Chondromalacia Patellae: Difference between revisions

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== Definition/Description  ==
== Definition/Description  ==


Chondromalacia patellae (CMP) is referred as anterior knee pain due to the physical and biomechanical changes <ref name="Lee Herrington et al.">Lee Herrington and Abdullah Al-Sherhi, A Controlled Trial of Weight-Bearing Versus Non–Weight-Bearing Exercises for Patellofemoral Pain, journal of orthopaedic sports physical therapy, 2007, 37(4), 155-160</ref>. It manifests as a softening, swelling, fraying, and erosion of the hyaline cartilage underlying the patella and sclerosis of underlying bone <ref name="gagliardi">Gagliardi et al., Detection and Staging of Chondromalacia Patellae: Relative Efficacies of Conventional MR Imaging, MR Arthrography, and CT Arthrography, ARJ, 1994, 163, 629-636</ref> which means that the articular cartilage of the posterior surface of the patella is going though  degenerative changes <ref name="radiography">http://www.e-radiography.net/radpath/c/chondromalaciap.htm</ref>.
Chondromalacia patellae (CMP) is referred to as anterior knee pain due to the physical and biomechanical changes <ref name="Lee Herrington et al.">Herrington L, Al-Sherhi A. [https://pubmed.ncbi.nlm.nih.gov/17469667/ A controlled trial of weight-bearing versus non-weight-bearing exercises for patellofemoral pain]. J Orthop Sports Phys Ther. 2007 Apr;37(4):155-60. doi: 10.2519/jospt.2007.2433. </ref>. The articular cartilage of the posterior surface of the patella is going though degenerative changes <ref name="radiography">http://www.e-radiography.net/radpath/c/chondromalaciap.htm</ref> which manifest as a softening, swelling, fraying, and erosion of the hyaline cartilage underlying the patella and sclerosis of the underlying bone. <ref name="gagliardi">Gagliardi JA, Chung EM, Chandnani VP, Kesling KL, Christensen KP, Null RN, et al. [https://www.ajronline.org/doi/10.2214/ajr.163.3.8079858 Detection and staging of chondromalacia patellae: relative efficacies of conventional MR imaging, MR arthrography, and CT arthrography]. AJR Am J Roentgenol. 1994 Sep;163(3):629-36. doi: 10.2214/ajr.163.3.8079858. </ref>


Chondromalacia patellae is one of the most frequently encountered causes of anterior knee pain among young people. It’s the number one cause in the United States with an incidence as high as one in four people.<sup>[51]</sup> The word chondromalacia is derived from the Greek words chrondros, meaning cartilage and malakia, meaning softening. Hence chondromalacia patellae is a softening of the articular cartilage on the posterior surface of the patella which may eventually lead to fibrillation, fissuring and erosion.<sup>[40]</sup>  
Chondromalacia patellae is one of the most frequently encountered causes of anterior knee pain among young people. It’s the number one cause in the United States with an incidence as high as one in four people.<ref name=":7">Laprade J, Culham E, Brouwer B. [https://pubmed.ncbi.nlm.nih.gov/9513865/ Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome]. J Orthop Sports Phys Ther. 1998; 27: 197–204
</ref> The word chondromalacia is derived from the Greek words - chrondros, meaning cartilage, and malakia, meaning softening. Hence chondromalacia patellae is a softening of the articular cartilage on the posterior surface of the patella which may eventually lead to fibrillation, fissuring, and erosion.<ref name=":6">Gordon HM. [https://www.sciencedirect.com/science/article/pii/S000495141461028X?via%3Dihub Chondromalacia patellae]. Aust J Physiother. 1977 Sep;23(3):103-6. doi: 10.1016/S0004-9514(14)61028-X.</ref>


<br>CMP is one of the main conditions under the blanket term, [[Patellofemoral Pain Syndrome|Patellofemoral pain syndrome]] (PFPS) <ref name="Lee Herrington et al." /><ref name="ubsport">http://www.ubsportsmed.buffalo.edu/education/patfem.html</ref>&nbsp;and is also known as Runner’s Knee.<ref name="orthopedics">http://orthopedics.about.com/cs/patelladisorders/a/chondromalacia.htm</ref><br>  
The differential diagnosis of chondromalacia includes [[Patellofemoral Pain Syndrome|patellofemoral pain syndrome]] and [[patellar tendinopathy|patellar tendinopathy]]. Chondromalacia patella is not considered to be under the umbrella term of PFPS.<ref name=":4">Wiles P, Andrews PS, Devas MB. [https://boneandjoint.org.uk/Article/10.1302/0301-620X.38B1.95 Chondromalacia of the patella]. Bone & Joint Journal. 1956 Feb 1;38(1):95-113.</ref><ref>Blazer K. Diagnosis and treatment of patellofemoral pain syndrome in the female adolescent. Physician Assistant. 2003 Sep 1;27(9):23-30.</ref><ref name=":5">Fernández-Cuadros ME, Albaladejo-Florín MJ, Algarra-López R, Pérez-Moro OS. [https://www.imbiodent.com/articulos/imagenes/articulos/pdfs/116/50.-efficiency-of-plateletrich-plasma-prp-comparedto-ozone-infiltrations-on-patellofemoral-painsyndrome-and-chondromalacia-_-1-.pdf Efficiency of Platelet-rich Plasma (PRP) Compared to Ozone Infiltrations on Patellofemoral Pain Syndrome and Chondromalacia: A Non-Randomized Parallel Controlled Trial]. Diversity & Equality in Health and Care. 2017 Aug 4;14(4):203-211</ref> The pathophysiology is different and therefore there is an alternative treatment.<ref name=":4" /><ref name=":5" />Chondromalacia patella can be present in patellofemoral pain but not everyone with patellofemoral pain syndrome will have chondromalacia patella.<ref>Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, Lynch AD, Snyder-Mackler L, McDonough CM. [https://www.jospt.org/doi/10.2519/jospt.2019.0302?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Patellofemoral Pain]. J Orthop Sports Phys Ther. 2019 Sep;49(9):CPG1-CPG95. doi: 10.2519/jospt.2019.0302. </ref>


== Clinically Relevant Anatomy [[Image:Vastus.png|thumb|right]] ==
== Clinically Relevant Anatomy ==
[[Image:Vastus.png|thumb|right]]  
The knee comprises 4 major bones: the femur, tibia, fibula and the patella. The patella articulates with the femur at the trochlear groove. <ref>http://emedicine.medscape.com/article/1898986-overview#aw2aab6b3 fckLR</ref> Articular cartilage on the underside of the patella allows the patella to glide over the femoral groove, necessary for efficient motion at the knee joint. <ref name="Anderson">Anderson MK. Fundamentals of Sports Injury Management, second edition, Lippincott Williams &amp; Wilkins, 2003, p. 208</ref> Excess and persistent turning forces on the lateral side of the knee can harm the nutrition of the articular cartilage and more specifically in the medial and central area of the patella, where degenerative change will occur more readily. <ref name="Beeton">Beeton KS. Manual Therapy Masterclasses: The Peripheral Joints, Churchill Livingstone, 2003, p.50-51</ref>


The knee&nbsp;comprises of 4 major bones: the femur, tibia, fibula and the patella. The patella articulates with the femur at the trochlear groove.  <ref>http://emedicine.medscape.com/article/1898986-overview#aw2aab6b3 fckLR(Levels of Evidence: 5E)</ref> Articular cartilage on the underside of the patella&nbsp;allows the patella to glide over the femoral groove, necessary for efficient motion at the knee joint. <ref name="Anderson">ANDERSON M. K. ,Fundamentals of Sports Injury Management, second edition, Lippincott Williams &amp; Wilkins, 2003, p. 208 (Levels of Evidence: 5F)</ref>&nbsp;Excess and persistent turning forces on the lateral side of the knee can have a negative effect on the nutrition of the articular cartilage and more specifically in the medial and central area of the patella, where degenerative change will occur more readily. <ref name="Beeton">BEETON K. S., Manual Therapy Masterclasses, The Peripheral Joints, Churchill Livingstone, 2003, p.50-51 fckLR(Levels of Evidence: 5E)</ref>[[Image:Femoral groove.png|thumb|right]]
The quadriceps insert into the patella via the quadriceps tendon and are divided into four separate muscles: rectus femoris (RF), vastus lateralis (VL), vastus intermedius (VI) and vastus medialis (VM). The VM has oblique fibres which are referred to as the vastus medialis obliques (VMO)<ref name="spieren">Kendall FP, Hulsman P, Zuidgeest A. Spieren: tests en functies, Nederland:Bohn Stafleu van Loghum, 469p (383)</ref>  


The quadriceps insert into the patella via the quadriceps tendon and are divided into four separate muscles: rectus femoris (RF), vastus lateralis (VL), vastus intermedius (VI) and vastus medialis&nbsp;(VM). The VM has oblique fibres which are referred to the vastus medialis obliques (VMO)<ref name="spieren">Florence Peterson Kendall et al., Spieren : tests en functies, Bohn Stafleu van Loghum, Nederland, 469p (383)</ref>
These muscles are active stabilisers during knee extension, especially the VL (on the lateral side) and the VMO (on the medial side). The VMO is active during knee extension but does not extend the knee. Its function is to keep the patella centred in the trochlea. This muscle is the only active stabiliser on the medial aspect, so its functional timing and amount of activity are critical to patellofemoral movement, the smallest change having significant effects on the position of the patella. [[Image:Femoral groove.png|thumb|right]]Not only do the quadriceps influence the patella position, but also the passive structures of the knee. These passive structures are more extensive and stronger on the lateral side than the medial side, with most of the lateral retinaculum arising from the iliotibial band (ITB). If the ITB is under excessive tension, excessive lateral tracking and/or lateral patellar tilt can occur. This is because the tensor fasciae lata is tight, as the ITB itself is a non-contractile structure.<ref name="Beeton" />.<br>  
 
These muscles are active stabilisers during knee extension, especially the VL (on the lateral side) and the VMO (on the medial side). The VMO is active during knee extension, but does not extend the knee. Its function is to keep the patella centred in the trochlea. This muscle is the only active stabiliser on the medial aspect, so it's functional timing and amount of activity is critical to patellofemoral movement, the smallest change having significant effects on the position of the patella.  
 
<br>Not only do the quadriceps influence patella position, but also the passive structures of the knee. These passive structures are more extensive and stronger on the lateral side than they are on the medial side, with most of the lateral retinaculum arising from the iliotibial band (ITB). If the ITB is under excessive tension, excessive lateral tracking and/or lateral patellar tilt can occur. This can as a result of&nbsp;the tensor fasciae lata being tight, as the ITB itself is a non contractile structure.&nbsp;<ref name="Beeton" />.<br>  


Other significant anatomical structures: [[Image:Q angle.png|thumb|right]]  
Other significant anatomical structures: [[Image:Q angle.png|thumb|right]]  


*Femoral anteversion <ref name="Nyland">NYLAND J et al., Femoral anteversion influences vastus medialis and gluteus medius EMG amplitude: composite hip abductor EMG amplitude ratios during isometric combined hip abduction-external rotation, Elsevier, vol. 14, issue 2, April 2004, p. 255-261. (Levels of Evidence: 2C)</ref> or medial torsion of the femur is a condition which changes the alignment of the bones at the knee. This may lead to overuse injuries of the knee due to malalignment of the femur in relation to the patella and tibia. <ref name="Milner">MILNER C. E., Functional Anatomy For Sport And Exercise: Quick Reference, Routledge, 2008, p. 58-60 fckLR(Levels of evidence: 5E)</ref>
*Femoral anteversion <ref name="Nyland">Nyland J, Kuzemchek S, Parks M, Caborn DN. [https://www.sciencedirect.com/science/article/abs/pii/S1050641103000786?via%3Dihub Femoral anteversion influences vastus medialis and gluteus medius EMG amplitude: composite hip abductor EMG amplitude ratios during isometric combined hip abduction-external rotation]. J Electromyogr Kinesiol. 2004 Apr;14(2):255-61. doi: 10.1016/S1050-6411(03)00078-6.  </ref> or medial torsion of the femur is a condition that changes the alignment of the bones at the knee. This may lead to overuse injuries of the knee due to malalignment of the femur to the patella and tibia. <ref name="Milner">Milner CE. Functional Anatomy For Sport And Exercise: Quick Reference, Routledge, 2008, p58-60 </ref>
 
