Chondromalacia Patellae

Overview:

Chondromalacia patellae refers to softening of the cartilage. The specific site where this degenerative change is usually seen is the undersurface of the knee cap. It is a condition where a young patient will present with clicking noises and inability to sit cross legged initially. Gradually this increases and the patient may develop resting pain post activity also. Most patients are young, females & have both sided involvement. Being young, they present late as most consider this self limiting.

Normal mechanics
Altered mechanics

Symptoms:

By the time these patients present to OPD they are found to have severe symptoms and in ability to perform ADL. Early stages of chondromalacia patellae have much better prognosis with only conservative therapy whereas later stages unanimously have a poorer prognosis with respect to high demand activities. There is a vague pain around the knee cap while and after performing ADL. Typically it presents with a clicking sound or crepitus on doing range of motion exercises at the knee typically involving bending beyond 90 degrees. Most common causes include a misaligned force tracking the knee cap abnormally. 

Treatment:

Correction of the biomechanics is perhaps the most important factor that provides long term relief in patients suffering from chondromalacia patellae. Most patients do well with only physiotherapy and rehabilitation but few may require a surgical procedure to cure the degenerating or osteochondral defects associated with it. Arthritis of the patello-femoral joint is a close differential. It has subtle differences from chondromalacia.

Differences between Chondromalacia patellae & Osteo-arthritis

Vastus medialis obliqus is a part of the quadriceps muscle and also the first muscle to go into weakness and pain with the advent of Chondromalacia and Patello-femoral pain syndrome. The strengthening of the abductors of the hip and the quadriceps muscle are essential to allevate symptoms. 

Illio-tibial band tightness is also considered a contributing factor in many athletes and may require sequential stretching and release to improve chondromalacia. Kinesio-taping in the hands of an expert physiotherapist may also have beneficial role in addition to orthotics. Severe cases , specially children with angular deformities may need surgical correction.

Trocheoplasty, Tibial tuberosity transfer, medial patellofemoral ligament reconstruction and lateral tissue release are common ones.

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MPFL reconstruction(green) & tibial tuberosity transfer(red) in a young female for severe chondromalacia patellae due to mal alignment.