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Chondromalacia Patella (Runner's Knee)

I. Description

II. Causes

III. Symptoms

IV. Diagnosis

V. Treatment

VI. Exercises


Description

The term Chondromalacia Patella (Runner’s Knee) literally translated means “soft cartilage.” More specifically, the condition actually involves the fraying and degeneration of the cartilage underneath the Patella (kneecap). The undersurface of the patella is covered with a layer of smooth cartilage that normally glides effortlessly across the knee during bending of the joint. In some individuals, often athletes, the kneecap tends to rub against one side of the knee joint, and the cartilage surface becomes irritated and painful. Once the cartilage lining the patella has been damaged, the uneven surface area leads to further joint dysfunction, pain and grinding. Chondromalacia patella typically affects adolescents and young adults; knee pain in older adults is more commonly brought on by arthritis. Women are twice as likely to develop the condition, possibly due to the wider pelvis increasing the angle where the bones in the knee joint meet. Chondromalacia patella is also referred to as patellafemoral pain syndrome.

Causes

Chondromalacia Patella is a general term for damage and irritation of the cartilage under the kneecap that may be caused by:
  • Direct trauma such as fracture or dislocation
  • Sudden increase in exercise involving the knee (overuse)
  • Patellar Tracking Problems- the patella is misaligned due to muscle imbalances (see more below)
  • Bad Q-Angle: The Q-Angle is a measure of the angle between the quadriceps and the patella tendon. This measurement can be used to assess the alignment of the knee joint- helpful for determining propensity for overuse injuries and evaluating treatments. A well-aligned Q angle (measured while standing) is between 18 and 22 degrees. For women, it tends to be on the higher end, likely due to the wider pelvis. A higher than normal Q-angle can lead to patellar tracking problems, and Chondromalacia patella. Over pronation of the feet can also contribute to a higher Q-angle.

About Patellar Tracking Problems

Patellar tracking disorders are characterized by strength imbalances of the inner and outer thigh muscles which cause the patella (kneecap) to move outside of its natural groove (patellar tracking disorder). The patella is compressed against the condyles (round prominences on the end of bones) of the femur, damaging the layer of cartilage beneath. Weight training with poor form or biomechanical problems in the foot or ankle can cause these strength imbalances to develop. There are two types of patellar tracking problems: Patello-Femoral Arthralgia (PFA) and Excessive Lateral Pressure Syndrome (ELPS). Determining which type of patellar tracking problem may be present can provide insight for evaluating treatment options.

  • Patello-Femoral Arthralgia (PFA) If the lateral thigh muscle (Vastus lateralis) is weak, the patella will be pulled towards the inside of the joint- referred to as medial patellar tracking. The medial patellar facet is compressed into the medial femoral condyle causing excessive wear and tear, pain and grinding on the inside of the kneecap.
  • Excessive Lateral Pressure Syndrome (ELPS) If the medial thigh muscle is weak (Vastus medialis), the patella will be pulled towards the outside of the joint- (lateral patellar tracking). The lateral patellar facet is compressed against the lateral femoral condyle causing excessive wear and tear, pain and grinding on the outside of the kneecap. Improper foot pronation is a common cause of ELPS. Foot pronation refers to the natural side-to-side movement of the foot during walking or running. Normally, the foot rolls slightly inward with each step to disperse the weight of impact, and at the end of the gait cycle, the foot pushes off evenly from the front of the foot. Pronation problems include overpronation (the foot rolls excessively inwards in the push-off phase) and underpronation (the foot rolls excessively outward in the push-off phase).

Symptoms

Symptoms of Chondromalacia Patella include a dull, aching pain underneath the knee cap.
  • PFA: Pain on the inside of the kneecap, especially when walking uphill or climbing stairs.
  • ELPS: Pain on the outside of the kneecap especially walking downhill or descending stairs.
  • Pain when squatting or kneeling.
  • Sitting for prolonged periods of time with the knee bent at 90 degrees such as during a movie (known as “theatre knee”). Grinding noise or sensation when extending the knee.


Diagnosis

Orthopedic Tests

An orthopedic professional may use these tests to assess the presence and/or type of patellar tracking problems that may exist. Exercises may be helpful in reducing the muscle imbalances once the test. The appropriate exercise may be determined by the results of the orthopedic tests for PFA and ELPS.