*The [[Q Angle|Q-angle]]: or quadriceps angle is the geometric relationship between the pelvis, the tibia, the patella and the femur<ref name="Milner" /><ref name="Singh">Singh V. Clinical And Surgical Anatomy, second edition, Elsevier, 2007, p228- 230. </ref> and is defined as the angle between the first line from the anterior superior iliac spine to the centre of the patella and the second line from the centre of the patella to the tibial tuberosity <ref>Asseln M, Eschweiler J, Zimmermann F, Radermacher K. [https://www.degruyter.com/document/doi/10.1515/bmt-2013-4115/html The Q-Angle and its Effect on Active Knee Joint Kinematics - a Simulation Study]. Biomed Tech (Berl). 2013 Aug;58 Suppl 1:/j/bmte.2013.58.issue-s1-D/bmt-2013-4115/bmt-2013-4115.xml. doi: 10.1515/bmt-2013-4115.  </ref>.
*The [['Q' Angle|Q-angle]]: or 'quadriceps angle' is the geometric relationship between the pelvis, the tibia, the patella and the femur&nbsp;<ref name="Milner" />&nbsp;<ref name="Singh">SINGH V., Clinical And Surgical Anatomy, second edition, Elsevier, 2007, p. 228- 230. fckLR(Levels of Evidence: 2C)</ref> and is defined as the angle between the first line from the anterior superior iliac spine to the centre of&nbsp; the patella and the second line from the centre of the patella to the tibial tuberosity <ref>ASSLEN M. et al., The Q-angle and its Effect on Active Joint Kinematics – a Simulation Study, Biomed Tech 2013; 58 (suppl 1). (Levels of Evidence: 3B)</ref>.  


If there is an increased adduction and/or internal rotation of the hip, the Q angle will increase. When the Q angle is increased, the relative valgus of the lower extremity increases as well. This higher Q angle and valgus will increase the contact pressure on the lateral side of the patellofemoral joint (which is also increased by external rotation of the tibia) <ref name=":0">Erik P. Meira, Jason Brumitt. “Influence of the Hip on Patients With Patellofemoral Pain Syndrome: A Systematic Review.” Sports Health: A Multidisciplinary Approach, September/October 2011; vol. 3, 5: pp. 455-465</ref>  
If there is increased adduction and/or internal rotation of the hip, the Q-angle will increase, which increases the relative valgus of the lower extremity. This higher Q-angle and valgus will increase the contact pressure on the lateral side of the patellofemoral joint (which is also increased by external rotation of the tibia) <ref name=":0">Meira EP, Brumitt J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445210/ Influence of the hip on patients with patellofemoral pain syndrome: a systematic review]. Sports Health. 2011 Sep;3(5):455-65. doi: 10.1177/1941738111415006. </ref>


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==


The etiology of CMP is poorly understood, although it is believed that the causes of chondromalacia are injury, generalised constitutional disturbance and patellofemoral contact <ref name="iraj salehi">Iraj Salehi, Shabnam Khazaeli, Parta Hatami, Mahdi Malekpour, Bone density in patients with chondromalacia patella, Springer-Verlag, 2009</ref>,&nbsp;or as a result of trauma to the chondrocytes in the articular cartilage (leading to proteolytic enzymatic digestion of the superficial matrix). It amy also be caused by instability or maltracking of the patella which softens the articular cartilage. <ref name="Macmull">MACMULL S., The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae, International orthopaedics, Jul 2012, 36(7), 1371-1377. (Levels of Evidence: 1B)</ref> Chondromalacia patella is usually described as an overload injury, caused by malalignment of the femur to the patella and the tibia. <ref>BARTLETT R., Encyclopedia of International Sports Studies, Routledge, 2010, p. 90. (Levels of Evidence: 5F)</ref><br>
The aetiology of CMP is poorly understood, although it is believed that the causes of chondromalacia are injury, generalised constitutional disturbance and patellofemoral contact <ref name="iraj salehi">Salehi I, Khazaeli S, Hatami P, Malekpour M. [https://link.springer.com/article/10.1007/s00296-009-1149-3 Bone density in patients with chondromalacia patella]. Rheumatol Int. 2010 Jun;30(8):1137-8. doi: 10.1007/s00296-009-1149-3.</ref>, or as a result of trauma to the chondrocytes in the articular cartilage (leading to proteolytic enzymatic digestion of the superficial matrix). It may also be caused by instability or maltracking of the patella which softens the articular cartilage. <ref name="Macmull">Macmull S, Jaiswal PK, Bentley G, Skinner JA, Carrington RW, Briggs TW. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385894/ The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae]. Int Orthop. 2012 Jul;36(7):1371-7. doi: 10.1007/s00264-011-1465-6. </ref> Chondromalacia patella is usually described as an overload injury, caused by malalignment of the femur to the patella and the tibia. <ref>Bartlett R. Encyclopedia of International Sports Studies, Routledge, 2010, p90.</ref>  
 
Main reasons for patellar malalignment<br>
* Q-angle: An abnormality of the Q-angle is one of the most significant factors of Patellar malalignment. A normal Q-angle is 14° for men and 17° for women. An increase in Q-angle can result in an increased lateral pull on the patella.
* Muscular tightness of:
Rectus femoris: affects patellar movement during flexion of the knee.
 
Tensa Fascia late; affects the influence of the ITB


Hamstrings: during running tight hamstrings increase knee flexion which results in increased ankle dorsiflexion. This causes compensatory pronation in the talocrural joint.  
Main reasons for patellar malalignment;
* Q-angle: An abnormality of the Q-angle is one of the most significant factors of patellar malalignment. A normal Q-angle is 14° for men and 17° for women. An increase can result in an increased lateral pull on the patella.
* Muscular tightness of:
** Rectus femoris: affects patellar movement during flexion of the knee.
** Tensa Fascia late; affects the influence of the ITB
** Hamstrings: during running, tight hamstrings increase knee flexion resulting to increased ankle dorsiflexion. This causes compensatory pronation in the talocrural joint.
** Gastrocnemius: tightness will result in compensatory pronation in the subtalar joint.  


Gastrocnemius: tightness will result in compensatory pronation in the subtalar joint.
* Excessive pronation: prolonged pronation of the subtalar joint is caused by internal rotation of the leg. This internal rotation will result in malalignment of the patella.
* Excessive pronation: prolonged pronation of the subtalar joint is caused by internal rotation of the leg. This internal rotation will result in malalignment of the patella.
* Patella alta: this is a condition where the patella is positioned in an abnormally superior position. it is present when the length of the patellar tendon is 20% greater than the height of the patella.
* Patella alta: this is a condition where the patella is positioned in an abnormally superior position. It is present when the length of the patellar tendon is 20% greater than the height of the patella.
* Vastus medialis insufficiency: the function of the vastus medialis is to realign the patella during knee extension. If the strength of VM is insufficient this will cause a lateral drift of the patella.<ref>Jenny McConnell. “The management of chondromalacia patellae: a long term solution.” Australian Journal of Physiotherapy, volume 32, issue 4, 1986, pages 215-223</ref>
* Vastus medialis insufficiency: the function of the vastus medialis is to realign the patella during knee extension. If the strength of VM is insufficient this will cause a lateral drift of the patella.<ref>McConnell J. The management of chondromalacia patellae: a long term solution. Australian Journal of Physiotherapy; 1986, 32(4): 215-223</ref>
Muscular balance between the VL and VM is important. Where VM is weaker the patella is pulled too far laterally which can cause increased contact with the condylus lateralis, leading to degenerative disease.<ref name="aafp">http://www.aafp.org/afp/991101ap/2012.htm</ref> <br>
A muscular balance between the VL and VM is important. Where VM is weaker the patella is pulled too far laterally which can cause increased contact with the condylus lateralis, leading to degenerative disease.<ref name="aafp">http://www.aafp.org/afp/991101ap/2012.htm</ref>


Degenerative changes of the articular cartilage can be caused by <ref name="Logan">LOGAN A. L., The Knee Clinical Applications, Aspen Publishers, 1994, p. 131. (Levels of Evidence: 5F)</ref>:  
Degenerative changes of the articular cartilage can be caused by <ref name="Logan">Logan AL. The Knee Clinical Applications. Aspen Publishers, 1994, p131.</ref>:  


*Trauma: instability caused by a previous trauma or overuse during recovery
*Trauma: instability caused by previous trauma or overuse during recovery
 
*Repetitive microtrauma and inflammatory conditions
*Repetitive micro trauma and inflammatory conditions
*Postural distortion: causes malposition or dislocation of the patella in the trochlear groove


*Postural distortion: causes malposition or dislocation of the patella in the trochlear groove
Hip positioning and strength are linked to the prevalence of patellofemoral pain syndrome. Therefore, hip strengthening and stability exercises may be useful in the treatment program of patellofemoral pain syndrome.<ref name=":0" />


Hip positioning and strength are linked to the prevalence of patellofemoral pain syndrome. Therefore, hip strengthening and coordination exercises may be useful in the treatment program of patellofemoral pain syndrome.<ref name=":0" />  
Some authors use the term “patellar pain syndrome” instead of “chondromalacia” to describe “anterior knee pain”. <ref name="Manske">Manske RC. Postsurgical Orthopedic Sports Rehabilitation: Knee &amp; Shoulder, 2006, Mosby:Elsevier, p446-451.</ref>


Some authors use the term “patellar pain syndrome” instead of “chondromalacia” in order to describe “anterior knee pain”. <ref name="Manske">MANSKE R. C., Postsurgical Orthopedic Sports Rehabilitation: Knee &amp; Shoulder, 2006, Mosby Elsevier, p. 446, 451. (Levels of Evidence: 5E)</ref><br>  
== Stages of the Disease ==
In the early stages, chondromalacia shows areas of high sensitivity to fluid sequences. This can be associated with the increased thickness of the cartilage and may also cause oedema. In the latter stages, there will be a more irregular surface with focal thinning that can expand to and expose the subchondral bone. <ref name="Wessely">Wessely M, Young M. Essential Musculoskeletal MRI: A Primer for the Clinician. Churchill Livingstone Elsevier, 2011, p115.</ref>  


'''Stages of disease'''<br>In the early stages, chondromalacia shows areas of high sensitivity on fluid sequences. This can be associated with the increased thickness of the cartilage and may also cause oedema. In the latter stages, there will be a more irregular surface with focal thinning that can expand to and expose the subchondral bone. <ref name="Wessely">WESSELY M., YOUNG M., Essential Musculoskeletal MRI: A Primer for the Clinician, Churchill Livingstone Elsevier, 2011, p. 115. (Levels of Evidence: 5E</ref><br>Chondromalacia patella is graded based on the basis of arthroscopic findings, the depth of cartilage thinning and associated subchondral bone changes. Moderate to severe stages can be seen on [[MRI Scans|MRI]]. <ref name="Munk">MUNK P. L., RYAN A. G., Teaching Atlas of Musculoskeletal Imaging, Thieme, 2008, p. 68-70. (Levels of Evidence: 5E)</ref><br>  
Chondromalacia patella is graded based on arthroscopic findings, the depth of cartilage thinning and associated subchondral bone changes. Moderate to severe stages can be seen on [[MRI Scans|MRI]]. <ref name="Munk">Munk PL, Ryan AG. Teaching Atlas of Musculoskeletal Imaging. Thieme, 2008, p68-70.</ref>  


*Stage 1: softening and swelling of the articular cartilage due to broken vertical collagenous fibres. The cartilage is spongy on arthroscopy.
*Stage 1: softening and swelling of the articular cartilage due to broken vertical collagenous fibres. The cartilage is spongy on arthroscopy.
 
*Stage 2: blister formation in the articular cartilage due to the separation of the superficial from the deep cartilaginous layers. Cartilaginous fissures affecting less than 1,3 cm² in area with no extension to the subchondral bone.
*Stage 2: blister formation in the articular cartilage due to the separation of the superficial from the deep cartilaginous layers. Cartilaginous fissures affecting less than 1,3 cm2 in area with no extension to the subchondral bone.
 
