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Chondromalacia Patellar.pptx

  1. Chondromalacia Patellar Dr.Ahmad Merajul Hasan Inam
  2. • 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.
  3. • 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.
  4. 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
  5. 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.
  6. 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
  7. 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.
  8. • Specific evaluation of the patellofemoral joint should include assessment of pain, effusion, quadriceps strength, patella mobility, and crepitus.
  9. • 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.
  10. 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
  11. 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.
  12. • 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.
  13. 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.
  14. 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.
  15. • 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.
  16. 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.
  17. 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
  18. 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
  19. 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.
  20. • 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.
  21. • 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
  22. • 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
  23. • 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
  24. 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.