Tests for Patello-Femoral Arthralgia (PFA): Medial Patella Scratch / Grinding Test

With the patient lying on the back with a fully straightened knee, the doctor will apply pressure 1322850254166to the kneecap, downward and to the medial aspect of the knee. As this position is held, the doctor will ask the patient to contract the thigh muscles (quadriceps). When the thigh muscles contract, the kneecap moves upwards and towards the center of the knee. If there is any inflammation present in the middle (medial) facet of the patella, a grinding sensation may be felt accompanied by hesitancy to contract the thigh muscles due to fear of pain. This is indicative of PFA. The following exercise may help strengthen the weaker lateral thigh muscle (Vastus lateralis).

EXERCISES FOR CORRECTING PATELLO-FEMORAL ARTHRALGIA (P.F.A.)

The goal of this exercise is to strengthen the weaker Vastus lateralis (outer quadriceps muscle). Patello-Femoral Arthraliga is characterized by a stronger inner thigh muscle (Vastus medialis) pulling the patella (kneecap) medially. Ankle weights (5 pounds) that wrap around the ankle or that may be draped over the ankle, or a weight machine are recommended for this exercise. 1322848400146

  1. Sit on the edge of chair or bench.
  2. Turn the toes inward, and extend the knees repeatedly the last 15 degrees of extension.
  3. Repeat three times a day, for three minutes at a time, over a three day period. After three days, increase the angle to 45, and then progress to 90 degrees, respectively for 3 days each. Continue over a 6-week period, increasing the ankle weight if able, to further challenge the muscles. 

 
Tests for Excessive Lateral Pressure Syndrome: Lateral Patella Scratch / Grinding Test

With the patient lying on the back with a fully straightened knee, the doctor will apply pressure to the kneecap, downward and to the outside (lateral aspect) of the knee1322846184160. As this position is held, the doctor will ask the patient to contract the thigh muscles (quadriceps). When the thigh muscles contract, the kneecap moves upwards and towards the center of the knee. If there is any inflammation present in the outside (lateral) facet of the patella, a grinding sensation or a hesitancy to contract the thigh muscles due to fear of pain may occur. This is indicative of ELPS. The following exercise may help improve the muscle stregnth of the medial thigh muscle (Vastus medialis).

EXERCISES FOR CORRECTING EXCESSIVE LATERAL PRESSURE SYNDROME (E.L.P.S.)

The goal of this exercises is to strengthen the weaker Vastus medialis (inner quadriceps muscle). Excessive Lateral Pressure Syndrome (ELPS) is characterized by a stronger inner thigh muscle (Vastus medialis) pulling the patella (kneecap) medially. Ankle weights (5 pounds) that wrap around the ankle or that may be draped over the ankle, or a weight machine are recommended for this exercise.
  1322849076119
  1. Sit on the edge of chair or bench. 
  2. Turn the toes outward, and extend the knees repeatedly the last 15 degrees of extension.
  3. Repeat three times a day, for three minutes at a time, over a three day period. After three days, increase the angle to 45, and then progress to 90 degrees, respectively for 3 days each. 
Continue the 90-degree extensions over a 4-week period, increasing the ankle weight if able, to further challenge and strengthen the muscles. At the end of a month, perform the same extension at 90 degrees but with the toes straight. This is a good exercise for preventing the opposite direction of patellar tracking disorder. It may also be beneficial to rotate back to the toes in, and toes out exercises, as well as toes straight, to define and work the whole quadriceps group.
 
Other types of testing: Although most cases of Chondromalacia Patella can be diagnosed with physical examination, history and symptoms there are other tests available.
  • X-rays- can visualize the Patella, but does not show details of the cartilage damage
  • Computerized tomography (CT scan)- This test combines X-ray images taken at many different angles, creating cross-sectional images of internal structures. CT scans image both bone and soft tissues, though higher levels of radiation are involved compared to x-rays.
  • Magnetic resonance imaging (MRI)- MRIs produce very detailed images of bones and soft tissues through the use of radio waves and a strong magnetic field. The cost is considerably higher than that of X-rays or CT scans, but is more effective at diagnosing Chondromalacia Patella.