*Stage 3: fissures ulceration, fragmentation, and fibrillation of cartilage extending to the subchondral bone but affecting less than 50% of the patellar articular surface.
*Stage 3: fissures ulceration, fragmentation, and fibrillation of cartilage extending to the subchondral bone but affecting less than 50% of the patellar articular surface.
*Stage 4: crater formation and eburnation of the exposed subchondral bone more than 50% of the patellar articular surface exposed, with sclerosis and erosions of the subchondral bone. Osteophyte formation also occurs at this stage.
*Stage 4: crater formation and eburnation of the exposed subchondral bone more than 50% of the patellar articular surface exposed, with sclerosis and erosions of the subchondral bone. Osteophyte formation also occurs at this stage.
 
Articular cartilage does not have any nerve endings, so CMP should not be considered as a true source of anterior knee pain,  rather, it is a pathological or surgical finding that represents areas of articular cartilage trauma or divergent loading. <ref name="Anderson" /> ''Kok et al'' showed that there is a significant association between subcutaneous knee fat thickness with the presence and severity of chondromalacia patellae. This could explain why women suffer more from the condition of chondromalacia than men.<ref>Kok HK, Donnellan J, Ryan D, Torreggiani WC. [https://www.sciencedirect.com/science/article/pii/S0846537112000423?via%3Dihub Correlation between subcutaneous knee fat thickness and chondromalacia patellae on magnetic resonance imaging of the knee]. Can Assoc Radiol J. 2013 Aug;64(3):182-6. doi: 10.1016/j.carj.2012.04.003. </ref>  
<br>Articular cartilage does not have any nerve endings, so CMP should not be considered as a true source of anterior knee pain,  rather, it is a pathological or surgical finding that represents areas of articular cartilage trauma or divergent loading. <ref name="Anderson"/> ''Kok et al'' showed that there is significant association between subcutaneous knee fat thickness with the presence and severity of chondromalacia patellae. This could explain why women suffer more from the condition chondromalacia than men &nbsp;<ref>KOK HK., Correlation between subcutaneous knee fat thickness and chondromalacia patellae on magnetic resonance imaging of the knee, Canadian Association of Radiologists journal, Aug 2013, 64(3), 182-186. (Levels of Evidence: 2B)</ref>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


There are important distinguishing features between chondromalacia patellae and [[Knee Osteoarthritis|Osteoarthritis]]. CMP affects just one side of the joint, the convex patellar side, <ref>ELLIS H., FRENCH H., KINIRONS M. T., French’s Index of differential diagnosis, 14th edition, Hodder Arnold Publishers, 2005. (Levels of Evidence: E)</ref>&nbsp;with excised patellas show localised softening and degeneration of the articular cartilage. <ref>ANDERSON J. R., Muir’s Textbook of Pathology, 12th edition, Lippincott Williams Wilkins, 1988 (Levels of Evidence: C)</ref> The main symptom of chondromalacia patellae is anterior knee pain,<ref name="iraj salehi" /> which is exacerbated by common daily activities that load the patellofemoral joint, such as running, stair climbing, squatting, kneeling <ref name="Lee Herrington et al." />,&nbsp;or changing from a sitting to a standing position <ref>MOECKEL E., NOORI M., Textbook of Pediatric Osteopathy, Elsevier Health Sciences 2008, p. 338. (Levels of Evidence: D)</ref>. The pain often causes disability affecting the short term participation of daily and physical activities.<ref name="Bill Vicenzino">Bill Vicenzino, Natalie Collins, Kay Crossley, Elaine Beller, Ross Darnell and Thomas McPoil, fckLRFoot orthoses and physiotherapy in the treatment of patellofemoralfckLRpain syndrome: A randomised clinical trial, BioMed Central, 2008</ref> Other symptoms are tenderness on palpating under the medial or lateral border of the patella <ref name="Shultz">SHULTZ S. J., HOUGLUM P. A., PERRIN D. H., Examination of Musculoskeletal injuries, third edition, Human Kinetics, 2010, p. 453. (Levels of Evidence: E)</ref>; crepitation, this may be demonstrated with motion <ref>DEGOWIN R. L., DEGOWIN E. L., DeGowin &amp; DeGowin’s Diagnostic Examination, 6th edition, McGraw Hill, 1994, p. 735. (Levels of Evidence: B)</ref>; minor swelling <ref name="Shultz" />; a weak vastus medialis muscle, and a high Q-angle <ref>EBNEZAR J., Textbook of Orthopedics¸ 4th edition, JP Medical Ltd, 2010, p. 426-427. (Levels of Evidence: E)</ref>. The vastus medialis is functionally divided into two components: the vastus medialis longus (VML) and the vastus medialis obliquus (VMO). The VML extends the knee, with the rest of the quadriceps muscle. The VMO does not extend the knee, but is active throughout knee extension. This component keeps the patella centred in the trochlea of the femur. <ref name="Beeton" />&nbsp;
There are important distinguishing features between chondromalacia patellae and [[Knee Osteoarthritis|Osteoarthritis]]. CMP affects just one side of the joint, the convex patellar side, <ref>Ellis H, French H, Kinirons MT. French’s Index of differential diagnosis. 14th edition, Hodder Arnold Publishers, 2005. </ref> with excised patellas show localised softening and degeneration of the articular cartilage. <ref>Anderson JR. Muir’s Textbook of Pathology. 12th edition, Lippincott Williams Wilkins, 1988</ref> The main symptom of chondromalacia patellae is anterior knee pain,<ref name="iraj salehi" /> which is exacerbated by common daily activities that load the patellofemoral joint, such as running, stair climbing, squatting, kneeling <ref name="Lee Herrington et al." />, or changing from a sitting to a standing position <ref>Moeckel E, Noori M. Textbook of Pediatric Osteopathy. Elsevier Health Sciences, 2008, p338.</ref>. The pain often causes disability affecting the short-term participation of daily and physical activities.<ref name="Bill Vicenzino">Vicenzino B, Collins N, Crossley K, Beller E, Darnell R, McPoil T. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2279129/ Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: a randomised clinical trial]. BMC Musculoskelet Disord. 2008 Feb 27;9:27. doi: 10.1186/1471-2474-9-27. PMID: 18304317; PMCID: PMC2279129.</ref> Other symptoms are tenderness on palpating under the medial or lateral border of the patella, <ref name="Shultz">Shultz SJ, Houglum PA, Perrin DH. Examination of Musculoskeletal injuries. 3rd edition. Human Kinetics, 2010, p453.</ref> crepitation (felt with motion), <ref name=":1">DeGowin RL, DeGowin EL. DeGowin &amp; DeGowin’s Diagnostic Examination. 6th edition. McGraw Hill, 1994, p735. </ref>; minor swelling, <ref name="Shultz" /> a weak vastus medialis muscle and a high Q-angle. <ref>Ebnezar J, Textbook of Orthopedics. 4th edition. India:JP Medical Ltd, 2010, p426-427. </ref> Vastus medialis is functionally divided into two components: the vastus medialis longus (VML) and the vastus medialis obliquus (VMO). The VML extends the knee, with the rest of the quadriceps muscle. The VMO does not extend the knee but is active throughout the knee extension. This component assists in keeping the patella centred in the femoral trochlea. <ref name="Beeton" />
 
<br>This condition <ref name="Shultz" />&nbsp;can cause a deficit in quadricep srength, therefore, building and/or maintaining quadriceps strength is essential.<ref name="Lee Herrington et al." /> A significant number of individuals are asymptomatic, but crepitation in flexion or extension is often present. <ref name="Murray">MURRAY R. O., JACOBSON H. G., The Radiology of Skeletal Disorders: exercises in diagnosis, second edition, Churchill Livingstone, 1990, p. 306-307. (Levels of Evidence: E)</ref>&nbsp;Chondromalacia is common in adolescents and females with idiopathic chondromalacia usually seen in young children and adolescents and the degenerative condition most common in the middle aged and older population. <ref name="Wessely" />  


This condition can cause a deficit in quadriceps strength, therefore, building and/or maintaining quadriceps strength is essential.<ref name="Lee Herrington et al." /> A significant number of individuals are asymptomatic, but crepitation in flexion or extension is often present. <ref name="Murray">Murray RO, Jacobson HG. The Radiology of Skeletal Disorders: exercises in diagnosis. 2nd edition. Churchill Livingstone, 1990, p306-307.</ref>Chondromalacia is common in adolescents and females with idiopathic chondromalacia usually seen in young children and adolescents and the degenerative condition is most common in the middle-aged and older population. <ref name="Wessely" />
== Differential Diagnosis  ==
== Differential Diagnosis  ==


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== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


Since its first description by Budinger in 1906, chondromalacia patella has been of significant clinical interest because diagnosis is often difficult. The chief reason for this is that the aetiology is often unknown and the correlation between the articular cartilage changes and the clinical system is poor. Patients affected by chondromalacia patella are young, between 15 and 35 years old, and many are highly active and are often considerably disabled by the symptoms of aching behind the patella, recurrent effusion of the knee, knee instability and crepitus.<ref>George Bentley, Ian J. Lesly and David Fischer. “Effect of aspirin treatment on chondromalacia patella” Annals of the rheumatic diseases, 1981, 40, p37-41.</ref>  
Since its first description by Budinger in 1906, chondromalacia patella has been of significant clinical interest because diagnosis is often difficult. The chief reason for this is that the aetiology is often unknown and the correlation between the articular cartilage changes and the clinical system is poor. Patients affected by chondromalacia patella are young, between 15 and 35 years old, and many are highly active and are often considerably disabled by the symptoms of aching behind the patella, recurrent effusion of the knee, knee instability and crepitus.<ref>Bentley G, Lesly IJ, Fischer D. Effect of aspirin treatment on chondromalacia patella. Annals of the rheumatic diseases, 1981; 40:37-41.</ref>  


The primary diagnostic approach for chondromalacia patellae is radiography with added arthrography. Key hole scintigraphy is a part of arthrography which is also used to diagnose the condition. <ref>Bahk YW, Park YH, Chung SK, Kim SH, Shinn KS. “Pinhole scintigraphic sign of chondromalacia patellae in older subjects: a prospective assessment with differential diagnosis.” Journal of Nuclear Medicine&nbsp;: Official Publication, Society of Nuclear Medicine 1994, 35(5):855-862</ref> MRI is an effective, non-invasive method with the ability to increase the sensitivity and specificity of the diagnosis .<ref>Kim, H. J., Lee, S. H., Kang, C. H., Ryu, J. A., Shin, M. J., Cho, K. J., &amp; Cho, W. S. (2011). Evaluation of the chondromalacia patella using a microscopy coil: comparison of the two-dimensional fast spin echo techniques and the threedimensional fast field echo techniques. Korean J Radiol, 12(1), 78-88</ref>  
The primary diagnostic approach for chondromalacia patellae is radiography with added arthrography. Pinhole scintigraphy, part of arthrography, is also used to diagnose the condition. <ref>Bahk YW, Park YH, Chung SK, Kim SH, Shinn KS. Pinhole scintigraphic sign of chondromalacia patellae in older subjects: a prospective assessment with differential diagnosis. J Nucl Med. 1994;35:855–862.</ref> MRI is an effective, non-invasive method with the ability to increase the sensitivity and specificity of the diagnosis.<ref>Kim HJ, Lee SH, Kang CH, Ryu JA, Shin MJ, Cho KJ, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3017887/ Evaluation of the chondromalacia patella using a microscopy coil: comparison of the two-dimensional fast spin echo techniques and the three-dimensional fast field echo techniques]. Korean J Radiol. 2011 Jan-Feb;12(1):78-88. doi: 10.3348/kjr.2011.12.1.78. </ref>  


== Outcome Measures  ==
== Outcome Measures  ==


There are different measurements: <ref>Crossley, Kay M., et al. "Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?." Archives of physical medicine and rehabilitation 85.5 (2004): 815-822.</ref><ref>Petersen, Wolf, et al. "Evaluating the potential synergistic benefit of a realignment brace on patients receiving exercise therapy for patellofemoral pain syndrome: a randomized clinical trial." Archives of orthopaedic and trauma surgery (2016): 1-8.</ref>
There are various measures: <ref>Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil. 2004 May;85(5):815-22. doi: 10.1016/s0003-9993(03)00613-0. </ref><ref name=":3">Petersen W, Ellermann A, Rembitzki IV, Scheffler S, Herbort M, Brüggemann GP, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4908172/ Evaluating the potential synergistic benefit of a realignment brace on patients receiving exercise therapy for patellofemoral pain syndrome: a randomized clinical trial]. Arch Orthop Trauma Surg. 2016 Jul;136(7):975-82. doi: 10.1007/s00402-016-2464-2. </ref>
* Anterior Knee Pain Scale: a 13 item questionnaire with categories related to various levels of current knee function.  
* Anterior Knee Pain Scale: a 13-item questionnaire with categories related to various levels of current knee function.  
* Visual analog scale
* Visual analog scale
*The five KOOS subscales: a scale about patients' experience over time with knee conditions. It consists of five subscales: Pain, other Symptoms, Function in daily living, Function in sport and recreation and knee related Quality of life.
*The five KOOS subscales: a scale about patients' experience over time with knee conditions. It consists of five subscales: Pain, other Symptoms, Function in daily living, Function in sport and recreation and knee-related Quality of life.


