What is chondromalacia patella?

Chondromalacia patella or chondromalacia patellae is a condition in which there is a softening, swelling, and erosion of the articular cartilage on the undersurface of the kneecap (patella).

Chondromalacia patella often affects young individuals, athletes. And it is more common in individuals who do a lot of jumping, running, cycling and overuse their knee.

Chondromalacia patella is one of the most common causes of anterior knee pain in adults. One of the most important things about chondromalacia patella is that there will be an anterior knee pain rather than pain in the knee joint. Females who wear heels can also suffer chondromalacia patella because heels are one of the leading causes of muscle imbalances.

What are the causes of chondromalacia patella?

What does patella do?

Patella is also known as the kneecap. The primary functional role of the patella is during knee extension. The simple fact is that the patella sits atop the anterior surface of the femoral condyles, increases the angle where the quadriceps tendon pulls the shaft of the tibia. The patella also acts to allow for smooth motion of the knee in flexion and extension.

When a normal person bends and straightens the knee, the work of the patella is to glide up and down over the thigh bone(femur) in a particular straight groove. ie, the backside of the patella(kneecap) glides over the cartilage of the thigh bone(femur).

What happens in the chondromalacia patella?

When the knee bends and straightens (flexion and extension) the work of the patella is to glide up and down over the thigh bone(femur) in a particular straight groove. But in chondromalacia patella, there will be improper gliding of the patella either due to muscular imbalances (tightness and weakness), abnormality in Q angle, etc. This improper gliding will lead to lateral drifting of the patella, which creates friction. And this friction will lead to damaging of patellar articular cartilage which causes pain. The main causes of improper gliding include – 

1- Tightness in the IT band and Vastus lateralis 

Because of the tightness in the IT band and vastus lateralis, The patella will start moving towards the lateral side. 

2- Tightness in Rectus femoris muscle 

Tightness in the rectus femoris muscle will affect the patellar movement as it will make the extension of the knee a little bit hard.

3- Tightness in hamstrings muscles  

Hamstring plays an essential role in flexing the knee. So if the hamstrings become tight, it will affect the patella movement and it becomes hard for the patellofemoral joint to flex the knee. So hamstrings flexibility is important.

4- Weakness of vastus medials oblique  

The work of vastus medialis oblique is to stabilize the patella during knee extension. Therefore weakness of this muscle will lead to lateral drifting of the patella.

5- Weakness of hip abductors 

Hip abductors will also indirectly affect the patellar movement. As weakness in hip abductors will also affect the patellar movement.

6- Q angle  

Q angles are also considered as a cause for patellar dislocation. Usually, the Q angle provides better strength, reasonable control to the knee.

 

Now what happens is that gastrocnemius often limits dorsiflexion. Causing more subtalar pronation which in turn increases the Q angle. And an increase in Q angle can lead to lateral pulling of the patella.

8- Complete/Partial displacement –

Complete or partial displacement of the patella from the trochlear groove will also lead to chondromalacia patella. A patient who suffers subluxation or dislocation of patella, they can often damage or tear their medial patellofemoral ligament.

Chondromalacia patella Grading

The grading system may help in determining the severity of the disease. There are generally four grades of chondromalacia patella.

Grade 1 –  In grade 1, there will be some swelling or softening of the patellar articular cartilage. But the appearance of the articular cartilage will be intact

Grade 2 – In grade 2, there will be softening along with the blister formation in the patellar articular cartilage. There will be the beginning of the patellar articular cartilage damage. i.e. less than 50% loss of the patellar articular cartilage thickness.

Grade 3 – In grade 3, there will be thinning of the patellar articular cartilage along with progressive worsening of the patellar articular cartilage—i.e. more than 50% loss of the patellar articular cartilage thickness.

Grade 4 – In grade 4, this is the most severe case, and there will be a full-thickness loss of the patellar articular cartilage. The subchondral bone will become visible and the patella will rub against the thigh bone(femur).

Chondromalacia patella symptoms

• You will feel hurt on the front part of the knee, and you will hear crunchy noises like crepitus when you bend or straighten your knee. It happens a lot in women’s than men because women have a greater Q angle than men.
• Going downstairs often hurts a lot more than going up, because stress on the knee is often higher while going down.
• A lot of times, you will feel like your knee often doesn’t get a lock. You will get catching sensation, and you might also get some grinding sensation mainly while going downstairs.
• This pain gets severe by sitting for a more extended period. While watching a movie in a theatre, your knees are bent for a more extended period which in turn increases the pain. Therefore, it is also known as Movie goer’s sign.

Diagnosis of chondromalacia patella

Your doctor will listen to all your symptoms and will perform a physical examination. Generally, the Patellar grinding test or Clarke’s sign is performed.