Treatment

Some simple measures can be done at home to help reduce symptoms of Chondromalacia Patella (runner’s knee). Rest the knee as much as possible while in pain, avoiding activities that increase pain.

At-home remedies for Chondromalacia Patella

To attempt to reduce continued degeneration of the cartilage under the knee cap, muscle imbalance must be corrected. Exercies can be incorporated into a treatment program along with products that can help manage symptoms and further recovery.
  • Resistance bands will enable you to perform quadriceps exercises and encourage stretching of the leg muscles. This can improve muscle imbalances that contribute to Chondromalacia Patella. Additionally, resistance bands provide a low-impact, knee-friendly form of strength training.
  • Chondromalacia Patella knee braces provide mild to moderate support knee braces with patella cut out.
  • Neoprene braces or warming type of braces to keep muscles warm to assist in muscle function and firing sequence.
  • PFA Braces: medial U-shaped buttress to keep the patella from going too far medially.
  • ELPS braces: lateral u-shaped buttress to keep the patella from going too far laterally.
  • Knee ice packs- cold therapy products can help soothe inflamed tissues and bring pain relief. Ice the knee for 10-15 minutes as needed but not more than once every hour or as directed by your physician.
  • Knee-friendly exercise equipment – non-pounding exercise such as cycling, stretching, and gentle aerobic activity such as rebounding (trampoline) walking can also be beneficial for relieving knee pain symptoms as well as strengthening the knee against further damage.
  • Taping- Your physician may suggest taping the knee to provide support during activities. Follow your doctor’s instructions on taping the knee for your condition.
  • Knee pain gels- These topical analgesics provide temporary, targeted relief that can help during a painful episode. Pain gels also encourage gentle massage of the area upon application, an additional benefit that can help reduce pain.
  • Knee-friendly sports/activities such as cycling and swimming may reduce repetitive knee stress that tends to occur in some sports. You may opt to avoid higher-impact sports such as soccer, rugby, and running until your condition improves.
  • Medications- Your doctor may suggest over-the-counter medications such as ibuprofen and acetaminophen to help reduce symptoms.

Professional Treatment for Chondromalacia Patella

  • Chiropractic care- When the patella is tracking improperly, it gets stuck or subluxated (out of place) and needs to be mobilized with professional adjustment along with re-balancing of muscular strength of the quadriceps muscle. Custom made orthotics may be necessary to help support fallen arches which are causing knee biomechanical dysfunctions. Improper alignment of the bones in the foot’s arches may require manipulation to properly restore motion and function of the biomechanics of the foot.
  • Surgery- Your doctor may prescribe arthroscopic surgery, a procedure wherein an arthroscope — a pencil-thin device equipped with a camera lens and light — is surgically inserted into the knee through a tiny incision. Surgical instruments are passed through the arthroscope to remove fragments of damaged cartilage.
  • Realignment- Depending on the severity, surgery may be needed to realign the angle of the kneecap or relieve pressure on the kneecap.


Exercises

Addressing the muscle imbalances in the quadriceps is critical to helping reduce further damage to the cartilage under the kneecap and improve symptoms. The main goal in rehabilitative exercises for Chondromalacia patella involves balancing muscle strength of the knee. Resistance band exercises as well as simple extensions can be very effective.

Resistance Band Sitting Knee Extension
  1. Attach one end of a resistance band to something sturdy, or have someone hold one end. Tie/attach the other end to your ankle.
  2. Sitting on a firm, sturdy chair or surface, while keeping your back straight, slowly straighten your knee, tightening the front of your thigh (quadriceps). Perform 3 sets of 10 repetitions if able, always paying attention to your body's limit and stopping any activity that causes pain.
Resistance Band Hamstring Curl
  1. Attach one end of a resistance band to something sturdy, or have someone hold one end. Tie/attach the other end to your ankle.
  2. Lay on your stomach
  3. Slowly bend your knee, tightening the back of your thigh (the hamstrings). Perform 3 sets of 10 repetitions if able, always paying attention to your body's limit and stopping any activity that causes pain.
Quadriceps Extension Exercises

This exercises involves no motion of the leg, but rather allows a passive, gradual, full extension of the patella through contraction and relaxation of the thigh muscles. The gradual increase of stress into the patella during these exercises does not overwhelm the cartilage. This exercise can be used for any cause of Chondromalacia.

