1----

R. Peter Welsh

Patellofemoral Arthralgia, Overuse Syndromes of the Knee, and Chondromalacia Patella

Les athletes se plaignent tres souvent d'arthralgie femoro-patellaire. Le plus souvent, 1'examen ne permet pas de preciser la vraie pathologie. On peut entreprendre un traitement conservateur, un Conservative treatment, an active exercise programme d'exercices actifs et certains sports sans program, and sports may be undertaken effet dommageable au genou. I1 faut differencier le without harm to the knee. The patellofemoral syndrome d'arthralgie femoro-patellaire de la chondromalacie de la rotule, oCu il y a arthralgia syndrome must be differentiated degenerescence du cartilage articulaire de la rotule, from true chondromalacia patella, where there et des autres sources de derangement interne, telle is actual degeneration of the patella's articular une maladie du menisque ou des lesions cartilage, and from other sources of internal osteochondrales. Un questionnaire attentif derangement such as meniscal disease or concernant le mode de debut, les activites osteochondral lesions. Careful attention to the declenchantes comme le fait de monter des escaliers, history of onset, and provoking activities such s'agenouiller et s'accroupir, permettra au medecin d'identifier l'arthralgie femoro-patellaire. On doit as climbing stairs, kneeling, and crouching, aussi rechercher d'autres syndromes frequents de will allow the physician to recognize surutilisation et les diff6rencier des problemes patellofemoral arthralgia. Other common attribuables a un vrai derangement interne.

SUMMARY Patellofemoral arthralgia is a very common syndrome affecting athletes. Most often, examination fails to define true pathology.

SOMMAIRE

overuse syndromes also should be looked for, and differentiated from problems due to true Key words: Patellofemoral arthralgia, overuse internal derangement. (Can Fam Physician syndromes, chondromalaca patella 1985; 31:573-576).
Dr. Welsh is deputy chief of staff, and director of the sports medicine clinic, at the Orthopedic and Arthritic Hospital, Toronto, and an assistant professor at the University of Toronto. Reprint requests to: Suite 319, 43 Wellesley St. East, Toronto, ON. M4Y lHl.

chondromalacia patella is a very specific entity, whereby the articular cartilage of the patella and occasionally of the opposing patellofemoral groove degenerates. Fortunately, true chondromalacia patella is relatively rare, but crepitus and subpatellar pain are probably the most common complaints seen in a sports medicine clinic, where F ALL COMMON knee mala- most knee problems will have some Fdies, the patellofemoral derange- associated patellofemoral dysfunction. ments are the most difficult to manage. Peripatellar and subpatellar pain is very common, particularly in patients Patellofemoral Arthralgia The most common presenting sympwho participate in running and jumping sports, yet overt pathology is sel- tom is pain in or around the knee, dom evident. The spectrum of normal associated with running, jumping, anatomy and physiology is so wide kicking, kneeling or crouching. Disthat it is difficult to determine which comfort is commonly aggravated by variants predispose to pain and dys- ascending and descending stairs; a senfunction. Very often, the site and ori- sation of instability or crepitus may gin of pain around the knee remains also be noted. On examination, the obscure. only positive findings may be tenderToo often, this syndrome of knee- ness to palpation around or over the cap pain has been called chondromala- patella and its tendons, or to comprescia patella. -This is erroneous, for sion of the patella against the femoral
CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985

condyles. There are no signs of internal derangement, there is no effusion, no lost range of motion or ligamentous instability. There may be some mild quadriceps wasting and, occasionally, some retropatellar crepitus, but usually the examiner is unable to detect major abnormality. This can lead the physician to underestimate the significance of the patient's complaints, or to erroneously label the condition chondromalacia. Both approaches do the patient a gross disservice. A specific diagnosis should be made in every instance.

