Chondromalacia patella dnbid lecture 2012

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Chondromalacia Patellae:

Chondromalacia Patellae Dr. Dibyendunarayan Bid [PT] Sarvajanik College of Physiotherapy, Rampura, Surat

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Chondromalacia literally means "softening of the cartilage", and Patellae means "the knee-cap". So Chondromalacia patellae means "softening of the articular cartilage of the knee-cap." Under normal circumstances, it is smooth and shiny, so that it glides smoothly along the articular groove of the femur as the knee bends. When it "softens", it may break down, causing irregularities along the undersurface of the patella.


Causes Chondromalacia patellae occurs in two distinct age-groups: It can happen in the older age-group (in the 40’s and beyond) when the articular cartilage breaks down as part of the wear-and-tear process that occurs with the rest of the body. The patella cartilage is one of the earliest places where cartilage breakdown occurs, and is slowly progressive, leading to degenerative arthritis (osteoarthritis) in the knee joint.

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It can occur frequently in teenagers (especially girls) when the articular cartilage "softens" in response to excessive and uneven pressure on the cartilage, due to structural changes in the legs with rapid growth, and muscle imbalance around the knee. During periods of rapid growth, especially in girls, any knee valgus (knock-knees) is accentuated, thereby increasing the Q-angle.

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Any flexion of the knee increases the tendency of the patella to dislocate. Undue pressure is placed on the lateral facet of the patella. Moreover, in many of these teenagers, the vastus lateralis and vastus medialis components of the Quadriceps muscle are not well-balanced. The vastus lateralis tends to be more powerful than the vastus medialis, thus increasing the tendency for the patella to track or dislocate laterally. This again puts undue pressure on the lateral facet. This uneven and excessive pressure on the lateral facet of the patella leads to cartilage "softening" and breakdown.


Symptoms The typical patient is a teenage girl complaining of pain in the front of her knee around the patella. She may also have pain that is deep-seated that may radiate to the back of the knee. The pain comes and goes, but usually with squatting, kneeling, and negotiating steps, especially going down the stairs. She may be engaged in strenuous sports, but experiences pain with repeated bending of the knees. Although girls are more often affected, boys can have this problem too.

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At this stage, there is no breakdown of the articular cartilage of the patella yet, and is totally reversible. In fact, many doctors may not use the term "chondromalacia patellae" at this stage, because there is no actual softening or breakdown of the cartilage. A more appropriate diagnosis would be "Anterior knee pain syndrome" or "Patellofemoral stress syndrome" .

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In fact, in the majority of patients, the pain comes and goes for a few years until growth is complete. At that point, the pain goes away permanently. In others, the pain gets increasingly worse during the teenage years, the articular cartilage of the patella may actually break down, and medical or surgical treatment may be necessary.


CLINICAL FEATURES Introspective teenage girl or athletic young adult Flat foot / Knock kneed athletes Spontaneous Pain in front of knee/ beneath the knee cap Maybe h/o recurrent displacements/injury Aggravated by activity/climbing down stairs/standing after prolonged sitting with knees flexed Both knees Swelling-give way-catching(not true locking) Grating/grinding sensation when knee is extended


Signs Appears Normal knee Malalignment /tilting of patella Quadriceps wasting Effusion Crepitus on moving the knee Tenderness under the edge of the patella Small high patella “Theatre sign”?

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Press patella against femur to elicit pain and asking patient to contract the quadriceps first with central pressure then compressing the medial facet and then the lateral facet Apprehension test + implies previous subluxation/dislocation. Patellar tracking with pt seated at edge of the couch, flexing and extending knee against resistance Patellar alignment gauged by Q angle-angle subtended by the line of quadriceps pull and the line of patellar ligament. Should not exceed 20 degrees Structures around knee and hip examined r/o referred pain


STAGES I:   swelling and softening of the cartilage II:   fissuring within the softened areas III: fasciculation of articular cartilage almost to level of subchondral bone; IV:  destruction of cartilage with subchondral bone exposed

Grading (Bentley 1992):

Grading (Bentley 1992) Grade I: area <0.5 cm diameter Grade II: Area 0.5 – 1.0 cm diameter Grade III: area 1.0 – 2.0 cm diameter Grade IV: area >2 cm diameter a: softening, swelling/fibrillation of cartilage b: Full thickness cartilage loss to bone


IMAGING X Rays- skyline view lateral view with knee half flexed Tangential views at 30, 60 and 90 degrees of flexion Best seen on slightly overexposed lateral X ray Axillary radiograph determines which facet is involved Most accurate to measure malpositon CT/MRI with knee in full extension and varying degrees of flexion.