== <br>Examination  ==
== Examination ==
Examination of the knee is 4 fold: observation, mobility, feel, X-ray.<ref name=":6" />
* '''Observation''': joint appearance is usually normal, but there may be a slight effusion.
* '''Mobility''': 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.
* '''Feel''': 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 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.
* '''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.<br>


Examination of the knee is 4 fold: observation, mobility, feel, X-ray.<ref>Helen M. Gordon&nbsp;: CHONDROMALACIA PATELLAE1 1Delivered at the XV Biennial Congress of the Australian Physiotherapy Association, Hobart, February 1977. Australian Journal of Physiotherapy, Volume 23, Issue 3, September 1977, Pages 103-106</ref><br>'''Observation''': joint appearance is usually normal, but there may be a slight effusion.<br>'''Mobility''': passive movements are usually full and painless, but repeated extension of the knee from flexion will produce pain and grating underneath the patella, especially if the articular surfaces are pressed together.<sup>&nbsp;<br></sup>'''Feel''': Pain and crepitus will be felt if the patella is pressed 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 produce a sharp pain under the patella. This may be apparent in both knees, but more severe on the affected side.&nbsp;<br>'''X-ray:''' a 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.<br><br>  
=== Tests ===
The patient's posture can be an initial clue as well as any observed asymmetries, such as; limb alignment in standing, internal femoral rotation, anterior or posterior pelvic tilt, hyperextended or ‘locked back’ knees, genu varum or valgum and abnormal pronation of the foot. Gait patterns may also be affected. <ref name="spieren" />


'''Tests '''<br>The patient's posture can be an initial clue as well as any observed asymmetries, such as; limb alignment in standing, internal femoral rotation, anterior or posterior pelvic tilt, hyperextended or ‘locked back’ knees, genu varum or valgum and abnormal pronation of the foot. Gait pattern may also be affected. <sup>[9]</sup><br>Next you have to test the mobility / range of motion (ROM) of the joint. With chondromalacia there is very often a limitation in the ROM. When there is a bursitis present, a passive flexion or active extension will be painful. You can also test the isometric power of the muscles, here especially the quadriceps. The affected leg will show a loss of power, according to the non-injured leg. There are also some specific test to diagnose anterior knee pain syndrome, of which CMP is a part: <sup>[33]</sup>  
Mobility and range of motion (ROM) of the joint are tested, which can be limited. if bursitis is present, passive flexion or active extension will be painful. Loss of power in the affected leg may also be present on isometric testing. There are specific tests for anterior knee pain syndrome: <ref name=":1" />  


*[http://www.physio-pedia.com/Patellar_Grind_Test Patellar-grind test ]a.k.a. Clarke’s sign&nbsp;: The purpose of this test is to detect the presence of patellofemoral joint disorder. Patient is positioned in supine or long sitting with the involved knee extended. The examiner places the web space of his hand just superior to the patella while applying pressure. The patient is instructed to gently and gradually contract the quadriceps muscle. A positive sign on this test is pain in the patellofemoral joint. (http://www.physio-pedia.com/Patellar_Grind_Test )
*[http://www.physio-pedia.com/Patellar_Grind_Test Patellar grind test] or Clarke’s sign: This test detects the presence of patellofemoral joint disorder. A positive sign on this test is a pain in the patellofemoral joint.
*Compression test  
*Compression test  
*[http://www.physio-pedia.com/Knee_Extension_Resistance_Test Extension-resistance test]&nbsp;: The extension resistance test is used to perform a maximal provocation on the muscle-tendon mechanism of the extensor muscles. The extension resistance test is positive when the affected knee shows less power to hold the pressure. If positive we can say the extensor mechanism of the knee is disturbed. The patient is instructed to perform an extension of the knee joint, while the therapist exercises pressure in the opposite direction (flexion). The therapist evenly builds up his pressure, the patient is to allow no movement in the joint. Resistance tests should be performed on both knees and compared to one another. (http://www.physio-pedia.com/Knee_Extension_Resistance_Test)
*[http://www.physio-pedia.com/Knee_Extension_Resistance_Test Extension-resistance test]: This test is used to perform a maximal provocation on the muscle-tendon mechanism of the extensor muscles and is positive when the affected knee demonstrates less power when trying to maintain the pressure.  
*The critical test: This test is done with the patient in high sitting. The patient must do isometric quadriceps contractions in 5 different angles (0°, 30°, 60°, 90° and 120°) while the femur is externally rotated. The contraction must be sustained for 10 seconds. If pain is produced by the isometric contractions, then the leg has to be brought into full extension. In this position the patella and femur have no more contact. The lower leg of the patient is supported by the therapist so the quadriceps can be fully relaxed. When the quadriceps is relaxed, the therapist is able to glide the patella medially. This glide is maintained while the isometric contractions are performed again. If this reduces the pain and the pain is patellofemoral in origin, there is a higher chance in a favourable outcome.<sup>[51]</sup>
*The critical test: This is done with the patient in high sitting and performing isometric quadriceps contractions at 5 different angles (0°, 30°, 60°, 90° and 120°) while the femur is externally rotated, sustaining the contractions for 10 seconds. If pain is produced then the leg is positioned in full extension. In this position, the patella and femur have no more contact. The lower leg of the patient is supported by the therapist so the quadriceps can be fully relaxed. When the quadriceps is relaxed, the therapist can glide the patella medially. This glide is maintained while the isometric contractions are again performed. If this reduces the pain and the pain is patellofemoral in origin, there is a high chance of a favourable outcome.<ref name=":7" />


Note that it is still possible to diagnose incorrectly, these test may help in determine chondromalacia but it is best to rule out other diagnoses. <sup>[5]</sup><br><br>
It is possible to diagnose incorrectly and these tests may aid in determining chondromalacia, but other possible conditions also need to be excluded.


== Medical Management <br>  ==
== Medical Management   ==


Exercise and education are two very important parts of therapy. The education should help the patient to understand the problem and how he should deal with it for an optimal recovery. The exercises should be focused on stretching and strengthening the knee. Stretching of the hamstring, iliotibial band, quadriceps and gastrocnemius are the most important. Strengthening exercises of the gluteal muscle.<sup>[58]</sup> (level1) It is also proven that fire needling and acupuncture in high stress points could relieve clinical symptoms of chondromalacia patellae and recovers the biodynamicall structure of patellae. <sup>[50]</sup> (level 1A)
Exercise and education are two important aspects of a treatment programme. Education helps the patient to understand the condition and how they should deal with it for optimal recovery. Exercise focus is on stretching and strengthening appropriate structures, such as the hamstring, quadriceps and gastrocnemius length and strength of the gluteal muscles.<ref name=":2">Clark DI, Downing N, Mitchell J, Coulson L, Syzpryt EP, Doherty M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1753277/ Physiotherapy for anterior knee pain: a randomised controlled trial]. Ann Rheum Dis. 2000 Sep;59(9):700-4. doi: 10.1136/ard.59.9.700.</ref> Fire needling and acupuncture may also relieve clinical symptoms of chondromalacia patellae and recover the biodynamical structure of the patellae. <ref>Huang J, Li L, Lou BD, Tan CJ, Liu Z, Ye Y, et al. [[https://pubmed.ncbi.nlm.nih.gov/25112086/ Efficacy observation on chrondromalacia patellae treated with fire needling technique at high stress points]]. Zhongguo Zhen Jiu. 2014 Jun;34(6):551-4. </ref>


If conservative measures fail, though, there are a number of possible surgical procedures. These procedures take place when the symptoms remain the same after the conservative measures. <ref name="Munk" />
If conservative measures fail, there are several possible surgical procedures. <ref name="Munk" />
* '''Chondrectomy''': also known as shaving. This treatment includes shaving down the damaged cartilage to the non-damaged cartilage underneath. The success of this treatment depends on the severity of the cartilage damage. 
* '''Drilling''' is also a method that is frequently used to heal damaged cartilage. However, this procedure has not so far been proven to be effective. More localised degeneration might respond better to drilling small holes through the damaged cartilage. This facilitates the growth of healthy tissue through the holes from the layers underneath.
* '''Full patellectomy''': This is the most severe surgical treatment. This method is only used when no other procedures are helpful, but a significant consequence is that the quadriceps will become weak. 
Two other treatments that may be successful: <ref name="Logan" />  
*'''Replacement of the damaged cartilage:''' The damaged cartilage is replaced by a polyethylene cap prosthesis. Early results have been good, but the eventual wearing of the opposing articular surface is inevitable.


The first option is called <u>shaving</u>,&nbsp;also known as chondrectomy. This treatment includes shaving down the damaged cartilage, just to the not-damaged cartilage underneath. The success of this treatment depends on the severity of the cartilage damage. <br><u>Drilling</u> is also a method that is frequently used to heal the damaged cartilage. However, this procedure has not so far been proved to be effective. More localized degeneration might respond better to drilling small holes through the damaged cartilage. This facilitates the growth of the healthy tissue through the holes, from the layers underneath.  
*'''Autologous chondrocyte transplantation''' under a tibial periosteal patch. <ref name="Logan" />
Simply removing the cartilage is not a cure for chondromalacia patellae. The biomechanical deficits need addressing and there are various procedures to aid in managing this.
* Tightening of the medial capsule (MC): If the MC is lax, it can be tightened by pulling the patella back into its correct alignment.
* Lateral release: A very tight lateral capsule will pull the patella laterally. Release of the lateral patellar retinaculum allows the patella to track correctly into the femoral groove.
* Medial shift of the tibial tubercle: Moving the insertion of the quadriceps tendon medially at the tibial tubercle, allows the quadriceps to pull the patella more directly. It also decreases the amount of wear on the underside of the patellar.  
* Partial removal of the patella
Although there is no overall agreement for the treatment of chondromalacia, the consensus is that the best treatment is a non-surgical one.<ref name="r.van linschoten">van Linschoten R, van Middelkoop M, Berger MY, Heintjes EM, Verhaar JA, Willemsen SP, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2764849/ Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open-label randomised controlled trial]. BMJ. 2009 Oct 20;339:b4074. doi: 10.1136/bmj.b4074. </ref>


The most severe surgical treatment is a full patellectomy. This operation is only used when no other procedures were helpful. A big consequence is that the quadriceps will weaken very hard. Two potential treatments may be successful: <ref name="Logan" /><br>
== Physical Therapy Management  ==


*<u>Replacement of the damaged cartilage</u>&nbsp;: The damaged cartilage is replaced by a polyethylene cap prosthesis. Early results have been good, but eventual wearing of the opposing articular surface is inevitable.
=== Exercise Program ===
 