Etiologic factors The patella is a sesamoid bone lying in the quadriceps apparatus, which enhances the mechanical action of the muscles during extension. The patella is subject not only to the forces directed along the line of the quadriceps muscles and the infrapatellar tendon, but also to the resultant vectors of these forces.
573

the pathogenesis of this condition. One feature common to all patients with patellofemoral arthralgia is that repetitive activity has resulted in a chronic overload or overuse syndrome; pain and diminished function are the consequences. This syndrome results not from trauma but from simple, everyday use, as in sports. The repetitive nature of the activity, such as running Abnormal patellar pressures or jumping, exceeds the body's tolerInflexibility of the quadriceps mus- ance to withstand what are scarcely cles is probably the most common more than normal loads. cause of primary, abnormal patellar pressures. During the adolescent Clinical examination growth spurt, bone growth may outClinical examination should deterstrip the rate at which muscle fibers mine precisely the pain's site of origin. stretch, causing abnormal muscle Is the discomfort medially or laterally tightness and excessive compressive related to the retinaculae? Is it related forces across the patella. As a result, to the infrapatellar or subpatellar fat patellofemoral arthralgia is common in pad? Is it related to the synovial plica teenagers. down the medial side of the joint or in Muscle injury, with hematoma and the suprapatellar pouch? Effusion may scar formation can cause similar ab- or may not be present, and examinanormal muscle tightness, as can surgi- tion of the patella will determine cal intervention. Indeed, over-zealous whether or not crepitus is present. In capsular closure after arthrotomy may trying to detect patella crepitus, do not significantly tighten the capsule, be confused by crepitus arising from thereby increasing the patellofemoral the soft tissues of the fat pad and synpressures. ovium. True patellofemoral crepitus will be elicited when the knee is exAbnormal patellar excursion tended against resistance from a flexed The line of the quadriceps' force is position, and should be confirmed basically along the shaft of the femur. with the knee in full extension, with The physiologic valgus of the knee de- the patella pressed down and moved fines a Q angle between the pull of the gently sideways, medially and lamuscle and of the infrapatellar tendon. terally. If crepitus is elicited in this poIn the normal knee, the patella's natu- sition, the patella itself is involved. In ral tendency to displace laterally is re- most cases of patellar arthralgia, the sisted by the medial stabilizing struc- patella itself will be undamaged. The rest of the standard knee examtures, the distal fibers of the vastus medialis and the medial retinaculum. ination should determine that there is Lateral excursion is further limited by no ligamentous instability or meniscal the prominent lateral femoral condyle. derangement. Note the leg's overall Genu valgum, excessive external tibial alignment, particularly any tendency torsion and pes planus effectively in- to genu valgum and any increase in the crease the Q angle and the lateral force patella's Q angle. The examination is and may predispose to lateral subluxa- not complete until the feet have been thoroughly examined for any tendency tion. Failure of the medial structures to heel varus or valgus position. A (i.e., a lax retinaculum or weak quad- valgus heel will predispose to overriceps, shortening or tightness of the pronation of the forefoot, and may lateral stabilizing structures, and bony produce abnormal loading of the paanomalies such as a flattened lateral tella, particularly with running. femoral condyle) also predispose to force imbalance, resulting in lateral Radiologic review Plain AP, lateral and tunnel views tilting or lateral excursion (subluxation or dislocation) of the patella. Minimal give basic information about the but persistent recurrent subluxation of knee's medial and lateral compartthe patella is a major contributing fac- ments. Skyline views of the patella are tor in the development of chondroma- required in order to give an impression lacia patella-but patellofemoral pres- of its relation to the lower end of the sures and trauma are also important in femur. Views at 30 and 600 will show
574

An increase in quadriceps load results in abnormal patellar pressures. The resulting pain is believed to be due to stimulation of nerve endings in the underlying subchondral bone but may also relate to strain in the retinacula or impingement of the fat pad or the synovium which are both richly endowed with nerve elements.

how the medial and lateral facets relate to the underlying femur, and give information on the joint space and the thickness of articular cartilage. In true chondromalacia patella, where there may be great crepitus and marked degeneration of the articular cartilage, often the cartilage space is not diminished. Rather, there is almost hypertrophy of the cartilaginous surface.

