CHODROMALACIA PATELLAE :-
Chondromalacia patellae is sometimes used synonymously with patellofemoral pain syndrome.
Chondromalacia patellae (also known as CMP) is inflammation of the underside of the patella and softening of the cartilage.
The cartilage under the kneecap is a natural shock absorber, and overuse, injury, and many other factors can cause increased deterioration and breakdown of the cartilage. The cartilage is no longer smooth and therefore movement and use is very painful. While it often affects young individuals engaged in active sports, it also afflicts older adults who overwork their knees.
ANATOMY OF PATELLOFEMUR :-
~ bony constraint of the patella within the trochlear groove
~ intracondylar groove
diameter of lateral femoral condyle > medial femoral condyle
bony constraint of groove is the primary constraint to lateral patellar instability when knee flexion is > 30 degrees
~ static stability of the patella within the trochlear groove
~ medial patellofemoral ligament (MPFL)
originates from the adductor tubercle to insert onto the superomedial border of the patella
primary constraint to lateral patellar instability with knee flexion 0 to 20 degrees
~ dynamic stability of the patella within the trochlear groove
vastus medialis = medial restraint to lateral translation
vastus lateralis = lateral restraint to medial translation
~ angular difference between the quadriceps tendon insertion and patella tendon insertion creates a valgus axis (Q angle)
creates a laterally directed force across the patellofemoral joint
~ superior, medial and lateral, geniculate arteries
~ inferior, medial and lateral, geniculate arteries
~ anterior geniculate artery
~ descending geniculate artery
The patellofemoral joint comprises the patella and the femoral trochlea. The patella acts as a lever and also increases the moment arm of the patellofemoral joint, the quadriceps and patellar tendons.8 Contact of the patella with the femur is initiated at 20 degrees of flexion and increases with further knee flexion, reaching a maximum at 90 degrees.
Stability of the patellofemoral joint involves dynamic and static stabilizers (Figure 1), which control movement of the patella within the trochlea, referred to as “patellar tracking.” Patellar tracking can be altered by imbalances in these stabilizing forces affecting the distribution of forces along the patellofemoral articular surface, the patellar and quadriceps tendons, and the adjacent soft tissues. Forces on the patella range from between one third and one half of a person’s body weight during walking to three times body weight during stair climbing and up to seven times body weight during squatting.10 Abnormalities of patellar tracking must be understood to appreciate the possible causes of PFPS and to determine the focus of treatment.
CAUSES OF CMP :-
poor alignment due to a congenital condition
weak hamstrings and quadriceps (the muscles in the back and front of your thighs, respectively)
muscle imbalance between the adductors and abductors (the muscles on the outside and inside of your thighs)
repeated stress to your knee joints, such as from running, skiing, or jumping
a direct blow or trauma to your kneecap
There are four grades, ranging from grade 1 to 4, that designate the severity of runner’s knee. Grade 1 is least severe, while grade 4 indicates the greatest severity.
Grade 1 : severity indicates softening of the cartilage in the knee area.
Grade 2 : indicates a softening of the cartilage along with abnormal surface characteristics. This usually marks the beginning of tissue erosion.
Grade 3 : shows thinning of cartilage with active deterioration of the tissue.
Grade 4 : the most severe grade, indicates exposure of the bone with a significant portion of cartilage deteriorated. Bone exposure means bone- to-bone rubbing is likely occurring in the knee.
SIGN & SYMPTOMS :-
~ Dull, aching pain that is felt:
Behind the kneecap
Below the kneecap
On the sides of the kneecap
~ a vague discomfort of the inner front of the knee, aggravated by activity (running, jumping, climbing or descending stairs) or by prolonged sitting with knees in a moderately bent position .
~ Some patients may also have a vague sense of “tightness” or “fullness” in the knee area.
~ Occasionally, if chronic symptoms are ignored, the associated loss of quadriceps (thigh) muscle strength may cause the leg to “give out.” Besides an obvious reduction in quadriceps muscle mass, mild swelling of the knee area may occur.
X-ray: an AP view of the patellofemoral joint is needed to detect any radiological change. In all but the most advanced cases, there is no convincing radiological change. In the latter stages, patellofemoral joint space narrows and osteoarthritic changes begin to appear.
~ observation of the position of the patella with the knee in 90° of flexion: patella alta, patella baja, or patellar lateralization may be present.
~ observation of patellar tracking in terminal extension (30-0°): a J-curve may be present.
~ assess the patellar glide:
a tight lateral retinaculum can decrease the medial glide; a medial glide of less than 5 mm (1 quadrant) can indicate a tight retinaculum. If a positive apprehension sign (fear of the patella popping out of position) is elicited with assessment of the patellar glide, suspect a patella subluxation or dislocation.
~ palpate the pain:
tenderness is often found on the patellar facets, the trochlea, and the peripatellar soft tissue. Tenderness to palpation at the superior or inferior poles of the patella usually indicates another pathology.
~ assess the patella compression test :
Compress and push the affected patella distally. Pain is a positive test associated with anterior knee pain. An active test, in which the patient contracts the quadriceps tendon against a compressed patella, has a high false-positive rate.
