We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Chondromalacia Patella
From WikiSM
(Redirected from Chondromalacia Patellae)
Contents
Other Names
- Chondromalacia Patellae (CMP)
- Chondromalacia of the patella
- Patellar chondral defects
- Idiopathic Chondromalacia Patellae
Background
- This page refers to chondromalacia of the Patella (CMP), a degenerative process of the articular cartilage
- It is a common cause of Patellofemoral Pain Syndrome, of which most clinical features overlap
History
- First described by Budinger in 1906 (need citation)
- Chondromalacia is derived from the Greek words
- Chrondros: cartilage
- Malakia: softening
Epidemiology
- Overall, epidemiology is poorly understood
- Men > women (need citation)
- Most common cause of chronic knee pain
Pathophysiology
- General: Chondromalacia (Main)
- The undersurface of the patella is covered with hyaline cartilage that articulates with the hyaline cartilage femoral groove
- Chondromalacia is defined by softening and then subsequent tearing, fissuring, and erosion of hyaline cartilage
- Causes include post-traumatic injuries, microtrauma wear and tear, and iatrogenic injections of medication
- Pain generation
- Poorly understood and likely multifactorial
Etiology
- Iatrogenic
- Chondrotoxic medications include Corticosteroids
- Overuse
- Majority of chondromalacia associated with repetitive microtrauma of the patellofemoral hyaline cartilage
- Patella Tracking issues
- Lateralization of the patella
- Tight lateral retinaculum
- Lateral synovial plica
- Patella Alta
- Patella Baja
- Other etiologies that can cause quad atrophy
- Complication of knee trauma
- Immobilization
- Surgical procedures
Pathoanatomy
- Patella
- Posterior surface covered with thick articular cartilage (up to 1 cm)
- Extensor Mechanism: Quadriceps Tendon inserts into Patella, Patella Tendon in turn attaches to Tibial Tubercle
- Patellofemoral Joint: Characterized by the articulation of the patella within the condylar groove of the femur
Risk Factors
- Biomechanical
- Abnormal Q Angle
- Pes Planus
- Genu Valgus
- Excessive pronation
- Patella Alta
- Muscle
- Tight Rectus Femorus
- Tight Tensa Fascia lata
- Tight Hamstrings
- Tight Gastrocnemius
- Vastus medialis insufficiency
Differential Diagnosis
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- History
- Patients will complain of anterior knee pain
- Worse with stairs, squatting, kneeling, running, prolonged periods of sitting
- May complain of bucking due to quadriceps inhibition reflex
- Onset is insidious
- Physical Exam: Physical Exam Knee
- Quadriceps muscle atrophy may be present
- Tenderness on palpating under the medial or lateral border of the patella
- Crepitus with range of motion
- Swelling/ effusion is often mild to non-exist
- Special Tests
- Patellar Grind Test: while supine with knee extended, apply a posteriorly directed force
- Patellar Apprehension Test: apply medial/lateral pressure while flexing/extending the knee
- Passive Patellar Glide: patella is moved medial/lateral with the knee fixed at 30° flexion
- Patella Alta Test
- Patellar Tilt Test: Attempt to lift lateral aspect of patella with thumb
- Squat Test: Patient is asked to perform repetitive squats
- Vastus Medialis Coordination Test
- Waldrens Test: Palpate patella while patient performs squats
- Step Down Test: Eccentric step down from an approx. 20 cm box
- Resisted Isometric Quadriceps Contraction
Evaluation
Radiographs
- Standard Knee Radiographs
- Often normal
- May show signs of Patellofemoral Arthritis
- Findings
- Chondrosis
- Shallow sulcus
- Patella Alta or Patella Baja
- Lateral patellar tilt
MRI
- Findings
- Increased signal in cartilage
CT
- Indications
- Fracture
- Evaluate patellofemoral alignment
- Findings
- Trochlear Geometry
- Tibial-tuberosity to trochlear groove distance (TT-TG distance)
Ultrasound
- Ultrasound is generally not indicated
- May be used to evaluate other causes of anterior knee pain
Classification
Outerbridge Classification
- Describes the severity of the degenerative process
- As seen on arthroscopy or MRI (fat saturated sequences)
- Often varied within the same knee
- Level 1
- Softening or swelling of the cartilage
- Arthroscopy: focal areas of hyper intensity with normal contour
- Level 2
- Defined by fibrillation, fragmentation of the hyaline cartilage
- Arthroscopy: blister-like swelling/fraying of articular cartilage extending to surface
- Level 3
- Fissuring of the articular cartilage to the level of subchondral bone, crab-meat appearance
- Arthroscopy: partial thickness cartilage loss with focal ulceration
- Level 4
- Eburnated bone devoid of articular cartilage covering.
- Arthroscopy: cartilage loss with underlying bone reactive changes
Management
Prognosis
- There is no definitive cure for chondromalacia patella
Nonoperative
- Indications
- Vast majority of patients
- General
- In most cases, management mirrors Patellofemoral Pain Syndrome
- There is no universally accepted standard of care
- Physical Therapy
- Emphasis on strengthening glutes, medial quadriceps
- Stretching of quadriceps
- Medications
- Patellar Brace
- Corticosteroid Injection
- Ice Therapy
- McConnel Taping (Kinesiology Taping)
- Foot Orthosis
- May be useful to correct pronation, internal rotation of foot, increased Q angle
Regenerative Therapy
- Mesenchymal Stem Cells
- One study of 3 patients showed benefit up to 1 year[1]
- Platelet Rich Plasma
- Prolotherapy
- One retrospective study showed statistically significant improvement in symptoms among patients[2]
Operative
- Indications
- Refractory cases
- Technique
- Chondral debridement
- Plica release
- Lateral retinacular release
- Patellar realignment surgery
Rehab and Return to Play
Rehabilitation
- No established guidelines
Return to Play
- No established guidelines
Complications
- Patellofemoral Osteoarthritis
- Inability to return to sport
- Chronic pain
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Pak, Jaewoo, Jung Hun Lee, and Sang Hee Lee. "A novel biological approach to treat chondromalacia patellae." PloS one 8.5 (2013): e64569.
- ↑ Hauser, Ross A., and Ingrid Schaefer Sprague. "Outcomes of prolotherapy in chondromalacia patella patients: improvements in pain level and function." Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders 7 (2014): CMAMD-S13098.
Created by:
John Kiel on 23 February 2021 16:12:10
Authors:
Last edited:
4 October 2022 15:54:18
Categories: