Chondromalacia Patellae

Definition/Description

Chondromalacia patellae (CMP) is referred to as anterior knee pain

due to the physical and biomechanical changes.

The articular cartilage of the posterior surface of the patella is

going though degenerative changes which manifests as a softening,
swelling, fraying, and erosion of the hyaline cartilage underlying
the patella and sclerosis of underlying bone.

Chondromalacia patellae is one of the most frequently encountered

causes of anterior knee pain among young people.

The word chondromalacia is derived from the Greek words

chrondros - cartilage and malakia-softening.

Hence chondromalacia patellae is a softening of the articular

cartilage on the posterior surface of the patella which may
eventually lead to fibrillation, fissuring and erosion.

The differential diagnosis of chondromalacia include patellofemoral

pain syndrome and patellar tendinopathy.

Clinically Relevant Anatomy

The knee comprises of 4 major bones: the femur, tibia, fibula and
the patella. The patella articulates with the femur at the trochlear
groove. Articular cartilage on the underside of the patella allows
the patella to glide over the femoral groove, necessary for efficient
motion at the knee joint. Excess and persistent turning forces on
the lateral side of the knee can have a negative effect on the
nutrition of the articular cartilage and more specifically in the
medial and central area of the patella, where degenerative change
will occur more readily.
The quadriceps insert into the patella via the quadriceps tendon
and are divided into four separate muscles: rectus femoris (RF),
vastus lateralis (VL), vastus intermedius (VI) and vastus
medialis (VM). The VM has oblique fibres which are referred to the
vastus medialis obliques (VMO)

These muscles are active stabilisers during knee extension,

especially the VL (on the lateral side) and the VMO (on the medial
side). The VMO is active during knee extension, but does not
extend the knee. Its function is to keep the patella centred in the
trochlea. This muscle is the only active stabiliser on the medial
aspect, so it's functional timing and amount of activity is critical to
patellofemoral movement, the smallest change having significant
effects on the position of the patella.

Not only do the quadriceps influence patella position, but also the
passive structures of the knee. These passive structures are more
extensive and stronger on the lateral side than they are on the
medial side, with most of the lateral retinaculum arising from the
iliotibial band (ITB). If the ITB is under excessive tension, excessive
lateral tracking and/or lateral patellar tilt can occur. This is can
be as a result of the tensor fasciae lata being tight, as the ITB itself
is a non contractile structure.

Other significant anatomical structures:

 Femoral anteversion or medial torsion of the femur is a condition
which changes the alignment of the bones at the knee. This may
lead to overuse injuries of the knee due to malalignment of the
femur in relation to the patella and tibia.
 The Q-angle: or quadriceps angle is the geometric relationship
between the pelvis, the tibia, the patella and the femur and is
defined as the angle between the first line from the anterior
superior iliac spine to the centre of the patella and the second line
from the centre of the patella to the tibial tuberosity.

If there is an increased adduction and/or internal rotation of the hip,

the Q-angle will increase, which increases the relative valgus of the
lower extremity as well. This higher Q-angle and valgus will increase
the contact pressure on the lateral side of the patellofemoral joint
(which is also increased by external rotation of the tibia).

Epidemiology /Etiology

causes of chondromalacia are

injury,

generalised constitutional disturbance and patellofemoral contact,

trauma to the chondrocytes in the articular cartilage.

instability or maltracking of the patella which softens the articular
cartilage.

Chondromalacia patella is usually described as an overload injury,

caused by malalignment of the femur to the patella and the tibia.

Main reasons for patellar malalignment;

 Q-angle: An abnormality of the Q-angle is one of the most

significant factors of patellar malalignment. A normal Q-angle is
14° for men and 17° for women. An increase can result in an
increased lateral pull on the patella.
 Muscular tightness of:

> Rectus femoris: affects patellar movement during flexion of the

knee.