Conservative treatment of chondromalacia patellae is both physical and highly advised. Short-wave diathermy can help to relieve pain and to increase the blood supply to the area, improving the nutrition supply to the articular cartilage. Care must be taken when planning an exercise programme.<ref name=":2" /> Conservative therapeutic interventions include the following:<ref name=":8" />
*Autologous chondrocyte transplantation under a tibial periosteal patch. <ref name="Logan" />
*Isometric quadriceps strengthening and stretching exercises<ref name="Lee Herrington et al." /> 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.<ref name=":2" /> 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.<ref name="spieren" /><ref name="aafp" />It has shown that closed kinematic chain exercises can improve patellofemoral joint performance by increasing quadriceps muscle strength and patellar alignment correction.<ref>Bakhtiary AH, Fatemi E. [https://bjsm.bmj.com/content/42/2/99.long Open versus closed kinetic chain exercises for patellar chondromalacia]. Br J Sports Med. 2008 Feb;42(2):99-102; discussion 102. doi: 10.1136/bjsm.2007.038109. </ref>
 
<br> Simply removing the cartilage is not enough to cure chondromalacia patellae. The biomechanical problem needs addressing and there are various procedures to aid re-alignment&nbsp;: <br>1. <u>Thightening of the medial capsule (MC)</u>&nbsp;: If the MC is lax, it can be tightened by pulling the patella back into its correct alignment. <br>2. <u>Lateral release</u>&nbsp;: A very tight lateral capsule will pull the patella laterally. Release of the lateral patellar retinaculum allows the patella to track correctly into the femoral groove. <br>3. <u>Medial shift of the tibial tubercle </u>: Moving the insertion of the quadriceps tendon medially at the tibial tubercle, allows the quadriceps to pull the patella more directly. It decreases also the amount of wear on the underside of the patella.<br>4.<u>Removal of a portion of the patella</u><br>
 
Although there is no agreement of the treatment of chondromalacia, there is a general consensus that the best treatment is a non-surgical one.<ref name="r.van linschoten">R van Linschoten et al., Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial, BMJ, 2009</ref><br><br>
 
== Physical Therapy Management <br>  ==
 
<br>
 
'''Exercise Program'''<br>
 
Conservative treatment of chondromalacia patellae is both physical and advisory.<br>Short-wave diathermy helps to relieve pain and increase the blood supply to the area, so improving the nutrition to the articular cartilage. Care must be taken when planning the exercise programme. <sup>[40]</sup> ( level 3 )<br><br>The most common way to treat chondromalacia patellae is by strengthening the quadriceps muscle, because it has a very significant role in the movement of the patella.<ref name="Lee Herrington et al." /> The best way to do this is with isometric quadriceps exercises and isotonic exercises in inner range. Isotonic quadriceps exercises through full range will only lead to increased pain and even joint effusion.<sup>[40]</sup>(level3) Stretching of the vastus lateralis and strengthening of the vastus medialis is often recommended, but they are difficult to isolate because they have the same innervation and insertion.<ref name="spieren" /><ref name="aafp" /> Therefore, it’s easier to strengthen the whole quadriceps.<br>  
 
Since the positioning and strength of the hip has a significant influence on anterior knee pain, training its strength and coordination is recommended. An increased hip adduction angle is associated with weakened hip abductors, so strengthening the hip abductors is advised. <sup>[45]</sup>(Level 1A)<br>Many cases of chondromalacia patellae are self-limiting and treatment is primarily nonsurgical. Conservative therapeutic interventions include the following: <sup>[52]</sup>( level 5)
 
*Isometric quadriceps strengthening and stretching exercises – restoration of good quadriceps strength and function is an important factor in achieving good recovery.
*Hamstring stretching exercises  
*Hamstring stretching exercises  
*Temporary modification of activity  
*Temporary modification of activity  
*Patellar taping  
*Patellar taping  
*Foot orthoses  
*Foot orthoses  
*Non-steroidal anti-inflammatory drugs
*NSAIDs
 
*Hip strength and stability training, as hip positioning and strength have a significant influence on anterior knee pain.
<br>In this aspect of the therapy, make sure to give strength exercises, resistance exercises and coordination exercises of the quadriceps. Here is an example of an exercise program<ref name="p. van der tas">P. van der Tas J.M. Klomp-Jacobs; Chondropathie Patellae; Maatschap voor Sport-Fysiotherapie, Manuele Therapie en Medische Trainings Therapie</ref>:
*Hip abductor strengthening as an increased hip adduction angle is associated with weakened hip abductors.<ref name="Bleakley C" />  
 
*Patellar realignment brace<ref name=":3" />  
<br><br>'''Coordination Exercises'''
''<u></u>''
<blockquote>
*Sit with the IL on a rolled towel under the fossa popliteum with no weight on the leg. [[Image:1.JPG|right|75x45px|1.JPG]]<span style="font-size: 13.28px;">Extend the leg fast an relax slowly 50x</span>
<br></blockquote><blockquote>
*stand on one leg (IL) with the knee slightly bent. Tap the foot of the HL [[Image:2.JPG|right|46x49px|2.JPG]]in front, left, right and behind you on the floor
 
<br>
 
<br>
</blockquote><blockquote>
*Jumping: from left to right, from the back to the front, in a square and [[Image:3.JPG|right|149x47px|3.JPG]]in a diamond.
</blockquote>
<br>
 
<br>
<blockquote>
*By increasing the depth of a squat exercise progressively, the activity of the M. Gluteus Medius will increase. Thus, adding single-leg squats on a physioball to the program, lower extremity coordination and hip position in relation to the knee, may improve. Perform single-leg squats with a physioball between a wall and your back. the focus with this activity should be proper knee and hip positioning. <sup>[45]</sup>(Level 1A)
</blockquote><blockquote>
*Manual perturbations applied against the hip musculature in side lying with one leg raised. <sup>[45]</sup> (Level 1A)
 
*Performing a lunge with a twist. Perform a lunge while twisting your torso with your hands raised in front of you.<sup>[45]</sup> (Level 1A)
</blockquote>
<br> '''Strength Exercises'''<br>
<blockquote>
*Extend the IL for 10 seconds.[[Image:4.JPG|right|75x48px|4.JPG]]<br><br>
</blockquote> <blockquote>
*Strengthening the hip abductors begins with isometric exercises, performing prone heel squeezes will positively affect muscle recruitment of the hip abductors. <sup>[45]</sup> (Level 1A)<br><br>
</blockquote>
<br> '''<br>'''
 
'''Resistance Exercises'''
<blockquote>
*''<u></u>''sit at the front of a chair with both legs extended just above the floor.[[Image:6.JPG|right|70x75px|6.JPG]]<span style="font-size: 13.28px;">&nbsp;Push the heel of the healthy leg(HL) against the heel of the injured leg(IL).&nbsp;</span>Make sure there is no movement in both legs. Hold for 7 seconds.
</blockquote> <blockquote>
*Sit with the IL on a rolled towel under the fossa popliteum, [[Image:7.JPG|right|75x43px|7.JPG]]<span style="font-size: 13.28px;">with a weight on the leg</span>
 
<br>
 
<br>
</blockquote> <blockquote>
*Stand with the IL, slightly bent, in front of the extended HL. Bend the IL[[Image:8.JPG|right|47x50px|8.JPG]]<span style="font-size: 13.28px;">&nbsp;slowly. Make sure the knee never passes the foot. Move your&nbsp;</span>weight to the IL. When you feel pain, quit immediately.
 
<br>
 
<br>
</blockquote> <blockquote>
*stand with the IL on a step. Touch with the HL the floor by bending the [[Image:9.JPG|right|50x50px|9.JPG]]<span style="font-size: 13.28px;">IL, first with the toes, then with the foot, then with the heel of the foot.</span>
 
<br>
 
*Standing abduction with a resistance band. <sup>[45] </sup>(Level 1A)
 
<br>
 
*Side-to-side walking with a resistance band. <sup>[45]</sup> (Level 1A)
</blockquote>
<br> <br>
 
Not only do you have to strengthen the quadriceps, stretching is also important. And hereby you can also stretch the hamstrings and the iliotibial band. <ref name="Anderson" />&nbsp;It is proven that patients with patellofemoral pain syndrome have shorter hamstrings than asymptomatic controls. Also are their hamstrings less flexible. It is recommended to stretch this tissues because it seems to improve the flexibility and knee function. Though it doesn’t improve pain or function by stretching alone. Including stretching in the therapy, in addition to active treatments, gives positive outcomes. <ref>HARVIE D. et al., A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works?, J. Multidiscip Healthc. 2011, vol. 4, p. 383 – 392. (Levels of Evidence: 1A)</ref><br>
 
<br>
 
'''Ice &amp; Drugs'''
 
<br> Ice is sure to decrease pain, but is more frequently used to treat acute injuries. The efficacy of ice is questioned and the exact effect isn’t clear too. Therefore, more studies are required to create evidence based guidelines.<ref name="aafp" /><ref name="Bleakley C">Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sport Med. 2004; 32:251-261</ref><br>The benefit of anti-inflammatory drugs ([[NSAID Gastropathy|NSAID]]’s) has not yet been proved. Although a lot of treatments for CMP aren’t proved either, the potential side effects of NSAID’s may be more severe than the side effects of ice and exercise. Therefore, a judicious trail may be worthwile<ref name="aafp" />.<br>  
 
<br>'''Tapes and braces'''
 
<br> Taping the patella into a certain position may be helpful, but the scientific evidence is varied. A commonly used technique is the ‘[[Taping|McConnell taping]]’. When taped properly, the McConnell tape may have a short-term pain relief.<ref name="aafp" /><ref name="derasari a.">Derasari A. et al.;McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study; Journal of the American Physical Therapy association; 2010 March; 90(3): 411–419</ref><ref name="naoko aminaka">Naoko Aminaka Phillip A Gribble; A Systematic Review of the Effects of Therapeutic Taping on Patellofemoral Pain Syndrome; Journal of Athletic Training; 2005 Oct–Dec; 40(4): 341–351</ref><br>  
 
Every form of supporting the patella and knee joint has proven that it can possibly reduce pain and symptoms but it is also possible it will change the tracking of the patella. Though it can be helpful because during the rehabilitation, patients will avoid certain movements to reduce the pain. This can cause a less functioning of the quadriceps. So using a brace or every form of support, that relieves the patient from pain, may aid in the recovery, as they will dare to use their quadriceps. This can be used for patients preoperatively as well as postoperatively. However there is suggested to use a brace which allows variation in the medial patellar pull and pressure. <ref name="Manske" /><br>
 
<br>'''Foot Orthoses<br>'''
 
<br> Foot orthoses may be helpful in the pain relief of the knee, but only if the patient has signs of an excessive foot pronation, or a lower extremity alignment profile that includes excessive lower extremity internal rotation during weight bearing and increased Q-angle at the same time as he suffers from chondromalacia. When made properly, the orthotics will cause biomechanical changes (for example: a reduction in the Q-angle and internal rotation) in the lower leg by preventing overpronation in pes planus and providing a better support for normal feet and [[Pes cavus]].<ref name="Bill Vicenzino" /><ref name="aafp" /> <ref name="Manske" /><br>
 
&nbsp;
 
'''Other'''  
 
Using a foam roller could also be considered due to its pain relieving effect. Running on an injury will leave you with tight and stiff muscles, which a foam roller and some quad stretching can loosen up. Just take care not to stretch if it irritates your knee.<sup>[54]</sup>
 
<sup></sup>
 
== Key Research&nbsp;  ==
 
<sup></sup>
 
== <sup></sup>Resources  ==
 
[http://www.tlichtpuntje.be/info/patellaafwijkingen.htm http://www.tlichtpuntje.be/info/patellaafwijkingen.htm ]<br>[https://en.wikipedia.org/wiki/Chondromalacia_patellae https://en.wikipedia.org/wiki/Chondromalacia_patellae] <br>[http://www.physio-pedia.com/Patellar_Grind_Test http://www.physio-pedia.com/Patellar_Grind_Test ]<br>[http://www.physio-pedia.com/Knee_Extension_Resistance_Test http://www.physio-pedia.com/Knee_Extension_Resistance_Test] <br>[http://www.medicinenet.com/patellofemoral_syndrome/article.htm http://www.medicinenet.com/patellofemoral_syndrome/article.htm ]<br>
 
