What is the recommended treatment for a patient with chondromalacia patellae?

Treatment for Chondromalacia Patellae

Begin with a structured 3-6 month trial of eccentric quadriceps strengthening exercises combined with relative rest, as this conservative approach achieves complete recovery in approximately 80% of patients and should be exhausted before considering any surgical intervention. 1, 2

Initial Conservative Management (First 3-6 Months)

Exercise Therapy - The Cornerstone

• Implement eccentric strengthening exercises as your primary intervention, targeting the quadriceps and surrounding muscle groups at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets, performed 2-3 days per week with at least 48 hours rest between sessions 1
• Closed kinetic chain exercises (semi-squats) are superior to open kinetic chain exercises (straight leg raises) for reducing Q angle, decreasing crepitation, and increasing quadriceps strength 3
• Progress resistance and repetitions gradually as strength improves, ensuring pain doesn't significantly worsen during or after exercise 1
• Include stretching exercises for quadriceps and hamstrings 2-3 days per week, holding static stretches for 10-30 seconds after warming muscles with light aerobic activity 1

Activity Modification

• Reduce repetitive loading activities that reproduce pain (jumping, stair navigation, prolonged sitting) while avoiding complete immobilization, which causes muscular atrophy and deconditioning 1, 2
• Maintain low-impact aerobic activities like walking or cycling for 30-60 minutes on most days to support cardiovascular fitness and tendon health 1

Pain Management

• Use topical NSAIDs preferentially over oral NSAIDs to eliminate gastrointestinal hemorrhage risk while providing short-term pain relief, though neither affects long-term outcomes 1, 4
• Apply cryotherapy through a wet towel for 10-minute periods for acute pain relief 1, 4
• Consider acetaminophen up to 4,000 mg/day if NSAIDs are contraindicated, counseling patients to avoid other acetaminophen-containing products 5

Adjunctive Therapies

• Apply medially directed patellar taping for short-term relief when elevated symptom severity hinders rehabilitation 5, 1, 4
• Incorporate deep transverse friction massage in combination with supervised exercise for additional pain reduction 1, 4

Patient Education - Critical Component

• Explain that chondromalacia represents chronic tendinosis rather than acute inflammation, and that pain doesn't necessarily correlate with tissue damage 1, 4
• Set realistic expectations: approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1, 4
• For overweight patients, strongly recommend weight loss counseling as this improves outcomes 5

When Conservative Treatment Fails After 3-6 Months

Reassessment

• If favorable outcomes are not observed after a realistic 3-6 month trial period, reassess the intervention strategy before proceeding to more invasive options 1
• Confirm diagnosis with ultrasonography (94% specificity) or MRI (78% sensitivity, 86% specificity) if not already performed 1

Advanced Conservative Options

• Consider intraarticular corticosteroid injections for pain relief, but never inject directly into the tendon substance as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 1, 4
• Extracorporeal shock wave therapy is a safe, noninvasive option for chronic cases 4

Surgical Management - Last Resort

Surgery is justified only after 3-6 months of well-managed conservative treatment has failed and the patient continues to experience significant pain affecting quality of life or inability to return to desired activity level 1, 4, 2

Surgical techniques include:

• Open or arthroscopic excision of abnormal tendinous tissue 1, 2
• Longitudinal tenotomies to release areas of scarring and fibrosis 1, 2
• Modified tibial tubercle osteotomy for well-aligned patellofemoral joints when conservative measures have failed, with 72% good or excellent patient satisfaction at 5 years 6

Critical Pitfalls to Avoid

• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment - natural history studies show 81% of conservatively treated patients have mild or no pain at 12 years versus only 57% of those who underwent surgery 7
• Avoid multiple corticosteroid injections as they weaken tendon structure despite short-term symptom relief 1, 4
• Never completely immobilize the knee as this causes muscular atrophy and deconditioning 1
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease 1

Expected Outcomes

• With appropriate conservative treatment, approximately 80% of patients recover completely within 3-6 months 1, 4
• Younger patients (≤20 years) have better outcomes than older patients 7, 6
• Patients with lowest pre-operative function scores benefit most from surgical intervention if it becomes necessary 6