> Tensa Fascia late; affects the influence of the ITB

> Hamstrings: during running tight hamstrings increase knee

flexion which results in increased ankle dorsiflexion. This causes
compensatory pronation in the talocrural joint.

> Gastrocnemius: tightness will result in compensatory pronation

in the subtalar joint.

 Excessive pronation: prolonged pronation of the subtalar joint is

caused by internal rotation of the leg. This internal rotation will
result in malalignment of the patella.
 Patella alta: this is a condition where the patella is positioned in an
abnormally superior position. It is present when the length of the
patellar tendon is 20% greater than the height of the patella.
 Vastus medialis insufficiency: the function of the vastus medialis is
to realign the patella during knee extension. If the strength of VM is
insufficient this will cause a lateral drift of the patella. [21]

Muscular balance between the VL and VM is important. Where VM

is weaker the patella is pulled too far laterally which can cause
increased contact with the condylus lateralis, leading to
degenerative disease. [22]

Degenerative changes of the articular cartilage can be caused

by [23]:
 Trauma: instability caused by a previous trauma or overuse during
recovery
 Repetitive micro trauma and inflammatory conditions
 Postural distortion: causes malposition or dislocation of the patella
in the trochlear groove

Hip positioning and strength are linked to the prevalence of

patellofemoral pain syndrome. Therefore, hip strengthening and
stability exercises may be useful in the treatment program of
patellofemoral pain syndrome. [17]

Some authors use the term “patellar pain syndrome” instead of

“chondromalacia” in order to describe “anterior knee pain”. [24]

Stages of the disease

In the early stages, chondromalacia shows areas of high sensitivity

on fluid sequences. This can be associated with the increased
thickness of the cartilage and may also cause oedema.

In the latter stages, there will be a more irregular surface with

focal thinning that can expand to and expose the subchondral
bone.

Chondromalacia patella is graded based on the basis of

arthroscopic findings, the depth of cartilage thinning and
associated subchondral bone changes. Moderate to severe stages
can be seen on MRI.

 Stage 1: softening and swelling of the articular cartilage due to

broken vertical collagenous fibres. The cartilage is spongy on
arthroscopy.
 Stage 2: blister formation in the articular cartilage due to the
separation of the superficial from the deep cartilaginous layers.
Cartilaginous fissures affecting less than 1,3 cm² in area with no
extension to the subchondral bone.
 Stage 3: fissures ulceration, fragmentation, and fibrillation of
cartilage extending to the subchondral bone but affecting less than
50% of the patellar articular surface.
 Stage 4: crater formation and eburnation of the exposed
subchondral bone more than 50% of the patellar articular surface
exposed, with sclerosis and erosions of the subchondral bone.
Osteophyte formation also occurs at this stage.
 Articular cartilage does not have any nerve endings, so CMP
should not be considered as a true source of anterior knee pain,
rather, it is a pathological or surgical finding that represents areas
of articular cartilage trauma

Characteristics/Clinical Presentation

There are important distinguishing features between

chondromalacia patellae and Osteoarthritis. CMP affects just one
side of the joint, the convex patellar side, with excised patellas
show localised softening and degeneration of the articular
cartilage. The main symptom of chondromalacia patellae is
anterior knee pain, which is exacerbated by common daily
activities that load the patellofemoral joint, such as running, stair
climbing, squatting, kneeling , or changing from a sitting to a
standing position . The pain often causes disability affecting the
short term participation of daily and physical activities. Other
symptoms are tenderness on palpating under the medial or lateral
border of the patella, crepitation (felt with motion); minor
swelling, a weak vastus medialis muscle and a high Q-angle.
Vastus medialis is functionally divided into two components: the
vastus medialis longus (VML) and the vastus medialis obliquus
(VMO). The VML extends the knee, with the rest of the quadriceps
muscle. The VMO does not extend the knee, but is active
throughout knee extension. This component assists in keeping the
patella centred in the femoral trochlea.

