What is the best management approach for a patient with chondromalacia patellae?

Management of Chondromalacia Patellae

Conservative management with quadriceps strengthening exercises, particularly closed kinetic chain exercises like semi-squats, should be the initial and primary treatment for chondromalacia patellae, with at least 6 weeks of supervised physical therapy required before considering any surgical intervention. 1, 2

Initial Conservative Management (First-Line Treatment)

Exercise Therapy

• Closed kinetic chain exercises (semi-squats) are superior to open kinetic chain exercises (straight leg raises) for treating chondromalacia patellae, demonstrating significantly reduced Q angle, decreased crepitation, increased quadriceps strength, and improved thigh circumference 2
• Start with 20 exercises twice daily, increasing by 5 exercises every 2 days over a 3-week program 2
• All patients must complete and document at least 6 weeks of supervised physical therapy with objective documentation of compliance and failure before surgical intervention is considered 1
• Arthro-muscular rehabilitation should be regarded as the principle task, avoiding polypragmasy (excessive multiple treatments) 3

Pharmacological Management

• Paracetamol (acetaminophen) is the preferred first-line oral analgesic for pain control, though efficacy is uncertain and likely small 4, 5
• NSAIDs can be used when paracetamol is insufficient, but long-term use carries gastrointestinal and cardiovascular risks 4
• Tramadol (with or without paracetamol) is an alternative when NSAIDs are contraindicated 5

Adjunctive Therapies

• Chondroitin sulfate (800-1200 mg daily) may provide symptomatic relief with a favorable safety profile compared to long-term NSAIDs 5
• Glucosamine and chondroitin are safe with mild and infrequent adverse effects, making them safer alternatives to long-term NSAID use 5

Bracing and Orthoses

• Patellofemoral braces are conditionally recommended for patients with patellofemoral knee osteoarthritis causing significant impact on ambulation, joint stability, or pain 4
• Kinesiotaping is conditionally recommended for knee joint involvement 4
• Optimal management with bracing requires clinician familiarity with various brace types and expertise in fitting 4

Surgical Management (After Failed Conservative Treatment)

Indications for Surgery

Surgery should only be considered after persistent patellofemoral pain following at least 6 months of conservative management 6

Arthroscopic Treatment Options

For patients with minimal osteoarthritis (Tönnis grade ≤1):

Based on Lesion Size (Outerbridge Classification)

• Grade 1 (cartilage softening and swelling): Continue conservative management 1
• Grade 2 (fragmentation and fissuring <1.5 cm diameter): Arthroscopic lavage and/or shaving 1, 6
• Grade 3 (fragmentation >1.5 cm diameter): Consider microfracture for contained, full-thickness defects 1
• Grade 4 (exposed subchondral bone): May require more advanced cartilage restoration techniques 1

Specific Surgical Techniques

• Arthroscopic lavage produces early remission in all patient groups and has minimal morbidity 6
• Arthroscopic shaving offers particular advantage in post-traumatic cases 6
• Lateral release plus shaving and lavage is beneficial for patients with maltracking patellae and approximately half of idiopathic cases 6
• Arthroscopic chondroplasty demonstrates 78% patient satisfaction with excellent/good results in 49% of cases at 40-month follow-up 7

Important Surgical Considerations

• Age, sex, grade of lesion, and duration of symptoms prior to surgery do not correlate with final surgical results 7
• Restraint is advised regarding operative treatment, as 81% of conservatively treated patients have mild or no pain at 12-year follow-up compared to only 57% of those undergoing partial chondrectomy 8
• Results are better for patients aged 20 years or younger 8

Common Pitfalls to Avoid

• Do not proceed directly to surgery without documented failure of at least 6 weeks of supervised conservative therapy 1
• Avoid polypragmasy (using multiple simultaneous treatments without clear benefit) in conservative management 3
• Do not use stem cell injections, as they are not recommended due to heterogeneity and lack of standardization 1, 9
• Lateral release for unstable patellae produces good results in only 25% of patients, so careful patient selection is critical 6

Long-Term Monitoring

Long-term monitoring is important as chondromalacia may progress to osteoarthritis if not properly managed 1