What is Chondromalacia Patella?
Chondromalacia patella refers to a condition involving pain underneath the kneecap (patella). Crepitus (cracking) is also commonly present. These symptoms are thought to arise due to damage to the cartilage that lies underneath the patella. Symptoms may be aggravated with running, squatting, walking up a stairs or sitting with the knee flexed. Chondromalacia patella is often referred to as ‘runner’s knee’.
Ross discussing Knee Pain on KFM radio:
What causes Chondromalacia Patella?
Chondromalacia patella may arise due to acute trauma or gradual overload of the knee structures over time. The patella may move abnormally within its groove due to imbalances in quadriceps muscle activity or lack of control at the hip or pelvis. This abnormal tracking of the patella is thought to increase the pressure on one part of the cartilage of the knee, resulting in knee pain. Although it is generally believed that the pain arises due to degeneration of the cartilage underneath the kneecap, there is some debate regarding the exact source of the pain. Chondromalacia literally translates as ‘cartilage softening’. Chondromalacia normally occurs in young athletes and is more common in females than in males.
There are many causes of anterior knee pain; the lumbar spine and hip are other potential sources of knee pain referral. If pain presents in the front of the knee without injury to the underlying cartilage then this is referred to as patellofemoral pain syndrome.
Physiotherapy Treatment of Chondromalacia Patella
Physiotherapy will involve assessment of the alignment of the patella & observation for potential muscle imbalances around the knee & hip. A patella that lies too high on the femur (patella alta) is one example of an abnormality that can give rise to abnormal muscle forces at the knee thus giving rise to pain.
The initial physiotherapy approach for chondromalacia patella is to decrease the pain at the knee. This may require a period of activity modification in order to avoid aggravation of knee pain. Your physiotherapist will advise you on the appropriate amount of activity modification or rest required in order to facilitate recovery. Once pain has decreased then the next goal is to normalise knee alignment & improve muscle control about the knee & hip. Manual soft tissue therapy to the quadriceps and mobilisation for the knee, ankle & hip joint may be used to restore normal function.
Tightness of the muscles around the knee can give rise to increased traction on the patella with movements such as running & jumping. This can worsen symptoms if it is not addressed appropriately. Using specific muscle testing & range of motion analysis your physiotherapist will determine the appropriate exercises for your particular presentation. Although the traditional approach was focused on strengthening the quadriceps muscle only, the research now indicates the significance of hip and trunk control on knee biomechanics. Not only is muscle strength important but also the timing of muscle activation is vital in maintaining optimal joint position during movement. Oftentimes the muscles of the hip, including the gluteals, can fail to fire appropriately & may affect knee alignment. Likewise, impaired foot & ankle control may affect knee function & can increase the stress on the knee joint during loading.
Once appropriate muscle strength has been developed then your physiotherapist will introduce advanced exercises to encourage appropriate muscle recruitment at rapid speed. None of the exercises should induce significant pain & if they do then the exercises should be stopped & your physiotherapist should be consulted immediately.
Because of the muscle inhibition and resultant muscle wasting around the knee from chondromalacia patella, it is important that a consistent long-term view is taken to rehabilitation. As muscle hypertrophy takes eight weeks or more to develop then the patient must adhere to their programme beyond this window of time. In fact, muscle strength gains are unlikely to plateau for at least six months (American College of Sports Medicine 2009), and in patients with muscle atrophy from chondromalacia patella this time frame may be even longer. With this in mind, most patients should be monitored over a 12 month period after commencement of rehabilitation.
Are Orthotics Useful for Treating Chondromalacia Patella
The single largest randomised controlled trial exploring the use of orthotics for chondromalacia patella found that they provided no additional benefit when added to a multi-faceted physiotherapy approach or compared with physiotherapy alone (Collins et al. 2009). It has been theorised that there may be certain patients who may benefit from the use of orthotics; however, at present there is no evidence to back up this approach.
Here at the Physio Clinic – Naas & Newbridge our goal will be to get you back to your normal activity levels as soon as possible with a graduated rehabilitation programme. If following instructions regarding appropriate exercise and adequate rest then most patients respond very well to treatment.
For further information on conditions treated go to:
www.physioclinic.ie/conditions
References
American College of Sports Medicine. Progression models in resistance training for healthy adults. Medicine & Science in Sports & Exercise 2009;41(3):687-708.
https://www.ncbi.nlm.nih.gov/pubmed/19204579
Collins et al. (2009) Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised controlled trial. British Journal of Sports Medicine; 43(3): 169-71. https://www.ncbi.nlm.nih.gov/pubmed/19270165