== Clinical Bottom Line  ==
 
<br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==


<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1RQQ955bivekjtuIeEbqjzR1uasP0NSfaxOzigsJzEwDNhsISG</rss>  
Not only is strengthening important, but stretching should also be part of the programme. <ref name="Anderson" /> It has been shown that patients with patellofemoral pain syndrome have shorter and less flexible hamstrings than asymptomatic individuals.. Although stretching can improve flexibility and knee function, it doesn’t necessarily directly improve pain.<ref>Harvie D, O'Leary T, Kumar S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215347/ A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works?] J Multidiscip Healthc. 2011;4:383-92. doi: 10.2147/JMDH.S24595.</ref>


<br>  
Another form of therapy is warm needling. In combination with rehabilitation exercises, it has a prolonged pain-relieving effect than in warm needling in combination with medication<ref>Qiu L, Zhang M, Zhang J, Gao LN, Chen DW, Liu J, et al. [https://www.sciencedirect.com/science/article/pii/S025462720960039X Chondromalacia patellae treated by warming needle and rehabilitation training]. J Tradit Chin Med. 2009 Jun;29(2):90-4. doi: 10.1016/s0254-6272(09)60039-x.</ref>


Read for Credit
=== Ice Medication ===
<div class="coursebox">
Ice may be useful for reducing pain in an acute flare-up, but not as a long-term treatment protocol.<ref name="Bleakley C">Bleakley C, McDonough S, MacAuley D. [https://journals.sagepub.com/doi/10.1177/0363546503260757?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials]. Am J Sports Med. 2004 Jan-Feb;32(1):251-61. doi: 10.1177/0363546503260757. </ref> NSAIDs may also be of benefit in the short term to relieve pain so that knee function and mobility are normalised and an exercise programme can begin.
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=== Taping and Braces ===
Would you like to earn certification to prove your knowledge on this topic?
Taping the patella to influence its movement may provide some short-term relief, but the evidence is varied. A commonly used technique is ‘[[Taping|McConnell taping]] or kinesiotaping. <ref name="derasari a.">Derasari A, Brindle TJ, Alter KE, Sheehan FT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836141/ McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study]. Phys Ther. 2010 Mar;90(3):411-9. doi: 10.2522/ptj.20080365.</ref><ref name="naoko aminaka">Aminaka N, Gribble PA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1323297/ A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome]. J Athl Train. 2005 Oct-Dec;40(4):341-51. </ref>


All you need to do is pass the quiz relating to this page in the Physiopedia member area.  
Supporting the patella and knee joint by bracing is a further way to reduce pain and symptoms, but it will also alter patella tracking and reduce the active function of the quadriceps. Bracing may be useful in the short term to offer patients some support and pain relief to help them avoid antalgic movements and normalise gait as much as possible.  Bracing can also be used for patients pre- and postoperatively, but a brace should allow variation in medial pull on the patellar and pressure.<ref name="Manske" /> Wearing a patellar realignment brace and following physical therapy has a synergistic effect on patients with chondromalacia patellae.<ref name=":3" />


[https://members.physio-pedia.com/quizzes/chondromalacia-patellae/ Go to Quiz]
=== Foot Orthoses ===
Foot orthoses are another option for pain relief, but only in cases where lower limb mechanics are deemed to be contributing to the knee pain, which may be due to:  
* Poor pronation control, 
* Excessive lower limb internal rotation during weight-bearing
* An increased Q-angle.<ref name="Bill Vicenzino" /> <ref name="Manske" />


<br>[http://members.physio-pedia.com/ Find out more about a Physiopedia membership]  
=== Foam Roller ===
Using a foam roller cab be useful for relieving tight musculature and reducing pressure over the patella.<ref name=":8">Macdonald GZ, Button DC, Drinkwater EJ, Behm DG. [https://journals.lww.com/acsm-msse/fulltext/2014/01000/foam_rolling_as_a_recovery_tool_after_an_intense.19.aspx Foam rolling as a recovery tool after an intense bout of physical activity]. Med Sci Sports Exerc. 2014 Jan;46(1):131-42. doi: 10.1249/MSS.0b013e3182a123db. </ref>


|}
</div>
== References  ==
== References  ==
<references />


<references /><br>  
<br>
<blockquote>39. McConnell, Jenny. "The management of chondromalacia patellae: a long term solution." Australian Journal of Physiotherapy 32.4 (1986): 215-223.<br>40. Helen M. Gordon&nbsp;: CHONDROMALACIA PATELLAE1 1Delivered at the XV Biennial Congress of the Australian Physiotherapy Association, Hobart, February 1977. Australian Journal of Physiotherapy, Volume 23, Issue 3, September 1977, Pages 103-106<br>41. Wibeeg, Gunnar. "Roentgenographs and anatomic studies on the femoropatellar joint: with special reference to chondromalacia patellae." Acta Orthopaedica Scandinavica 12.1-4 (1941): 319-410. <br>42. Bentley, George. "The surgical treatment of chondromalacia patellae." Bone &amp; Joint Journal 60.1 (1978): 74-81.<br>43. Bahk YW, Park YH, Chung SK, Kim SH, Shinn KS. “Pinhole scintigraphic sign of chondromalacia patellae in older subjects: a prospective assessment with differential diagnosis.” Journal of Nuclear Medicine&nbsp;: Official Publication, Society of Nuclear Medicine [1994, 35(5):855-862]<br>44. Calmbach, Walter L., and Mark Hutchens. "Evaluation of patients presenting with knee pain." Part II. Am Physician 68 (2003): 917-22.<br>45. Erik P. Meira, Jason Brumitt. “Influence of the Hip on Patients With Patellofemoral Pain Syndrome: A Systematic Review.” Sports Health: A Multidisciplinary Approach, September/October 2011; vol. 3, 5: pp. 455-465. (Level of Evidence: 1A)<br>46. KE Marks, G Bentley. “patella alta and chondromalacia.” Bone &amp; Joint Journal, vol. 60-B, no. 1, p71-73.<br>47. Marcus A. Rottermich, Neal R. Glaviano, Jiacheng Li, Joe M. Hart. “Patellofemoral pain.” Clin Sports Med 34 (2015), p313-327.<br>48. Eugene Hong, Michael C. Kraft. “Evaluating Anterior Knee Pain.” Med Clin N Am 98 (2014), p697-717.<br>49. Jenny McConnell. “The management of chondromalacia patellae: a long term solution.” Australian Journal of Physiotherapy, volume 32, issue 4, 1986, pages 215-223. <br>50. Zhongguo Zhen Jiu. 2014 Jun;34(6):551-4. [Efficacy observation on chrondromalacia patellae treated with fire needling technique at high stress points]<br>51. Laprade J, Culham E, Brouwer B (1998) Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 27: 197–204<br>52. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384485/chondromalacia_patellae.pdf <br>53. Kim, H. J., Lee, S. H., Kang, C. H., Ryu, J. A., Shin, M. J., Cho, K. J., &amp; Cho, W. S. (2011). Evaluation of the chondromalacia patella using a microscopy coil: comparison of the two-dimensional fast spin echo techniques and the threedimensional fast field echo techniques. Korean J Radiol, 12(1), 78-88. doi: 10.3348/kjr.2011.12.1.78<br>54. Davis, John. "Runner’s Knee: Symptoms, Causes and Research-Backed Treatment Solutions for Patellofemoral Pain Syndrome."<br>55. Petersen, Wolf, et al. "Evaluating the potential synergistic benefit of a realignment brace on patients receiving exercise therapy for patellofemoral pain syndrome: a randomized clinical trial." Archives of orthopaedic and trauma surgery (2016): 1-8.<br>56. Crossley, Kay M., et al. "Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?." Archives of physical medicine and rehabilitation 85.5 (2004): 815-822. <br>57. George Bentley, Ian J. Lesly and David Fischer. “Effect of aspirin treatment on chondromalacia patella” Annals of the rheumatic diseases, 1981, 40, p37-41. <br>58. CLARK, D. I., N. DOWNING, J. MITCHELL, L. COULSON, E. P. SYZPRYT, and M. DOHERTY. Physiotherapy for anterior knee pain: a randomised controlled trial. Ann. Rheum. Dis. 59:700–704, 2000.<br> </blockquote>
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Knee]] [[Category:Condition]] [[Category:Knee_Conditions]] [[Category:Musculoskeletal/Orthopaedics]]
[[Category:Knee]]  
[[Category:Conditions]]  
[[Category:Knee - Conditions]]  
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Sports Medicine]]

Latest revision as of 16:16, 25 March 2024

Original Editors - Francky Petit as part of the Vrije Universiteit Brussel's Evidence-based Practice project

Top Contributors - Francky Petit, Gianni Delmoitie, Scott Cornish, Admin, Kim Jackson, Ine Van de Weghe, Uchechukwu Chukwuemeka, Scott Buxton, George Prudden, Robbe Luyckx, Sem Bras, Tessa Fransis, 127.0.0.1, Nupur Smit Shah, Evan Thomas, WikiSysop, Wanda van Niekerk and Naomi O'Reilly

Definition/Description[edit | edit source]

Chondromalacia patellae (CMP) is referred to as anterior knee pain due to the physical and biomechanical changes [1]. The articular cartilage of the posterior surface of the patella is going though degenerative changes [2] which manifest as a softening, swelling, fraying, and erosion of the hyaline cartilage underlying the patella and sclerosis of the underlying bone. [3]

Chondromalacia patellae is one of the most frequently encountered causes of anterior knee pain among young people. It’s the number one cause in the United States with an incidence as high as one in four people.[4] The word chondromalacia is derived from the Greek words - chrondros, meaning cartilage, and malakia, meaning softening. Hence chondromalacia patellae is a softening of the articular cartilage on the posterior surface of the patella which may eventually lead to fibrillation, fissuring, and erosion.[5]

The differential diagnosis of chondromalacia includes patellofemoral pain syndrome and patellar tendinopathy. Chondromalacia patella is not considered to be under the umbrella term of PFPS.[6][7][8] The pathophysiology is different and therefore there is an alternative treatment.[6][8]Chondromalacia patella can be present in patellofemoral pain but not everyone with patellofemoral pain syndrome will have chondromalacia patella.[9]

Clinically Relevant Anatomy[edit | edit source]

Vastus.png

The knee comprises 4 major bones: the femur, tibia, fibula and the patella. The patella articulates with the femur at the trochlear groove. [10] Articular cartilage on the underside of the patella allows the patella to glide over the femoral groove, necessary for efficient motion at the knee joint. [11] Excess and persistent turning forces on the lateral side of the knee can harm the nutrition of the articular cartilage and more specifically in the medial and central area of the patella, where degenerative change will occur more readily. [12]

The quadriceps insert into the patella via the quadriceps tendon and are divided into four separate muscles: rectus femoris (RF), vastus lateralis (VL), vastus intermedius (VI) and vastus medialis (VM). The VM has oblique fibres which are referred to as the vastus medialis obliques (VMO)[13]

These muscles are active stabilisers during knee extension, especially the VL (on the lateral side) and the VMO (on the medial side). The VMO is active during knee extension but does not extend the knee. Its function is to keep the patella centred in the trochlea. This muscle is the only active stabiliser on the medial aspect, so its functional timing and amount of activity are critical to patellofemoral movement, the smallest change having significant effects on the position of the patella.

Femoral groove.png

Not only do the quadriceps influence the patella position, but also the passive structures of the knee. These passive structures are more extensive and stronger on the lateral side than the medial side, with most of the lateral retinaculum arising from the iliotibial band (ITB). If the ITB is under excessive tension, excessive lateral tracking and/or lateral patellar tilt can occur. This is because the tensor fasciae lata is tight, as the ITB itself is a non-contractile structure.[12].
Other significant anatomical structures:

Q angle.png
  • Femoral anteversion [14] or medial torsion of the femur is a condition that changes the alignment of the bones at the knee. This may lead to overuse injuries of the knee due to malalignment of the femur to the patella and tibia. [15]
  • The Q-angle: or quadriceps angle is the geometric relationship between the pelvis, the tibia, the patella and the femur[15][16] and is defined as the angle between the first line from the anterior superior iliac spine to the centre of the patella and the second line from the centre of the patella to the tibial tuberosity [17].

