Chondromalacia
Visible cartilage alterations |
Leads to patellofemoral arthritis |
Can occur at any age - common in teenagers and incidence increases with age |
More common in females |
Stages
Stage 1: Cartilaginous swelling and softening |
Stage 2: Partial thickness fissuring |
Stage 3: Full thickness fasciculations |
Stage 4: Cartilage destruction with exposure of subchondral bone (onset of DJD) |
Patella cartilage
- Thicker, more permable, less stiff and more compressible than other cartilage |
- Imbalanced actions of dynamic knee stabilisers can stress the patella cartilage and joint |
Risk Factors
- Alteration of normal patellofemoral mechanics |
- Imbalance of dynamic knee stabilisers |
- Lateral tracking disorders |
- Tightness in lateral knee capsule |
- Weakness of Vastus medialis or quads |
- Pes Planus |
- Hip abductor weakness |
- Joint overload/overuse |
- Trauma (prior cruciate ligament injury, f# or patella subluxation) |
- Patella hypermobility |
- Quads, ITB hypertonicity |
- Obesity |
- Hypermobility/instability |
Presentation
- Complaints similar to PFPS |
- Dull peripatellar pain |
- Aggravated by activities that load the joint e.g. prolonged walking, running, squatting, kneeling, jumping, arising from a seated position or stair climbing |
- Crepitus, locking, giving way |
- TTP: soleus, hamstring, iliopsoas, piriformis, thigh adductor, ITB, posterior hip capsule (tightness) |
- Weakness in quads/hamstrings/glut med/max |
- Can present with back pain (biomechanics) |
- +ve patella compression +ve patella grind test |
- Differentiation between patella and meniscus during two legged squat - meniscal pain is aggravated by the bottom of the squat and PFP is present during ascent and descent |
Imaging
- If knee f# is suspected (hx of trauma/OA) |
- Other considerations = significant swelling, recent hx of knee surgery and no improvement with conservative care |
- Presence of osteophytes, cysts, subchondral sclerosis, articular space narrowing |
- MRI gold standard |
DDx
- F# |
- Infection |
- Neoplasm |
- Patella/Quad tendinopathy |
- Bursitis |
- Cartilaginous irritation (osteochondritis dissecans, PF arthritis) |
- Sinding Larsen Johanson syndrome |
- ITB syndrome |
- Bipartate patealla |
- Referred pain from spine/hip |
Management
- Fear avoidance behaviours should be addressed |
- Reduction of pain provoking activities |
- Ice and electrotherapy |
- NSAIDs (short term) |
- Myofascial release and stretching of TFL, Gastrosoleus, hamstring, piriformis, hip rotators and psoas |
- Strengthening of Glut med and VMO |
- Pillow Push, Supine heel slide, terminal knee extension, clams, posterior lunge |
- Eccentric quads strengthening (squats) |
- SMT of lumbosacral and lower extremities |
- Hypermobility of ipsilateral SI joint is common |
- Kinesiotaping |
- Glucosamine sulfate can be effective |
- Arch support for hyperpronation |
PFPS
- Excessive/imbalanced forces on the knee |
- Young athletes affected |
- Patella tracking = static and dynamic stabilisers of the lower extremity |
- Imbalance of these alters the distribution of forces to the PF articular surfaces and soft tissues |
- Lateral tracking (patella migrates laterally due to pull of quads and natural valgus of the LL |
Risk Factors
- Pes Planus - causes internal rot of the tibia |
- Glut medius weakness |
- Loss of core stability |
- Overuse/overload of joint |
- Trauma |
- Tight lateral knee capsule |
- Patella hypermobility |
- Muscular imbalance - quads/itb hypertonicity , vastus medialis or quads weakness |
Presentation
- Dull peripatellar pain |
- Aggravated by activities that load the joint: prolonged walking, running, squatting, jumping, kneeling, arising from a seated position, stair climbing (walking down stairs/downhill) |
- May be swelling |
- Crepitus, locking, giving way (if cartilage is damaged) |
- Gait changes - greater knee flex, greater ankle dorsiflexion, greater transverse plane hip motion in stance phase
Chronic cases may show: greater frontal plane hip motion, greater knee abduction, reduced ankle eversion/greater ankle inversion |
- Assess for hypertonicity in soleus, hamstring, iliopsoas, piriformis, thigh adductor muscles, ITB and posterior hip capsule |
- Assess weakness in quads, hamstrings, glut med |
- Patella Grind +ve Patella glide +ve patella tracking (patella tracking during AROM - knee flex/ext |
- Can be differentiated between meniscus and PF pain by squat - meniscal pain usually at the bottom of the squat - PF pain is present during ascent and descent |
Imaging
- Knee radiographs to rule out f# or other pathology |
- May be appropriate for pts with significant swelling, recent hx of knee surgery, pain does not improve with con care |
DDx
- f# |
- Neoplasm |
- Patellar/quad tendinopathy |
- Osgood-schlatters |
- Bursitis |
- Cartilage irritation - osteochondritis dissecans, chondromalacia patella, PF arthritis |
- Sinding-Larsen Johansson syndrome |
- Plica |
- ITB syndrome |
- Bipartite patella |
- Referred pain from spine/hip |
Management
- Decrease fear avoidance behaviours |
- Retraining of faulty movement patterns |
- Electrotherapy |
- NSAIDs |
- Myofascial release of hypertonic muscles (TFL, gastrosoleus, hamstring, piriformis, hip rotators, psoas, ITB, VL, posterior hip capsule, lateral knee retinaculum |
- Strengthening of gluts and VMO (pillow push, supine heel slide, terminal knee extension, clam, glute bridge, semi-stiff deadlift, posterior lunge, monster walk) |
- Closed chain exercises + eccentric quads strengthening |
- SMT/EMT of LS and LL |
- Arch supports |
- Surgical intervention if fails con care |
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