What is the recommended management for a 23‑year‑old female professional footballer with a 3‑day knee effusion, intact posterior cruciate ligament and other ligaments, and a central patellar chondral lesion measuring 3 mm craniocaudal × 10 mm transverse, involving 25 % of cartilage thickness with low‑grade subchondral edema?

Management of Patellar Chondral Surface Injury in a Professional Footballer

This 23-year-old professional footballer with a partial-thickness patellar chondral delamination (25% depth, 3×10 mm) and intact basal layer should undergo initial conservative management with structured physical therapy, activity modification, and NSAIDs, followed by arthroscopic assessment and bioabsorbable pin fixation if symptoms persist beyond 6-8 weeks, as this approach preserves the intact articular surface and prevents progression to full-thickness defects. 1, 2

Initial Conservative Management (First 6-8 Weeks)

Conservative treatment should be attempted first for this partial-thickness lesion with intact basal layer, though it serves primarily as a temporizing measure. 1 The key goals are to relieve clinical symptoms, obtain painless full range of motion and muscle strength, and improve function without increasing cartilage degeneration. 3

Pharmacological Management

• Start with NSAIDs as first-line analgesic for pain control and inflammation management, as paracetamol efficacy is uncertain and likely small in chondral injuries. 1
• NSAIDs should be used cautiously with awareness of gastrointestinal and cardiovascular risks with prolonged use. 1

Activity Modification and Load Management

• Immediate cessation of high-impact football activities including running, cutting, and jumping movements that generate patellofemoral compression with shear stress. 3
• The early rehabilitation stage (0-6 weeks) should comprise passive, active-assistive, and non-weight bearing range of motion exercises, as exposing healing cartilage to shear stress under compression has adverse effects on the healing process. 3

Bracing

• Patellofemoral bracing is conditionally recommended for significant impact on ambulation, joint stability, or pain, requiring clinician expertise in fitting. 1
• Kinesiotaping can be used as an adjunct for knee joint involvement. 1

Physical Therapy Protocol

• Focus on improving sensorimotor function and decreasing pain without increasing cartilage degeneration. 3
• Structured rehabilitation protocol is essential, though no high-quality evidence demonstrates that specific exercise programs improve outcomes compared with natural course. 4
• Progress from passive range of motion to active-assistive exercises before advancing to strengthening. 3

Surgical Intervention Criteria and Timing

Surgical intervention should be considered if conservative management fails after 6-8 weeks or if the athlete has persistent effusion, mechanical symptoms, or inability to return to sport-specific activities. 1, 4

Indications for Arthroscopic Surgery

• Persistent symptoms despite 6-8 weeks of conservative treatment 1
• Ongoing joint effusion (present in this case) 5
• Mechanical symptoms suggesting unstable cartilage 2
• Inability to progress in rehabilitation or return to sport 6

Surgical Technique for Partial-Thickness Delamination

For this specific lesion (partial-thickness delamination with intact basal layer and intact articular surface), bioabsorbable pin fixation is the preferred technique to salvage the delaminated cartilage and prevent progression to full-thickness defects. 2

Arthroscopic Assessment

• The delaminated area is easily recognized at arthroscopy by its bogginess on probing. 2
• Assess the quality of the overlying cartilage and extent of delamination. 2

Fixation Technique

• Bioabsorbable pin fixation allows the cartilage to be salvaged and optimizes patient outcomes by avoiding deterioration to full-thickness chondral lesion once the articular surface separates. 2
• This technique is superior to debridement for partial-thickness lesions with intact surface, as it preserves the hyaline cartilage. 2, 6

Alternative: Transosseous Suture Fixation

• If the delaminated fragment is extensive (>2.7 cm²), transosseous PDS sutures provide very good results without necessity of hardware removal surgery. 6
• This method is more appropriate than screws as it avoids a second surgery for hardware removal. 6

When NOT to Use Microfracture

Microfracture is NOT indicated for this lesion because:

• The basal layer is intact (microfracture requires exposed subchondral bone) 7, 1
• The lesion is partial-thickness, not full-thickness 1
• Microfracture is only appropriate for contained, full-thickness defects <4 cm² with minimal osteoarthritis 1, 4

Postoperative Rehabilitation After Surgical Fixation

Early Phase (0-6 Weeks)

• Passive and active-assistive range of motion exercises without weight-bearing to avoid shear stress on healing cartilage. 3
• Restriction in weight-bearing is recommended for all cartilage repair procedures except debridement. 3
• The rehabilitation program should be modified depending on the surgical procedure, considering estimated healing time and extent of pain and effusion. 3

Progressive Loading Phase (6-12 Weeks)

• Gradual progression to weight-bearing as tolerated based on lesion size, nature, and location. 3
• Advance to closed-chain strengthening exercises. 3

Return to Sport Phase (3-6 Months)

• Sport-specific training progression only after achieving full painless range of motion and adequate strength. 3
• For professional athletes, return to pre-injury activities occurs in 72-82% of patients with cartilage fixation versus 69% with debridement alone. 6

Critical Pitfalls to Avoid

Do NOT Perform Simple Debridement

• Debridement alone results in inferior outcomes (mean Kujala score 78.5, IKDC 74.3) compared to cartilage fixation (Kujala 89.3, IKDC 87.2). 6
• Debridement converts a salvageable partial-thickness lesion into a full-thickness defect. 2

Do NOT Use Stem Cell Injections

• The American College of Rheumatology/Arthritis Foundation does not recommend stem cell injections for cartilage regeneration due to concerns regarding heterogeneity and lack of standardization. 1, 4

Do NOT Delay Surgical Intervention if Conservative Treatment Fails

• Untreated delaminated cartilage may progress to full-thickness defects once the articular surface separates, requiring more complex interventions. 2
• Chondromalacia may progress to osteoarthritis if not properly managed, requiring long-term monitoring. 1

Prognosis and Return to Elite Sport

With appropriate surgical fixation of the delaminated cartilage, this athlete has an excellent prognosis for return to professional football. 2 All three patients in the bioabsorbable pin fixation series made excellent recovery with healed lesions on MRI. 2

The mean follow-up outcomes for cartilage fixation show:

• Kujala score: 89.3 6
• IKDC score: 87.2 6
• Return to pre-injury activities: 82% 6
• No patellar re-dislocation events 6

Regular monitoring for symptom recurrence or progression is essential, as long-term monitoring is important given that chondromalacia may progress to osteoarthritis if not properly managed. 1