If there is increased adduction and/or internal rotation of the hip, the Q-angle will increase, which increases the relative valgus of the lower extremity. This higher Q-angle and valgus will increase the contact pressure on the lateral side of the patellofemoral joint (which is also increased by external rotation of the tibia) [18]

Epidemiology /Etiology[edit | edit source]

The aetiology of CMP is poorly understood, although it is believed that the causes of chondromalacia are injury, generalised constitutional disturbance and patellofemoral contact [19], or as a result of trauma to the chondrocytes in the articular cartilage (leading to proteolytic enzymatic digestion of the superficial matrix). It may also be caused by instability or maltracking of the patella which softens the articular cartilage. [20] Chondromalacia patella is usually described as an overload injury, caused by malalignment of the femur to the patella and the tibia. [21]

Main reasons for patellar malalignment;

  • Q-angle: An abnormality of the Q-angle is one of the most significant factors of patellar malalignment. A normal Q-angle is 14° for men and 17° for women. An increase can result in an increased lateral pull on the patella.
  • Muscular tightness of:
    • Rectus femoris: affects patellar movement during flexion of the knee.
    • Tensa Fascia late; affects the influence of the ITB
    • Hamstrings: during running, tight hamstrings increase knee flexion resulting to increased ankle dorsiflexion. This causes compensatory pronation in the talocrural joint.
    • Gastrocnemius: tightness will result in compensatory pronation in the subtalar joint.
  • Excessive pronation: prolonged pronation of the subtalar joint is caused by internal rotation of the leg. This internal rotation will result in malalignment of the patella.
  • Patella alta: this is a condition where the patella is positioned in an abnormally superior position. It is present when the length of the patellar tendon is 20% greater than the height of the patella.
  • Vastus medialis insufficiency: the function of the vastus medialis is to realign the patella during knee extension. If the strength of VM is insufficient this will cause a lateral drift of the patella.[22]

A muscular balance between the VL and VM is important. Where VM is weaker the patella is pulled too far laterally which can cause increased contact with the condylus lateralis, leading to degenerative disease.[23]

Degenerative changes of the articular cartilage can be caused by [24]:

  • Trauma: instability caused by previous trauma or overuse during recovery
  • Repetitive microtrauma and inflammatory conditions
  • Postural distortion: causes malposition or dislocation of the patella in the trochlear groove

Hip positioning and strength are linked to the prevalence of patellofemoral pain syndrome. Therefore, hip strengthening and stability exercises may be useful in the treatment program of patellofemoral pain syndrome.[18]

Some authors use the term “patellar pain syndrome” instead of “chondromalacia” to describe “anterior knee pain”. [25]

Stages of the Disease[edit | edit source]

In the early stages, chondromalacia shows areas of high sensitivity to fluid sequences. This can be associated with the increased thickness of the cartilage and may also cause oedema. In the latter stages, there will be a more irregular surface with focal thinning that can expand to and expose the subchondral bone. [26]

Chondromalacia patella is graded based on arthroscopic findings, the depth of cartilage thinning and associated subchondral bone changes. Moderate to severe stages can be seen on MRI. [27]

  • Stage 1: softening and swelling of the articular cartilage due to broken vertical collagenous fibres. The cartilage is spongy on arthroscopy.
  • Stage 2: blister formation in the articular cartilage due to the separation of the superficial from the deep cartilaginous layers. Cartilaginous fissures affecting less than 1,3 cm² in area with no extension to the subchondral bone.
  • Stage 3: fissures ulceration, fragmentation, and fibrillation of cartilage extending to the subchondral bone but affecting less than 50% of the patellar articular surface.
  • Stage 4: crater formation and eburnation of the exposed subchondral bone more than 50% of the patellar articular surface exposed, with sclerosis and erosions of the subchondral bone. Osteophyte formation also occurs at this stage.

Articular cartilage does not have any nerve endings, so CMP should not be considered as a true source of anterior knee pain, rather, it is a pathological or surgical finding that represents areas of articular cartilage trauma or divergent loading. [11] Kok et al showed that there is a significant association between subcutaneous knee fat thickness with the presence and severity of chondromalacia patellae. This could explain why women suffer more from the condition of chondromalacia than men.[28]

Characteristics/Clinical Presentation[edit | edit source]

There are important distinguishing features between chondromalacia patellae and Osteoarthritis. CMP affects just one side of the joint, the convex patellar side, [29] with excised patellas show localised softening and degeneration of the articular cartilage. [30] The main symptom of chondromalacia patellae is anterior knee pain,[19] which is exacerbated by common daily activities that load the patellofemoral joint, such as running, stair climbing, squatting, kneeling [1], or changing from a sitting to a standing position [31]. The pain often causes disability affecting the short-term participation of daily and physical activities.[32] Other symptoms are tenderness on palpating under the medial or lateral border of the patella, [33] crepitation (felt with motion), [34]; minor swelling, [33] a weak vastus medialis muscle and a high Q-angle. [35] Vastus medialis is functionally divided into two components: the vastus medialis longus (VML) and the vastus medialis obliquus (VMO). The VML extends the knee, with the rest of the quadriceps muscle. The VMO does not extend the knee but is active throughout the knee extension. This component assists in keeping the patella centred in the femoral trochlea. [12]

This condition can cause a deficit in quadriceps strength, therefore, building and/or maintaining quadriceps strength is essential.[1] A significant number of individuals are asymptomatic, but crepitation in flexion or extension is often present. [36]Chondromalacia is common in adolescents and females with idiopathic chondromalacia usually seen in young children and adolescents and the degenerative condition is most common in the middle-aged and older population. [26]

Differential Diagnosis[edit | edit source]

Diagnostic Procedures[edit | edit source]

Since its first description by Budinger in 1906, chondromalacia patella has been of significant clinical interest because diagnosis is often difficult. The chief reason for this is that the aetiology is often unknown and the correlation between the articular cartilage changes and the clinical system is poor. Patients affected by chondromalacia patella are young, between 15 and 35 years old, and many are highly active and are often considerably disabled by the symptoms of aching behind the patella, recurrent effusion of the knee, knee instability and crepitus.[37]

The primary diagnostic approach for chondromalacia patellae is radiography with added arthrography. Pinhole scintigraphy, part of arthrography, is also used to diagnose the condition. [38] MRI is an effective, non-invasive method with the ability to increase the sensitivity and specificity of the diagnosis.[39]

Outcome Measures[edit | edit source]

There are various measures: [40][41]

  • Anterior Knee Pain Scale: a 13-item questionnaire with categories related to various levels of current knee function.
  • Visual analog scale
  • The five KOOS subscales: a scale about patients' experience over time with knee conditions. It consists of five subscales: Pain, other Symptoms, Function in daily living, Function in sport and recreation and knee-related Quality of life.

Examination[edit | edit source]

Examination of the knee is 4 fold: observation, mobility, feel, X-ray.[5]

  • Observation: joint appearance is usually normal, but there may be a slight effusion.
  • Mobility: 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.
  • Feel: 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 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.
  • 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.

Tests[edit | edit source]

The patient's posture can be an initial clue as well as any observed asymmetries, such as; limb alignment in standing, internal femoral rotation, anterior or posterior pelvic tilt, hyperextended or ‘locked back’ knees, genu varum or valgum and abnormal pronation of the foot. Gait patterns may also be affected. [13]

Mobility and range of motion (ROM) of the joint are tested, which can be limited. if bursitis is present, passive flexion or active extension will be painful. Loss of power in the affected leg may also be present on isometric testing. There are specific tests for anterior knee pain syndrome: [34]

  • Patellar grind test or Clarke’s sign: This test detects the presence of patellofemoral joint disorder. A positive sign on this test is a pain in the patellofemoral joint.
  • Compression test
  • Extension-resistance test: This test is used to perform a maximal provocation on the muscle-tendon mechanism of the extensor muscles and is positive when the affected knee demonstrates less power when trying to maintain the pressure.
  • The critical test: This is done with the patient in high sitting and performing isometric quadriceps contractions at 5 different angles (0°, 30°, 60°, 90° and 120°) while the femur is externally rotated, sustaining the contractions for 10 seconds. If pain is produced then the leg is positioned in full extension. In this position, the patella and femur have no more contact. The lower leg of the patient is supported by the therapist so the quadriceps can be fully relaxed. When the quadriceps is relaxed, the therapist can glide the patella medially. This glide is maintained while the isometric contractions are again performed. If this reduces the pain and the pain is patellofemoral in origin, there is a high chance of a favourable outcome.[4]

It is possible to diagnose incorrectly and these tests may aid in determining chondromalacia, but other possible conditions also need to be excluded.

Medical Management[edit | edit source]

Exercise and education are two important aspects of a treatment programme. Education helps the patient to understand the condition and how they should deal with it for optimal recovery. Exercise focus is on stretching and strengthening appropriate structures, such as the hamstring, quadriceps and gastrocnemius length and strength of the gluteal muscles.[42] Fire needling and acupuncture may also relieve clinical symptoms of chondromalacia patellae and recover the biodynamical structure of the patellae. [43]

If conservative measures fail, there are several possible surgical procedures. [27]

  • Chondrectomy: also known as shaving. This treatment includes shaving down the damaged cartilage to the non-damaged cartilage underneath. The success of this treatment depends on the severity of the cartilage damage.
  • Drilling is also a method that is frequently used to heal damaged cartilage. However, this procedure has not so far been proven to be effective. More localised degeneration might respond better to drilling small holes through the damaged cartilage. This facilitates the growth of healthy tissue through the holes from the layers underneath.
  • Full patellectomy: This is the most severe surgical treatment. This method is only used when no other procedures are helpful, but a significant consequence is that the quadriceps will become weak.

Two other treatments that may be successful: [24]

  • Replacement of the damaged cartilage: The damaged cartilage is replaced by a polyethylene cap prosthesis. Early results have been good, but the eventual wearing of the opposing articular surface is inevitable.
  • Autologous chondrocyte transplantation under a tibial periosteal patch. [24]

Simply removing the cartilage is not a cure for chondromalacia patellae. The biomechanical deficits need addressing and there are various procedures to aid in managing this.

  • Tightening of the medial capsule (MC): If the MC is lax, it can be tightened by pulling the patella back into its correct alignment.
  • Lateral release: A very tight lateral capsule will pull the patella laterally. Release of the lateral patellar retinaculum allows the patella to track correctly into the femoral groove.
  • Medial shift of the tibial tubercle: Moving the insertion of the quadriceps tendon medially at the tibial tubercle, allows the quadriceps to pull the patella more directly. It also decreases the amount of wear on the underside of the patellar.
  • Partial removal of the patella

Although there is no overall agreement for the treatment of chondromalacia, the consensus is that the best treatment is a non-surgical one.[44]

Physical Therapy Management[edit | edit source]

Exercise Program[edit | edit source]

Conservative treatment of chondromalacia patellae is both physical and highly advised. Short-wave diathermy can help to relieve pain and to increase the blood supply to the area, improving the nutrition supply to the articular cartilage. Care must be taken when planning an exercise programme.[42] Conservative therapeutic interventions include the following:[45]

  • Isometric quadriceps strengthening and stretching exercises[1] 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.[42] 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.[13][23]It has shown that closed kinematic chain exercises can improve patellofemoral joint performance by increasing quadriceps muscle strength and patellar alignment correction.[46]
  • Hamstring stretching exercises
  • Temporary modification of activity
  • Patellar taping
  • Foot orthoses
  • NSAIDs
  • Hip strength and stability training, as hip positioning and strength have a significant influence on anterior knee pain.
  • Hip abductor strengthening as an increased hip adduction angle is associated with weakened hip abductors.[47]
  • Patellar realignment brace[41]

Not only is strengthening important, but stretching should also be part of the programme. [11] It has been shown that patients with patellofemoral pain syndrome have shorter and less flexible hamstrings than asymptomatic individuals.. Although stretching can improve flexibility and knee function, it doesn’t necessarily directly improve pain.[48]

Another form of therapy is warm needling. In combination with rehabilitation exercises, it has a prolonged pain-relieving effect than in warm needling in combination with medication[49]

Ice Medication[edit | edit source]

Ice may be useful for reducing pain in an acute flare-up, but not as a long-term treatment protocol.[47] NSAIDs may also be of benefit in the short term to relieve pain so that knee function and mobility are normalised and an exercise programme can begin.