Management
Nearly all these syndromes will respond to a conservative approach. Occasionally the aggravating activity may be carried out at a reduced level, coupled when necessary with altered technique and form. For example, a change from running to cycling may be necessary, the emphasis being on maintaining basic fitness until the process's natural history runs its course. Although physiotherapy with shortwave diathermy and ultrasound often relieves symptoms, intensive, individual exercise therapy must be maintained. Isometric quadricep setting and straight leg raising, followed by progressive, resisted exercises over the final five to ten degrees of knee extension are emphasized. Resisted exercises through the full range of motion are to be avoided, because they apply excessive compression across the patella. Sequential faradism can be applied if muscle bulk is significantly reduced. Stretching must be equally emphasized, in an effort to reduce the loads across the joint and at the same time enhance the strength of the muscle group. Orthotics aimed at correcting pes planus and heel valgus may help when the condition is contributing to abnormal patellar mechanics, particularly in association with genu valgum. The patient with patellofemoral arthralgia not due to true degeneration or wear must be reassured that continuing the activity is safe and will not lead to degeneration, chondromalacia, or patellofemoral arthritis. Many athletes with a patellofemoral overload syndrome fear that continuing the activity will harm them. In many cases, it is only by working at a modified level of activity, gradually pushing the threshold of tolerance upward, that athletes can overcome the disqomforts associated with this syndrome. A runner may be forced to continue with a
CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985

less demanding running program for many weeks before he can increase the mileage, and then he will find that as he strives for a new plateau, the syndrome will recur. However, if the examiner is convinced that there is no underlying pathology, the athlete can push on further with his sport. These syndromes are particularly troublesome not only to runners, but in most racquet sports and in any jumping sports such as basketball or volleyball.

Chondromalacia Patella
Few patients who present with a patellofemoral overload syndrome, or patellofemoral arthralgia, will actually have true degenerative wear. These are individuals with true chondromalacia patella. The pathogenesis of chondromalacia patella is poorly understood; abnormal patellofemoral excursion and patellofemoral pressure are two of the causative factors. Trauma may also be significant; there is no doubt that in the young patient, there is often a history of direct trauma to the front of the knee, from a fall or direct blow. In these patients, landing on the point of the patella causes it to impact against the femur, resulting in a direct contusion to the joint surface. This may well be the first stage in the breakdown of the cartilaginous surface, and may account for many cases of true chondromalacia patella. Often, however, there is no history of direct trauma to the knee, and hormonal factors may well have played a role in the development of this condition. During adolescence, and particularly during the growth spurt, the patella's articular cartilage appears to proliferate, without the orderly regulation of growth that normally prevails. As a result, the ground substance breaks down, and the collagenous fibrils of the articular cartilage become disrupted, instead of forming normal arcades. The cartilage becomes fronded and looks almost like crabmeat, with deep crypts and clefts down to the chondral plate. With this breach in the integrity of the articular surface, the mechanical forces on the cartilage become deranged and further degeneration occurs. For the patient with chondromalacia patella, patellar loading becomes very uncomfortable indeed. Stairs and steps are difficult, crouching and kneeling likewise almost impossible and any of
CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985

the running sports where jarring and impact loading occurs are impossible. Often there will be associated effusion and there's a coarse crepitus, which can be elicited on resisted loading of the knee when the leg is brought from a flexed to an extended position. Furthermore, in full extension any lateral movement of the patella is associated with very definite crepitus, and associated pain. Very commonly, one of the most troublesome symptoms is recurrent effusion in the knee. This may make definitive treatment necessary. Chondromalacia patella can truly be diagnosed only pathologically. This requires clinical review of the knee by direct visualization, and through a surgical specimen. Arthroscopy makes this much easier, and also makes it possible to debride some of the coarser areas. Often, this will be sufficient. The conservative management of chondromalacia patella follows the same pattern as that for patellofemoral arthralgia. In addition, patients may require nonsteroidal anti-inflammatory drugs. Enteric-coated ASA should be used for adolescents, particularly if they are going through the growth spurt. During this phase, the cartilage is at its most hypertrophic. The ASA definitely eases pain and has an antiinflammatory effect. It may also have a beneficial effect on the maturation of the articular cartilage, although this is unproven.