Patellar grinding test or Clarke’s sign – 

The patient is positioned in a supine position with the involved knee in an extended position. Now therapist will place the webspace of the thumb on the superior border of the patella.

And after that therapist asks you to contract the quadriceps as you just began to extend the knee, the therapist will apply downward and inferior pressure on the patella. If you will feel pain or you are not able to complete the test, it will be an indication that the test is positive.

In case if the diagnosis is not precise or there will be no improvement in the symptoms, the doctor will go for the following options.

Radiological examination –

Standard knee X-ray –

Usually, standard knee X-rays cannot detect chondromalacia of the patella, but they may help rule out arthritis or inflammation.

MRI – 

Generally, when the symptoms become severe doctors will order MRI, it will give you a detailed analysis of knee joint structure.

Arthroscopy –

An endoscope or camera is inserted into the knee joint to look for the changes in articular cartilage.

Chondromalacia patella Treatment

Medical treatment 

• The first line of treatment will focus on resting the knee, and this could be achieved by placing your knee in a straight position. Do not bend it so that there will be less stress on the knee. Avoid movements that trigger the damaging of articular cartilage.
• After that apply ice or cold pack to the affected area for 10-15 minutes for one week. Cover the ice or cold pack with the towel.
• Take Nonsteroidal anti-inflammatory medicines such as ibuprofen, Zerodol sp for pain relief.

Chondromalacia patella Physiotherapy treatment

Generally, there are two types of physiotherapy treatment for treating chondromalacia patella. One is given in conservative cases, and another is given after surgery. The below treatment is followed in conservative cases. And the physiotherapy treatment which is given after surgery is explained at last.

• The therapist will go for Mcconnell taping to bring back the patella into the groove and to have it stay there. So that it can not move out of the groove and not give too much pain.
• Generally, vastus medialis obliques become weak, so your therapist will focus on strengthening the weak VMO. Isometric exercises are being performed.
• Vastus lateralis and IT band, hamstrings and Rectus femoris muscle will become tight, so your therapist will focus on increasing the flexibility of these muscles. So stretching exercises for these muscles is often recommended.
• Hip abductor strengthening exercises are given if there is a weakness in the hip abductors.
• By doing this strengthening and stretching exercises, it will allow the knee cap to ride in the groove. And it will also help in decreasing the inflammation and to bring back the functional mobility.
• The therapist will apply modalities like Hot water fermentation, Ultrasound, Laser for better healing and pain relief.

Chondromalacia patella surgery 

Chondromalacia patella surgery is usually performed when there is no relief from conservative treatment. Generally, there are three types of surgeries which include

Arthroscopic surgery

Arthroscopy surgery of chondromalacia patella is also referred to as “shaving of the patella”. In this procedure, your doctor inserts a camera into your joint and will directly look at the articular cartilage of the patella.

And they will get to know how much wear and tear are present in that area if there are any unstable cartilages flaps on the patella. They will shave/remove the damaged cartilage and make the surface smooth which in turn reduces your pain.

Lateral release is usually performed when you have patellar instability or patellar dislocation. In this procedure, the tight ligaments which lie on the outside of the patella are cut, to permit the patella to slide towards the middle of the femoral groove.

In a nutshell, the lateral release procedure is performed to shift back the patella to its normal position.

Patellectomy is usually indicated when there is severe destruction of the patellar articular cartilage and subchondral bone.

Chondromalacia patella recovery time

Recovery time in conservative cases – It may take about 4-6 weeks of physical therapy and after that several months of home exercise program which includes stretching and strengthening exercises. For more details, you can go above and read physiotherapy treatment followed in conservative cases.

Recovery time & Physiotherapy treatment after surgery – Just after the surgery, knee cast has been applied because bones and cartilage generally take time to heal. After some time when soft tissues got healed physiotherapy will be started.

• Icing will be done frequently to control the swelling and inflammation. Then electrical modalities such as SWD, ultrasound will be used for reducing pain and increasing blood flow.
• At first, gentle isometric exercises to the hips and quadriceps are performed. During isometric exercises, the muscle does not markedly change the length along with the joint does not move. Isometric exercises help in maintaining strength.
• After that for the strengthening of quadriceps muscles, assisted SLR is performed.
• After that, progressive resistive exercises, i.e. (gradually adding weight to build up muscle strength) are added to build up the knee joint muscle.
• After that, as you gain some amount of strength, your doctor will lessen your physiotherapy visits, and a home exercise plan will be given to you which you have to follow. So in a nutshell, it will take 2 to 3 months for the recovery after surgery.

You can also read –

Stages of osteoarthritis of the knee

R.I.C.E Therapy – For Soft Tissues Injuries

Muscle Strength Testing