FULL EXTENSION
  1. Sit on the edge of a chair, and fully extend the legs with the feet resting on their heels.
  2. Contract and relax the quadriceps muscles while watching the patella move. Perform this three times a day for three minutes, over a period of three weeks. 
1322861355155             1322858823150
                                    
               
15-90 DEGREES OFF OF FULL EXTENSION

This exercise can be used for any cause of Chondromalacia. 
  1. Sit on the edge of a chair, and fully extend the legs with the feet resting on their heels.
  2. Contract and relax the quadriceps at 15 degrees off of full extension, for three minutes a day, three times a day, for three days. 
  • Then, increase the angle to 45 degrees off of full extension. Relax and contract the quadriceps muscles, again for three minutes a day, three times a day over a three-day period.
  • Finally, increase the angle to 90 degrees off of full extension, contracting and relaxing the quadriceps muscles for three minutes a day, three times a day, over a three-day period.

MYOFACIAL RELEASE FOR QUADRICEPS MUSCLE GROUP

Myofacial release is a kind of soft-tissue therapy that incorporates massage and stretching to relax contracted muscles and promote circulation. Incorporating myofacial release into your quadriceps exercise routine may help keep the quadriceps muscles flexible and better able to perform alignment exercises. These exercises may be used for any cause of Chondromalacia.

Using a foam roller is much like getting a massage, and some discomfort may occur as muscles tense muscles and tissues are worked. Go slowly, and start small. Try to breathe deeply and allow the muscles time to relax into an exercise. If performed regularly, these exercises may become more comfortable as the muscles adapt. You may wish to drink plenty of water after performing these exercises, as you would after a sports or deep-tissue massage.

To perform Myofascial Release exercises, you will need:

IT Band Roll

This exercise helps loosen up your Ilio-Tibial Band (ITB) that runs down the outside of your leg from your hip to your knee. 
  1. Position your  body to lie on your side, with your hip bones pointed vertically.
  2. Lay on the foam roller, positioning it beneath the under the side of the leg just below the hip joint. Support your body weight on your hands, and the opposite leg (which is crossed out in front of the leg on the roll).
  3. Roll back and forth from below the hip until just above the knee (do not go below the knee). This exercises may be painful to perform if your IT band is tight. As your ITB becomes looser the exercise may become less uncomfortable. To increase pressure at this point, extend your supporting leg.
TFL Roll

The Tensor fasciae latae (TFL) is a small muscle that runs from the hip to the top of the pelvis. This exercise can help you target this ar1323367016218ea.
  1. Lay on your side so that the roller is placed just above the hip joint (but not on the hip joint). If you set the roller just above the bony part of the hip and below the pelvis you should be in the location of the TFL.
  2. Roll the foam roller, keeping it limited to just this area. Because the muscle is small, this exercise will only require a small rolling motion.
  3. Perform anywhere from 2-5 minutes, as your comfort level allows. Remember that this area may be tense or tight, so some discomfort may occur. Go slowly, and allow the muscle time to relax into exercises. 
  4. Lay on your opposite side and repeat the above steps.

Quad Roll
  1. Lay face down on your elbows with the roller under your quadriceps (front upper legs).
  2. Roll from the bottom of your pelvis to above your knee (but not over the knee).
  3. Perform anywhere from 2-5 minutes, as your comfort level allows. Remember that this area may be tense or tight, so some discomfort may occur. Go slowly, and allow the muscle time to relax into exercises.

Calf Roll
  1. Supporting your body weight with your hands on the floor, place both legs on the foam roller. Keep the toes pointed up.
  2. Cross one leg over the top for added weight (optional). If you are able, as you perform this exercise try to keep your torso above the ground, supporting your weight with your hands. If you are unable to do this, sit and drag your torso along as your roll.
  3. Beginning with the foam roller at the ankle, roll the calf over the foam roller from the ankle to just below the knee. The first few rolls, continue to roll up and down over the legnth of the calf. Once you find a tight or tender spot, if your comfort level allows, use the roller to massage these areas.
  4. Perform anywhere from 2-5 minutes, as your comfort level allows. Remember that this area may be tense or tight, so some discomfort may occur. Go slowly, and allow the muscle time to relax into exercises.
  5. Repeat the above steps for the opposite leg (if you crossed one leg over the other).


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