissuring <1.5 cm diameter - conservative management, consider surgery if refractory
• Grade 3: Fragmentation/fissuring >1.5 cm diameter - surgical candidates if conservative fails
• Grade 4: Full-thickness loss with exposed bone - typically requires arthroplasty

Critical Clinical Pitfalls

Do Not Miss These Red Flags

• Screen for referred pain from lumbar spine or sacroiliac joint - a comprehensive examination must include spine and pelvic evaluation, as these commonly refer pain to the hip region 2
• Always obtain plain radiographs first (AP pelvis and lateral hip) before advanced imaging to assess for osteoarthritis, dysplasia, or fractures 2
• Never diagnose based on imaging alone - incidental findings are common in asymptomatic individuals; clinical correlation is essential 2

Patient Education and Optimization

• Educate patients on modifiable risk factors: obesity, poor glycemic control (if diabetic), and nicotine use all increase surgical complications if arthroplasty becomes necessary 1
• Weight reduction is recommended if overweight or obese as part of non-pharmacological treatment 1
• Provide resources for risk factor modification early, as not all patients have medical, financial, or social support to modify these factors later 1

When to Refer for Surgical Evaluation

Consider orthopedic referral when:

• Pain and disability persist despite ≥3 months of appropriate conservative therapy (physical therapy, NSAIDs, and/or intra-articular injections) 1
• Radiographic evidence shows moderate-to-severe osteoarthritis with refractory symptoms 1
• Young patients (<50 years) with focal defects and preserved joint space who are candidates for joint-preserving procedures 1
• Progressive bone loss, deformity, or severe ligamentous instability develops - delaying surgery in these cases increases technical difficulty and revision risk 1

The key distinction: Mild-to-moderate chondromalacia without advanced osteoarthritis should be managed conservatively with the algorithm above, reserving surgery for focal defects in young patients or progression to end-stage disease requiring arthroplasty. 1