Chronic impingement syndromes often develop without specific history of trauma. With repetitive activity the fat pad becomes extremely sensitive, and examination will confirm distinct tenderness on either side of the ligamentum patella, and to patellar compression in the lower pole. Crepitus is often elicited, but this is soft, and should not be confused with crepitus of true chondromalacia patella. In my experience, problems with the fat pad occur far more frequently than true chondromalacia patella. With conservative treatments, fat pad syndromes will usually settle. Patients with true chondromalacia cannot exercise, but those with fat pad overload syndrome can certainly continue activity without fear of harm. Even so, some patients become so sensitive that even a steroid injection into the fat pad fails to give relief, and surgical excision becomes necessary.

Other Overuse Syndromes

Patellofemoral arthralgias must be differentiated from other very common overuse syndromes of the knee. These conditions are specific, defined entities which must not be confused with true internal derangements, such as meniscal pathology, ligamentous instability or osteochondral lesions of the joint surfaces.
Patellar tendonitis Inflammation of the distal tendon of the quadriceps muscle (suprapatellar tendonitis), of the origin of the infrapatellar tendon (infrapatellar tendonitis), and of the insertion of the infrapatellar tendon (Osgood-Schlatter disease), are all overuse syndromes associated with running and jumping. Pain and tenderness are usually localized to the inflamed area, the discomfort tends to develop during the course of the activity and often persists afterward. The initial treatments consist of physiotherapy with local ice frictions and ultrasound, and stretching exercises for the quadriceps. Oral nonsteroidal anti-inflammatory medications may be tried for ten to 15 days. As with all tendonitis, early aggressive treatment is more successful than later treatment when the condition is chronic. Occasionally a steroid injection into the tendon insertion may be needed,
575

Fat Pad Impingement

One of the most common forms of patellofemoral arthralgia, readily confused with chondromalacia patella, is the fat pad impingement syndrome. The significance of these very large, cushioning fat pads in the knee has often been overlooked. Lying deep to the ligamentum patella, they become pinched between the lower pole of the patella and the opposing femur. With repetitive activity they may hypertrophy, so that a tongue of tissue becomes pinched between the patella and the femur, leading to a painful overload syndrome. Acute impingement can occur with sudden forced extension of the knee. The fat pad is caught between the patella tendon and the underlying femoral condyle. The mechanism of injury can be elicited from the history, and from noting pain and tenderness, medial and lateral to the patella tendon or within the joint.

but be aware of tendon structures' propensity to collagenous breakdown. Also, infrapatellar tendons have been ruptured by injection at this site.

Osgood-Schlatter disease This is a localized tendonitis in adolescents, occurring at the insertion of the ligamentum patella into the proximal tibial epiphysis. Pressures on the sensitive growth area evoke a local discomfort which can be disabling. Ice, stretching exercises, and an infrapatellar strap may control pain and allow patients to continue sports. Osgood-Schlatter disease tends to be episodic and discomfort may sometimes be so severe that activity must be restricted for weeks at a time. Most adolescents pass through this condition in two to three years, but sometimes the symptoms persist until late adolescence or adulthood, with continuing problems around the tibial tubercle insertion. A localized ossicle of ununited epiphysis may be identified on plain X-rays, and excision required.

that it may be confused with internal derangement, but examination will reveal the tenderness is over the lateral femoral condyle, in the origin of the lateral ligament in the bursa, which underlies the iliotibial band. With this condition a runner must recognize that he cannot run further than the threshold of discomfort allows. When steady activity is maintained over a reduced distance, even at an increased pace, the condition will often disappear as mysteriously as it appeared. Ice friction treatments, ultrasound, stretching and strengthening exercises and oral anti-inflammatory medication are often necessary to alleviate the condition. Occasionally local steroid injection into the bursa may be indicated. Rarely, a surgical release becomes necessary.