Taping and Braces[edit | edit source]

Taping the patella to influence its movement may provide some short-term relief, but the evidence is varied. A commonly used technique is ‘McConnell taping or kinesiotaping. [50][51]

Supporting the patella and knee joint by bracing is a further way to reduce pain and symptoms, but it will also alter patella tracking and reduce the active function of the quadriceps. Bracing may be useful in the short term to offer patients some support and pain relief to help them avoid antalgic movements and normalise gait as much as possible. Bracing can also be used for patients pre- and postoperatively, but a brace should allow variation in medial pull on the patellar and pressure.[25] Wearing a patellar realignment brace and following physical therapy has a synergistic effect on patients with chondromalacia patellae.[41]

Foot Orthoses[edit | edit source]

Foot orthoses are another option for pain relief, but only in cases where lower limb mechanics are deemed to be contributing to the knee pain, which may be due to:

  • Poor pronation control,
  • Excessive lower limb internal rotation during weight-bearing
  • An increased Q-angle.[32] [25]

Foam Roller[edit | edit source]

Using a foam roller cab be useful for relieving tight musculature and reducing pressure over the patella.[45]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weight-bearing exercises for patellofemoral pain. J Orthop Sports Phys Ther. 2007 Apr;37(4):155-60. doi: 10.2519/jospt.2007.2433.
  2. ↑ http://www.e-radiography.net/radpath/c/chondromalaciap.htm
  3. ↑ Gagliardi JA, Chung EM, Chandnani VP, Kesling KL, Christensen KP, Null RN, et al. Detection and staging of chondromalacia patellae: relative efficacies of conventional MR imaging, MR arthrography, and CT arthrography. AJR Am J Roentgenol. 1994 Sep;163(3):629-36. doi: 10.2214/ajr.163.3.8079858.
  4. ↑ 4.0 4.1 Laprade J, Culham E, Brouwer B. Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 1998; 27: 197–204
  5. ↑ 5.0 5.1 Gordon HM. Chondromalacia patellae. Aust J Physiother. 1977 Sep;23(3):103-6. doi: 10.1016/S0004-9514(14)61028-X.
  6. ↑ 6.0 6.1 Wiles P, Andrews PS, Devas MB. Chondromalacia of the patella. Bone & Joint Journal. 1956 Feb 1;38(1):95-113.
  7. ↑ Blazer K. Diagnosis and treatment of patellofemoral pain syndrome in the female adolescent. Physician Assistant. 2003 Sep 1;27(9):23-30.
  8. ↑ 8.0 8.1 Fernández-Cuadros ME, Albaladejo-Florín MJ, Algarra-López R, Pérez-Moro OS. Efficiency of Platelet-rich Plasma (PRP) Compared to Ozone Infiltrations on Patellofemoral Pain Syndrome and Chondromalacia: A Non-Randomized Parallel Controlled Trial. Diversity & Equality in Health and Care. 2017 Aug 4;14(4):203-211
  9. ↑ Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, Lynch AD, Snyder-Mackler L, McDonough CM. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019 Sep;49(9):CPG1-CPG95. doi: 10.2519/jospt.2019.0302.
  10. ↑ http://emedicine.medscape.com/article/1898986-overview#aw2aab6b3 fckLR
  11. ↑ 11.0 11.1 11.2 Anderson MK. Fundamentals of Sports Injury Management, second edition, Lippincott Williams & Wilkins, 2003, p. 208
  12. ↑ 12.0 12.1 12.2 Beeton KS. Manual Therapy Masterclasses: The Peripheral Joints, Churchill Livingstone, 2003, p.50-51
  13. ↑ 13.0 13.1 13.2 Kendall FP, Hulsman P, Zuidgeest A. Spieren: tests en functies, Nederland:Bohn Stafleu van Loghum, 469p (383)
  14. ↑ Nyland J, Kuzemchek S, Parks M, Caborn DN. Femoral anteversion influences vastus medialis and gluteus medius EMG amplitude: composite hip abductor EMG amplitude ratios during isometric combined hip abduction-external rotation. J Electromyogr Kinesiol. 2004 Apr;14(2):255-61. doi: 10.1016/S1050-6411(03)00078-6.
  15. ↑ 15.0 15.1 Milner CE. Functional Anatomy For Sport And Exercise: Quick Reference, Routledge, 2008, p58-60
  16. ↑ Singh V. Clinical And Surgical Anatomy, second edition, Elsevier, 2007, p228- 230.
  17. ↑ Asseln M, Eschweiler J, Zimmermann F, Radermacher K. The Q-Angle and its Effect on Active Knee Joint Kinematics - a Simulation Study. Biomed Tech (Berl). 2013 Aug;58 Suppl 1:/j/bmte.2013.58.issue-s1-D/bmt-2013-4115/bmt-2013-4115.xml. doi: 10.1515/bmt-2013-4115.
  18. ↑ 18.0 18.1 Meira EP, Brumitt J. Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health. 2011 Sep;3(5):455-65. doi: 10.1177/1941738111415006.
  19. ↑ 19.0 19.1 Salehi I, Khazaeli S, Hatami P, Malekpour M. Bone density in patients with chondromalacia patella. Rheumatol Int. 2010 Jun;30(8):1137-8. doi: 10.1007/s00296-009-1149-3.
  20. ↑ Macmull S, Jaiswal PK, Bentley G, Skinner JA, Carrington RW, Briggs TW. The role of autologous chondrocyte implantation in the treatment of symptomatic chondromalacia patellae. Int Orthop. 2012 Jul;36(7):1371-7. doi: 10.1007/s00264-011-1465-6.
  21. ↑ Bartlett R. Encyclopedia of International Sports Studies, Routledge, 2010, p90.
  22. ↑ McConnell J. The management of chondromalacia patellae: a long term solution. Australian Journal of Physiotherapy; 1986, 32(4): 215-223
  23. ↑ 23.0 23.1 http://www.aafp.org/afp/991101ap/2012.htm
  24. ↑ 24.0 24.1 24.2 Logan AL. The Knee Clinical Applications. Aspen Publishers, 1994, p131.
  25. ↑ 25.0 25.1 25.2 Manske RC. Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder, 2006, Mosby:Elsevier, p446-451.
  26. ↑ 26.0 26.1 Wessely M, Young M. Essential Musculoskeletal MRI: A Primer for the Clinician. Churchill Livingstone Elsevier, 2011, p115.
  27. ↑ 27.0 27.1 Munk PL, Ryan AG. Teaching Atlas of Musculoskeletal Imaging. Thieme, 2008, p68-70.
  28. ↑ Kok HK, Donnellan J, Ryan D, Torreggiani WC. Correlation between subcutaneous knee fat thickness and chondromalacia patellae on magnetic resonance imaging of the knee. Can Assoc Radiol J. 2013 Aug;64(3):182-6. doi: 10.1016/j.carj.2012.04.003.
  29. ↑ Ellis H, French H, Kinirons MT. French’s Index of differential diagnosis. 14th edition, Hodder Arnold Publishers, 2005.
  30. ↑ Anderson JR. Muir’s Textbook of Pathology. 12th edition, Lippincott Williams Wilkins, 1988
  31. ↑ Moeckel E, Noori M. Textbook of Pediatric Osteopathy. Elsevier Health Sciences, 2008, p338.
  32. ↑ 32.0 32.1 Vicenzino B, Collins N, Crossley K, Beller E, Darnell R, McPoil T. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: a randomised clinical trial. BMC Musculoskelet Disord. 2008 Feb 27;9:27. doi: 10.1186/1471-2474-9-27. PMID: 18304317; PMCID: PMC2279129.
  33. ↑ 33.0 33.1 Shultz SJ, Houglum PA, Perrin DH. Examination of Musculoskeletal injuries. 3rd edition. Human Kinetics, 2010, p453.
  34. ↑ 34.0 34.1 DeGowin RL, DeGowin EL. DeGowin & DeGowin’s Diagnostic Examination. 6th edition. McGraw Hill, 1994, p735.
  35. ↑ Ebnezar J, Textbook of Orthopedics. 4th edition. India:JP Medical Ltd, 2010, p426-427.
  36. ↑ Murray RO, Jacobson HG. The Radiology of Skeletal Disorders: exercises in diagnosis. 2nd edition. Churchill Livingstone, 1990, p306-307.
  37. ↑ Bentley G, Lesly IJ, Fischer D. Effect of aspirin treatment on chondromalacia patella. Annals of the rheumatic diseases, 1981; 40:37-41.
  38. ↑ Bahk YW, Park YH, Chung SK, Kim SH, Shinn KS. Pinhole scintigraphic sign of chondromalacia patellae in older subjects: a prospective assessment with differential diagnosis. J Nucl Med. 1994;35:855–862.
  39. ↑ Kim HJ, Lee SH, Kang CH, Ryu JA, Shin MJ, Cho KJ, et al. Evaluation of the chondromalacia patella using a microscopy coil: comparison of the two-dimensional fast spin echo techniques and the three-dimensional fast field echo techniques. Korean J Radiol. 2011 Jan-Feb;12(1):78-88. doi: 10.3348/kjr.2011.12.1.78.
  40. ↑ Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil. 2004 May;85(5):815-22. doi: 10.1016/s0003-9993(03)00613-0.
  41. ↑ 41.0 41.1 41.2 Petersen W, Ellermann A, Rembitzki IV, Scheffler S, Herbort M, Brüggemann GP, et al. Evaluating the potential synergistic benefit of a realignment brace on patients receiving exercise therapy for patellofemoral pain syndrome: a randomized clinical trial. Arch Orthop Trauma Surg. 2016 Jul;136(7):975-82. doi: 10.1007/s00402-016-2464-2.
  42. ↑ 42.0 42.1 42.2 Clark DI, Downing N, Mitchell J, Coulson L, Syzpryt EP, Doherty M. Physiotherapy for anterior knee pain: a randomised controlled trial. Ann Rheum Dis. 2000 Sep;59(9):700-4. doi: 10.1136/ard.59.9.700.
  43. ↑ Huang J, Li L, Lou BD, Tan CJ, Liu Z, Ye Y, et al. [Efficacy observation on chrondromalacia patellae treated with fire needling technique at high stress points]. Zhongguo Zhen Jiu. 2014 Jun;34(6):551-4.
  44. ↑ van Linschoten R, van Middelkoop M, Berger MY, Heintjes EM, Verhaar JA, Willemsen SP, et al. Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open-label randomised controlled trial. BMJ. 2009 Oct 20;339:b4074. doi: 10.1136/bmj.b4074.
  45. ↑ 45.0 45.1 Macdonald GZ, Button DC, Drinkwater EJ, Behm DG. Foam rolling as a recovery tool after an intense bout of physical activity. Med Sci Sports Exerc. 2014 Jan;46(1):131-42. doi: 10.1249/MSS.0b013e3182a123db.
  46. ↑ Bakhtiary AH, Fatemi E. Open versus closed kinetic chain exercises for patellar chondromalacia. Br J Sports Med. 2008 Feb;42(2):99-102; discussion 102. doi: 10.1136/bjsm.2007.038109.
  47. ↑ 47.0 47.1 Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med. 2004 Jan-Feb;32(1):251-61. doi: 10.1177/0363546503260757.
  48. ↑ Harvie D, O'Leary T, Kumar S. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? J Multidiscip Healthc. 2011;4:383-92. doi: 10.2147/JMDH.S24595.
  49. ↑ Qiu L, Zhang M, Zhang J, Gao LN, Chen DW, Liu J, et al. Chondromalacia patellae treated by warming needle and rehabilitation training. J Tradit Chin Med. 2009 Jun;29(2):90-4. doi: 10.1016/s0254-6272(09)60039-x.
  50. ↑ Derasari A, Brindle TJ, Alter KE, Sheehan FT. McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study. Phys Ther. 2010 Mar;90(3):411-9. doi: 10.2522/ptj.20080365.
  51. ↑ Aminaka N, Gribble PA. A systematic review of the effects of therapeutic taping on patellofemoral pain syndrome. J Athl Train. 2005 Oct-Dec;40(4):341-51.


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