This condition can cause a deficit in quadricep strength, therefore,

building and/or maintaining quadriceps strength is essential. A
significant number of individuals are asymptomatic, but
crepitation in flexion or extension is often present.
Chondromalacia is common in adolescents and females with
idiopathic chondromalacia usually seen in young children and
adolescents and the degenerative condition is most common in the
middle aged and older population.

Differential Diagnosis

 Patellar subluxation
 Osteoarthritis
 Rheumatoid arthritis
 Anterior knee pain
 Patellofemoral pain syndrome

Diagnostic Procedures

Since its first description by Budinger in 1906, chondromalacia

patella has been of significant clinical interest because diagnosis is
often difficult. The chief reason for this is that the aetiology is
often unknown and the correlation between the articular cartilage
changes and the clinical system is poor. Patients affected by
chondromalacia patella are young, between 15 and 35 years old,
and many are highly active and are often considerably disabled by
the symptoms of aching behind the patella, recurrent effusion of
the knee, knee instability and crepitus.

The primary diagnostic approach for chondromalacia patellae is

radiography with added arthrography. Pinhole scintigraphy, part of
arthrography, is also used to diagnose the condition. MRI is an
effective, non-invasive method with the ability to increase the
sensitivity and specificity of the diagnosis.

Outcome Measures

There are various measures: [39][40]

 Anterior Knee Pain Scale: a 13 item questionnaire with categories

related to various levels of current knee function.
 Visual analog scale
 The five KOOS subscales: a scale about patients' experience over
time with knee conditions. It consists of five subscales: Pain, other
Symptoms, Function in daily living, Function in sport and
recreation and knee related Quality of life.

Diagnosis

X-ray: an AP view of the patellofemoral joint is needed to detect

any radiological change.In the latter stages, patellofemoral joint
space narrows and osteoarthritic changes begin to appear.

Tests

There are specific tests for anterior knee pain syndrome: [33]
 Patellar grind test or Clarke’s sign: This test detects the presence of
patellofemoral joint disorder. A positive sign on this test is pain in
the patellofemoral joint.
 Compression test
 Extension-resistance test: This test is used to perform a maximal
provocation on the muscle-tendon mechanism of the extensor
muscles and is positive when the affected knee demonstrates less
power to when trying to maintain the pressure.
 The critical test: This is done with the patient in high sitting and
performing isometric quadriceps contractions at 5 different angles
(0°, 30°, 60°, 90° and 120°) while the femur is externally rotated,
sustaining the contractions for 10 seconds. If pain is produced then
the leg is positioned in full extension. In this position the patella
and femur have no more contact. The lower leg of the patient is
supported by the therapist so the quadriceps can be fully relaxed.
When the quadriceps is relaxed, the therapist is able to glide the
patella medially. This glide is maintained while the isometric
contractions are again performed. If this reduces the pain and the
pain is patellofemoral in origin, there is a high chance of a
favourable outcome. [42]

It is possible to diagnose incorrectly and these tests may aid in

determining chondromalacia, but other possible conditions also
need to be excluded.

Exercise and education are two important aspects of a treatment

programme. Education helps the patient to understand the
condition and how they should deal with it for optimal recovery.
Exercise focus is on stretching and strengthening appropriate
structures, such as: hamstring, quadriceps and gastrocnemius
length and strength of the gluteal muscles. Fire needling and
acupuncture may also relieve clinical symptoms of chondromalacia
patellae and recovers the biodynamical structure of patellae.

If conservative measures fail, there are a number of possible

surgical procedures.

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.
 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.

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: [23]

 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.

 Autologous chondrocyte transplantation under a tibial periosteal

patch. [23]

Simply removing the cartilage is not a cure for chondromalacia

patellae. The biomechanical deficits need addressing and there are
various procedures to aid in managing this.