Pes anserine bursitis Pes anserine bursitis is an inflammation of the bursa underlying the sartorius, gracilis and semitendinosis tendon complex on the medial aspect of the knee. This troublesome condition affects cyclists, runners and swimmers Prepatellar bursitis and is treated locally with ultrasound Prepatellar bursitis causes pain and and ice frictions. Oral anti-inflammaswelling in the bursal tissue over the tory medication and local steroids may patella's anterior surface. The bursitis also be helpful. results from either direct trauma or repeated irritation. A fluctuating swell- Retinaculitis ing can be aspirated, a local steroid inInflammation of the medial and latjected and a compression dressing eral patella stabilizing structures preapplied. Follow-up care with an antiover inflammatory medication and therapy sents with pain and tenderness over the the retinaculae, where they play with ultrasound will settle most cases. underlying femoral condyles, pinching In longstanding cases, surgical excithe synovium and evoking pain from it sion of the bursa may be necessary. due to repetitive loading of the knee. It is important to distinguish retinaculitis Iliotibial band bursitis from true chondromalacia, for the This is a troublesome inflammation prognosis is very different. Flexibility of the bursa underlying the distal por- exercises, particularly stretching out tion of the iliotibial tract on the lateral the quadriceps, and patella mobilizing aspect of the knee. It results from the therapy help relieve pressures over the friction of repetitive knee flexion and femoral condylar margins. extension, associated with impact If the capsule of the knee is unduly loading of the knee, as in jogging. tightened following arthrotomy, there This is a perplexing condition, because can be marked increase in pressures the athlete has no previous indication over the condylar margins, causing of injury. It may strike suddenly, even pain. Pain after surgery often stems during a race, with a sharp pain over from overtightening the capsule; postthe lateral femoral condyle. It becomes operative stretching exercises for the so painful within 100 yards or so that quadriceps are therefore an important the athlete is forced to discontinue the adjunct to any surgical intervention. activity. On walking, the knee seems to improve spontaneously, but the pain returns when attempts are made to run Surgical Treatments again. Most management of patellofemoral This condition is so acute in onset
576

arthralgia syndromes and the other overuse syndromes around the knee must remain conservative. However, there are occasions when symptoms become completely refractory to physiotherapy and exercise. With true chondromalacia patella it may be necessary to arrest progressive degeneration. In managing chondromalacia patella, arthroscopy can be used to debride and shave the back surface of the patella. At the same time, the lateral retinaculum is released to relieve some of the pressure on the patella's lateral facet. The longterm results of such intervention remain in question; in some cases there is dramatic short-term relief, in others results may be disappointing. Open arthrotomy and articular shaving has been advocated in the past, but these procedures alone have not been proven to have longterm benefit. However, when coupled with a procedure to alleviate the pressures on the patella (as in the elevation of the tibial tubercle insertion of the ligamentum patella), there can be a definite benefit. A Maquet procedure whereby the ligamentum patella insertion is elevated forward can definitely diminish pressures on the patella and significantly enhance results. The fat pad overload syndrome can occasionally be so refractory that direct intervention is necessary. Arthroscopic excision of the fat pad can be attempted, but this structure is very extensive, and extremely vascular. I prefer to carry out a small arthrotomy, excise the fat pad completely and carefully cauterize the base to control any bleeding. Release of the ligamentum patella at its origin occasionally may be necessary in the athlete with a refractory jumper's knee syndrome. Similarly, release of the iliotibial tract may be necessary in those with ongoing symptoms from iliotibial friction syndrome.

Conclusion
The common patellofemoral arthralgias must be clearly differentiated from "true" pathologic processes such as chondromalacia and other internal derangements. These syndromes, though troublesome, can allow the athlete to continue an active sports program without fear of damaging the knee.
CAN. FAM. PHYSICIAN Vol. 31: MARCH 1985