Chondromalacia Patella – Presentation and Treatment

Chondromalacia patella is a condition characterized by softening and degeneration of the patellar articular cartilage. Chondromalacia patella is a term sometimes considered synonymous with patellofemoral pain syndrome but patellofemoral pain syndrome is a term that applies only to individuals without cartilage damage.

Chondromalacia patella is considered the most common cause of chronic knee pain.

Cartilage under patella or kneecap acts as natural shock absorber.  Overuse, injury, and many other factors can cause increased deterioration and breakdown of the cartilage.

Chondromalacia is common among young, athletic individuals, but may also occur in older adults who have arthritis of the knee. There is a female predilection.

Causes of Chondromalacia Patella

The patella is normally pulled over the end of the femur in a straight line by the quadriceps muscle. Patients with chondromalacia patella frequently have abnormal patellar tracking toward the lateral side of the femur causing femur to grate on and cause chronic inflammation and pain. Abnormal patellar movement occurs due to improper working of bones, tendons or ligaments.

The general causes are

Risk Factors for Chondromalacia patella

Age

Adolescents and young adults are at high risk as during growth spurts, the muscles and bones develop rapidly which may cause short-term muscle imbalances.

Flat Feet

Flat feet puts higher stress on knee joints.

Trauma

A prior injury like dislocation or subluxation of patella can increase risk of chondromalacia patella.

Chronic friction between the patella and femoral groove can also result in this.

Activity

High-activity level or that places pressure on your knee joints, this can increase the risk for knee problems.

Knee Pathologies

Inflammation as in arthritis can prevent the kneecap from functioning properly. Other conditions of the knee which can cause chondromalacia patella is patella alta [high riding patella] quadriceps imbalance, weak hamstrings, congenital abnormalities, patellar maltracking, synovial plicae, tight iliotibial band, neuromas, bursitis etc.

Overuse

Persons engaging in soccer, gymnastics, cycling, rowing, tennis, ballet, basketball, volleyball, running, combat sports, snowboarding, skateboarding and even swimming are at increased risk.

Clinical Presentation of Chondromalacia Patella

Chondromalacia patella is suspected in a person with anterior knee pain, especially in teenage females or young adults.

Patients with chondromalacia patellae usually present with anterior knee pain or vague discomfort of the inner side of the knee, aggravated by activity (running, jumping, climbing or descending stairs) or by prolonged sitting. There may be knee pain when kneeling or squatting or after sitting for long periods of time.

The patient may also complain of knee stiffness or tightness. The examination may reveal mild swelling of the knee.

Imaging

Plain radiographs of the knee cannot assess for cartilage changes and can only show bony changes if present e.g. that of osteoarthritis.

MRI is the modality of choice for assessing patellar cartilage and is able to display cartilage abnormalities.

Grading of Chondromalacia Patella

Grade I

Softening of the cartilage in the knee area.

Grade II 

Softening of the cartilage along with abnormal surface characteristics. This usually indicates the beginning of tissue erosion. 

Grade III 

Thinning of cartilage with the active deterioration of the tissue. 

Grade IV

Significant cartilage loss with bone exposure

Differential Diagnosis  

• Patellar Tendinosis
• Sinding-Larsen-Johansson disease
• Patellar sleeve fractures

Treatment of Chondromalacia Patella

• RICE therapy
• Curtailing the activities
• NSAIDs
• Exercises
  • Stretch and strengthen quadriceps especially vastus medialis
  • Cardiovascular conditioning
    • stationary bicycling
    • swimming
  • Proper training schedule
  • Proper footwear

With proper treatment, the patient generally return to full functional level.

Surgical options may be needed when the imbalance is severe or the patient does not show improvement, surgical options may be considered

• Arthroscopic debridement and lavage
• Articular resurfacing
• Instability correction
• Patellectomy

Prevention 

• Avoid repeated stress to your kneecaps.
• Use knee pads
• Quadriceps and hamstrings strengthening exercises, as well as your abductors and adductors.
• Wear shoe inserts that correct flat feet
• Maintain proper weight