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Diagnosis made only on Arthroscopy or surgery Arthroscopy is useful to r/o other causes of anterior knee pain. Also to know presence and extent of the lesion and probing of patella with soft probe Gauge patellofemoral congruence, tracking and alignment


DIFFERENTIAL DIAGNOSIS Patellofemoral overload- maltracking overuse Patellar instability- subluxation/tilt Intra-articular pathology- plica syndrome Meniscal disorders Osteochondritis dissecans Patellofemoral arthritis Peri-patellar disorders- bursitis/tendinitis/ apophysitis Bipartite patella; bone tumors Hip disorders- slipped capital femoral epiphysis


TREATMENT Conservative Operative

Conservative Rx:

Conservative Rx Reassurance Ice Application Physiotherapy Avoid stressful activities Stretching and strengthening medial quadriceps 15 mins 4 times/day – Quad sets (bicycling, pool running, swimming flutter kick) Aspirin / Ibuprofen / Naproxen Support for a valgus foot STEROIDS BEST AVOIDED

Operative Rx:

Operative Rx Indications: Abnormality correctable by operation Conservative Rx tried for at least 6 months Patient genuinely incapacitated

Surgical Options :

Surgical Options 1. Lateral Release 2. Proximal Realignment 3. Distal Realignment 4. Distal elevation of Patellar ligament 5. Chondroplasty 6. Patellectomy

Prevention :

Prevention In a sense, whether a child will develop this problem of anterior knee pain and chondromalacia patellae depends on the morphology of the knee and any muscle imbalance she may have. If she is lanky and knock-kneed, she is more likely to develop the condition. If she has tightness of her lateral muscles, she may be more prone to the problem.

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Regardless of the above, the best way to minimize the chances of developing Chondromalacia patellae is to warm-up and stretch out before sports, especially your quadriceps and hamstrings. If possible, vary your sports. For example, alternate running with swimming with bicycling. Avoid squatting, kneeling, stairs and hill running if you can. In addition there are some exercises that are helpful in preventing and helping the symptoms of anterior knee pain. These exercises should be done regularly, twice a day. If symptoms are already present, it will take about 6 weeks before you get the benefit of the exercise. So, the key is to be consistent, and persistent.

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Short-arc extensions are done sitting up or lying down. Use a rolled-up towel to support your thigh while you keep your leg and foot in the air for 5 seconds. Lower your foot as you bend your knee slowly. Repeat 10 times for each leg, twice a day.

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Straight-leg raises are done lying down. Lift your whole lower limb at the hip with the knee extended, and keep it up in the air for 5 seconds. Then lower slowly. Repeat 10 times for each leg, twice a day.

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Quadriceps isometric exercises are done sitting up, with your legs extended in front of you. Tighten your quadriceps muscles by pushing the knees down onto the floor. Hold for 5 seconds. Repeat 10 times each leg, twice a day.

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Stationary bicycling on low tension setting improves your exercise tolerance without stressing your knee. Adjust your seat high enough so that your leg is straight on the down stroke. Start with 15 minutes a day and work up to 30 minutes a day.

Medical Rx:

Medical Rx In most instances the X-rays are normal, but it is still important to rule out any other significant problems. The patella view or "sunrise" view may show the patella is displaced or tilted laterally, a confirmation that the vastus lateralis muscle is over-powering or too tight.

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For the teenager with chondromalacia, the objective of treatment is to restore normal patella alignment with the help of exercises. The only way to alter knee morphology is by performing surgery, and sometimes that is required. However, in most cases, exercises with or without formal physical therapy is all that is needed to correct the problem. The exercises described above concentrates on strengthening the vastus medialis obliquus (VMO), responsible for stabilizing the patella. Once that strengthens, and muscle balance is restored, the pain improves.

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In some cases, if the pain persists, prescribe physical therapy. The therapist will work at stretching the vastus lateralis, as well as strengthening the Quadriceps muscle and Hamstring muscles, using manual and electrical techniques. "patella taping" to keep the patella from tracking laterally.

Patellar taping Video :

Patellar taping Video

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A NSAID like Motrin is often prescribed. This is taken regularly, whether you feel pain or not. By decreasing the inflammation, the pain is often reduced.

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A knee brace is also often prescribed for patients who want to stay active in sports. The usual brace prescribed is known as a patella stabilizing brace . It consists of a knee sleeve with a patella cutout, and a horse-shoe pad based laterally to keep the patella from tracking laterally. With conservative treatment, about 85% of patients improve enough that no further treatment is needed. In about 15% of patients, the pain stays severe, or becomes worse that surgical treatment is needed.

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An MRI exam is usually not indicated for most cases of chondromalacia, unless the doctor suspects any other pathology. The form of surgery done is usually an arthroscopic surgery. It is usually performed as an outpatient procedure, under a light general anesthetic. The surgeon will check out the knee through the arthroscope, and confirms the lateral patella tracking.

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To correct the problem, a lateral release, consisting of dividing the vastus lateralis muscle is performed. By dividing the vastus lateralis, this muscle is weakened, and if tight, stretched out; hence restoring balance to the Quadriceps muscle. Post-operatively, Physical therapy for 6 weeks will restore the knee back to health, and the patient back to sports.

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In some patients, the pain continues even after surgery and intensive physical therapy. This happens especially in patients with severe structural problems, like markedly increased Q-angle and lateral subluxation or dislocation of the patella . When that happens, more than a lateral release is required. Open surgery is occasionally done for the recalcitrant case, and usually involve extensive open realignment of the Quadriceps mechanism and even bony correction.


Prognosis Most patients do well with treatment. It is important that you keep up with the Quadriceps exercises on an indefinite basis. It takes only 5 minutes twice a day, and is a worthwhile long-term investment for your knees. Also, make sure you stretch adequately and warm up before sports.

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