~ assess the Q-angle :
The Q-angle is the angle formed by a line created from the ASIS to the mid patella intersecting with a line created from the mid patella to the tibial tubercle with the knee in full extension. The average Q-angle for males is 14°, and the average for females is 17°. An increase in this angle can indicate abnormal patellar tracking.
MEDICAL TREATMENT :-
Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief—These include ibuprofen, naproxen, and aspirin.
Topical pain medication— These include creams or patches that are applied to the skin to help with soft tissue pain.
Prescription pain relievers.
1.Chondrectomy: also known as shaving. This treatment includes shaving down the damaged cartilage to the non damaged cartilage underneath. The success of this treatment depends on the severity of the cartilage damage.
2.Drilling is also a method that is frequently used to heal damaged cartilage. However, this procedure has not so far been proven to be effective. More localised degeneration might respond better to drilling small holes through the damaged cartilage. This facilitates the growth of the healthy tissue through the holes from the layers underneath.
3.Full patellectomy: This is the most severe surgical treatment. This method is only used when no other procedures were helpful, but a significant consequence is that the quadriceps will become weak.
Two other treatments that may be successful :
1.Replacement of the damaged cartilage : The damaged cartilage is replaced by a polyethylene cap prosthesis. Early results have been good, but eventual wearing of the opposing articular surface is inevitable.
2.Autologous chondrocyte transplantation under a tibial periosteal patch
PHYSIOTHERAPY TREATMENT :-
Placing of an ice or cold pack to the area for 15-20 minutes, four times daily, for several days. Do not apply ice directly to the skin. Wrap the ice or cold pack with a towel.
Taping to realign the kneecap
1.Straight Leg Raising :-
Lie down with one leg bent at a 90-degree angle with the foot flat on the floor and the other leg fully extended.
Tighten the quadriceps (thigh muscle) of the straight leg and raise it to a 45-degree angle.
Hold the leg in this elevated position for a second or two before slowly lowering it back to the ground.
Repeat for 20 repetitions then switch legs. You should do two or three sets per day.
2.External Hip Rotation :-
Lie on your side with the knees stacked and bent at 90-degree angles and the hips flexed at an angle of about 60-degrees.
Keeping your heels stacked together and the pelvis anchored and perpendicular to the ground, lift your top knee as high as you can, hold for a second or two then lower it.
Repeat this chondromalacia patella exercise 10 to 15 times per side for two or three sets.
Begin by standing with the heels about 6 inches away from a wall and the feet about a foot apart. Your back and butt should be pressed against the wall. Slowly slide the hips down the wall until the knees are bent at roughly a 45-degree angle. Hold that position for about five seconds, and then slowly slide back up to the starting position. It is important not to bend too quickly or too deeply as this can irritate the knee.
Repeat this motion 10 to 15 times for two to three sets.
4.Quadricep Contraction :-
Sit with both legs extended in front of you. Slide a rolled up towel or blanket under one knee so that it is slightly bent.
Lift the foot off the ground so that the knee straightens fully.
Hold the knee locked in extension for five seconds, then relax the quadriceps and slowly lower the leg back to its resting position.
Repeat for 10 repetitions and then switch legs. This should be done three to five times a day.
5.Hamstring Stretch :-
Lie on the floor on your back.
Loop a long bath towel around your toes and hold the ends of the towel in both hands.
Slowly pull on the towel to lift your straight leg up. Be sure to keep your knee straight. The leg without the towel should remain flat on the ground.
Bring your leg up until a stretch is felt behind your thigh. You may also feel a stretch behind your lower leg in your calf. This is normal.
Hold for 15 to 30 seconds, and then relax.
Repeat three to five times on each leg.
6.Calf Stretch :-
Stand near a wall with one foot in front of the other, front knee slightly bent.
Keep your back knee straight, your heel on the ground, and lean toward the wall.
Feel the stretch all along the calf of your back leg.
Hold this stretch for 20-30 seconds Switch legs, then alternate for a total of 3 repetitions.
Chondromalacia Knee Exercises to Avoid :-
While chondromalacia exercises can be great for fixing your kneecap pain, there are also some that should be avoided because they can do more harm than good. These generally include exercises that put a lot of stress on the knee. Some examples include:
~ Deep squats
~ Leg extension machine
DO’s & DON’Ts :-
Please avoid any movement or position of which makes you feel the pain.
It is better to avoid kneeling, squatting or sitting cross legged.
One may go up and down the steps occasionally but avoid repeated stair climbing.
Pain may get worse with exercise bicycle and walking on a treadmill with upward gradient (slope).
Don’t play sports that are notoriously deleterious to the knee joint like football, rugby, or even indoor soccer or squash/racketball.
Avoid repetitive motion exercises with little variation like road running, a treadmill, and road riding or spinning. Don’t play sports that are notoriously deleterious to the knee joint like football, rugby, or even indoor soccer or squash/racketball.
Avoid repetitive motion exercises with little variation like road running, a treadmill, and road riding or spinning.