 Tightening of the medial capsule (MC): If the MC is lax, it can be

tightened by pulling the patella back into its correct alignment.
 Lateral release: A very tight lateral capsule will pull the patella
laterally. Release of the lateral patellar retinaculum allows the
patella to track correctly into the femoral groove.
 Medial shift of the tibial tubercle: Moving the insertion of the
quadriceps tendon medially at the tibial tubercle, allows the
quadriceps to pull the patella more directly. It also decreases the
amount of wear on the underside of the patellar.
 Partial removal of the patella

Although there is no overall agreement for the treatment of

chondromalacia, the general consensus is that the best treatment
is a non-surgical one.[45]

Physical Therapy Management

 Exercise Program

Conservative treatment of chondromalacia patellae is both physical

and highly advised. Short-wave diathermy can help to relieve pain
and to increase the blood supply to the area, improving nutrition
supply to the articular cartilage. Care must be taken when
planning an exercise programme. (Level of Evidence
2B) [43] Conservative therapeutic interventions include the
following: [52]

 Isometric quadriceps strengthening and stretching exercises (Level

of Evidence 2B )[1] Restoration of adequate quadriceps strength and
function is an essential factor in achieving good recovery.The most
effective exercises are isometric and isotonic in the inner range.
Isotonic exercises through a full range of motion will only lead to
increased pain and even joint effusion. [43] Stretching of the vastus
lateralis and strengthening of the vastus medialis is often
recommended, but they are difficult to isolate due to shared
innervation and insertion. (Level of Evidence 1A) [12][22]It has shown
that closed kinematic chain exercices can improve patellofemoral
joint performance by increasing quadriceps muscle strenght and
patellar alingment correction. (Level of Evidence 1A) [46]
 Hamstring stretching exercises
 Temporary modification of activity
 Patellar taping
 Foot orthoses
 NSAIDS
 Hip strength and stability training, as hip positioning and strength
has a significant influence on anterior knee pain.
 Hip abductor strengthening as an increased hip adduction angle is
associated with weakened hip abductors. (Level of Evidence 1A) [47]
 Patellar realingment brace [40]

Not only is strengthening important, but stretching should also be

part of the programme. (Level of Evidence 1A) [10] It ha been shown
that patients with patellofemoral pain syndrome have shorter and
less flexible hamstrings than asymptomatic individuals.. Although
stretching can improve flexibility and knee function, it doesn’t
necessarily directly improve pain. (Level of Evidence 4) [48]

Another form of therapy is warm needling. In combination with

rehabilitation exercises it has a prolonged pain relieving effect than
in warm needling in combination with medication. (Level of
Evidence 1A)[49]

Ice medication

Ice may be useful for reducing pain in an acute flare up, but not
as a long term treatment protocol. [47] NSAIDS may also be of
benefit in the short term to relieve pain so that knee function and
mobility is normalised and an exercise programme can begin.

Taping and braces

Taping the patella to influence its movement may provide some

short term relief, but the evidence is varied. A commonly used
technique is ‘McConnell taping or kinesio taping. (Level of
Evidence 2B)[50][51]

Supporting the patella and knee joint by bracing is a further way

to reduce pain and symptoms, but it will also alter patella tracking
and reduce active function of the quadriceps. Bracing may be
useful in the short term to offer patients some support and pain
relief to help them avoid antalgic movements and normalise gait as
much as possible. Bracing can also be used for patients pre- and
postoperatively, but a brace should allow variation in medial pull
on the patellar and pressure. (Level of Evidence 1A )[24] Wearing a
patellar realingment brace and following physical therapy has a
synergistic effect on patients with chondromalacia patellae. [40]

Foot Orthoses

Foot orthoses are another option for pain relief, but only in cases
where a lower limb mechanics is deemed to be contributing to the
knee pain, which may be due to: poor pronation control, excessive
lower limb internal rotation during weight bearing and an
increased Q-angle. (Level of Evidence 2B) [31] [24]

Foam roller

Using a foam roller cab be useful for relieving tight musculature

and reducing pressure over the patella.