Chondromalacia Patellar
Dr.Ahmad Merajul Hasan Inam

• In 1906, for the first time, pathological changes in the patellar cartilage were
reported by Budinger et al. Then, Kelly et al. described these
pathological changes as chondromalacia patellar (CMP). Originally, the word
"chondromalacia" stemmed from Greek words. Chrondros means cartilage,
and malakia means softening.

• In general, chondromalacia (sick cartilage) is an affliction of the hyaline
cartilage coating of the articular surfaces of the bone. Chondromalacia
patella (CMP) is when the posterior articular surface of the patella starts
losing its density when in a healthy state and becomes softer with subsequent
tearing, fissuring, and erosion of the hyaline cartilage.

Etiology
• Several paths can lead to the development of chondromalacia patellae.Which
are as followes-
1. Lower Limb Malalignment and Patellar Maltracking-Patellar
maltracking, Foot and ankle anatomic variances etc
2. Muscular Weakness
3. Patellar Lesions

Pathophysiology
• The pathology characteristically starts in the middle of the medial patellar
facet, or just distal to it, and starts small, measuring about half an inch or
more in diameter. This will then progress to cartilage fibrillation, fissuring,
and fragmentation in the more advanced stages.

Staging
• Outerbridge classification of chondromalacia patellae (5 grades from 0 to IV):
• Grade 0: Normal cartilage
• Grade I: Intact articular surface but soft, swollen, and oedematous.Some fibrillation and
heterogeneity of the cartilage may be noted, which is translated on the MRI as high
signal intensity
• Grade II: Fissures and fragmentation of the articular surface ( an area half an inch or
less in diameter)
• Grade III: Focal, partial thickness cartilaginous defect. (an area more than half an inch
in diameter)
• Grade IV: Full thickness defect down to the subchondral bone

History and Physical
• Anterior knee pain is the most common chief complaint of patients with
chondromalacia patellar; however, a high proportion of patients will present
with insidious onset.
• This pain is usually made worse with activities that increase the stress on the
patellofemoral joint, for example, stair ascending or more frequently
descending, squatting, kneeling, and running.
• In addition to the anterior knee pain, effusion, wasting of the quadriceps,
and retropatellar crepitus have all been reported in patients with CMP.

• Specific evaluation of the patellofemoral joint should include assessment of
pain, effusion, quadriceps strength, patella mobility, and crepitus.

• Subjective Findings-
On Set-The condition occurs gradually after overuse or is due to no known
cause.In adult in those from 20 to 50 years of age.
Duration-because of the gradual onset patient generally present for treatment
at least 6 to 12 weeks after onset.
Frequency- The pateient may be able to recall recurrent episodes of knee
problems going back to their teens.

Area of Symptoms- Anterior aspect of the knee and to a lesser extent at the
sides of the knee or distally over the anterolateral or anteromedial aspects of
the tibia.
Type of Symptoms- most common complaint is of an ache either during or
after activity

Objective Finding-
• On Observation: joint appearance is usually normal, but there may be a slight
effusion or swelling over the distal half of patella.
• Active Movement -there is usually no discomfort or restriction in range of motion
experienced on testing of active movements of the hip, knee, or ankle.
• Passive Movement: passive movements are usually full and painless, but repeated
extension of the knee from flexion will produce pain and a grating feeling
underneath the patella, especially if the articular surfaces are compressed together.

• Resisted Movements- Isometric testing of the musculature of the hip, knee
and ankle will demonstrate full strength and will elicit no discomfort.
• Palpation:The physical examination test, which specifically evaluates the
knee for chondromalacia patellae, is Clark's test.
• Pain and crepitus will be felt if the patella is compressed against the femur,
either vertically or horizontally, with the knee in full extension. By displacing
the patella medially or laterally, the patellar margins and their articular
surfaces may be felt.

Tenderness of one or other margin may be elicited and more frequently the felt
medially. Resisting a static quadriceps contraction will generally produce a sharp
pain under the patella. This may be apparent in both knees, but more severe on
the affected side.
The physical examination test, which specifically evaluates the knee for
chondromalacia patellae, is Clark's test.

Imaginary Evaluation
• X-ray: an AP view of the patellofemoral joint is needed to detect any
radiological change. In all but the most advanced cases, there is no
convincing radiological change. In the latter stages, patellofemoral joint space
narrows and osteoarthritic changes begin to appear.
• CT scan: gives more information with regard to patellofemoral alignment by
delineating trochlear geometry.

• Arthrography with plain radiographs or CT arthrography
• MRI scan: is the modality of choice for articular cartilage assessment with
the best appearances on the T2 sequences.
• Arthroscopy: This is the most efficient modality in
diagnosing chondromalacia, and determining the location and size of
cartilage lesions as well as patella position.

Treatment / Management
Conservative management-
• A trial of longstanding conservative management for at least one year should
be the first line of treatment. This includes rest, activity restriction, and
nonsteroidal anti-inflammatory medication, which is proven to be more
effective than steroids.

Operative Management-
Available options include patellar cartilage excision, shaving, drilling, proximal
soft tissue, and distal bony patellar realignment surgery. The most effective and
most straightforward surgery with avoidance of quadriceps fibrosis and
dysfunction is a patellar tendon medial realignment with lateral release and
reefing of the medial quadriceps expansion

Physiotherapy Management
Therapeutic modalities-
Therapeutic modalities like ultrasound, cold, Phonophoresis, Iontophoresis,
neuromuscular electrical stimulation, electrical stimulation for pain control,
electromyography biofeedback, and laser; when combined with other
treatments, may be of some benefit for pain management or other symptoms.
There was no consistent evidence of any beneficial effect when a therapeutic
modality was used alone in the treatment of CMP

Exercise Therapy-
• Effectiveness of exercise therapy in reducing anterior knee pain and
improving knee function in patients with CMP.
• Exercise therapy is more effective in treating PFPS than no exercise was
limited with respect to pain reduction, and conflicting with respect to
functional improvement. open and closed kinetic chain exercises are equally
effective.

• Close kinetic chain exercises within the terminal degrees of knee extension may
improve Patellofemoral joint performance by increasing quadriceps muscle strength
and patellar alignment correction.
• Isometric quadriceps strengthening and stretching exercises. 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.

• 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.
• It has shown that closed kinematic chain exercises can improve
patellofemoral joint performance by increasing quadriceps muscle strength
and patellar alignment correction

• Semisquat exercises (closed kinetic chain) are more effective than SLR
exercise (open kinetic chain) in the treatment of patellar Chondromalacia.
• Hip strengthening and a coordination program may be useful in a
conservative treatment plan for CMP

• Taping-
• McConnell Taping Shifts the Patella Inferiorly in Patients With
Patellofemoral Pain.Inferior shift in patellar displacement with taping
partially explains the decrease in pain due to increases in contact area.
• Patellar taping seems to reduce pain and improve function in people with
Patellofemoral pain syndrome during activities of daily living and
rehabilitation exercise

Bracing-
• A realignment brace on patients receiving exercise therapy the use of a
medially directed realignment brace leads to better outcomes in patients with
PFPS than exercise alone after 6 and 12 weeks of treatment.