Chondromalacia Patellae

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Definition/Description[edit | edit source]

Chondromalacia patellae (CMP) is referred as anterior knee pain due to the physical and biomechanical changes [1]. It manifests as a softening, swelling, fraying, and erosion of the hyaline cartilage underlying the patella and sclerosis of underlying bone [2] which means that the articular cartilage of the posterior surface of the patella is going though degenerative changes [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.[51] 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.[40]


CMP is one of the main conditions under the blanket term, Patellofemoral pain syndrome (PFPS) [1][4] and is also known as Runner’s Knee.[5]

Clinically Relevant Anatomy
Vastus.png
[edit | edit source]

The knee comprises of 4 major bones: the femur, tibia, fibula and the patella. The patella articulates with the femur at the trochlear groove. [6] 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. [7] 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. [8]

Femoral groove.png

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 the vastus medialis obliques (VMO)[9]

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.


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 the tensor fasciae lata being tight, as the ITB itself is a non contractile structure. [8].

Other significant anatomical structures:

Q angle.png
  • Femoral anteversion [10] 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. [11]
  • The Q-angle: or 'quadriceps angle' is the geometric relationship between the pelvis, the tibia, the patella and the femur [11] [12] 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 [13].

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) [14]

Epidemiology /Etiology[edit | edit source]

The etiology of CMP is poorly understood, although it is believed that the causes of chondromalacia are injury, generalised constitutional disturbance and patellofemoral contact [15], 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. [16] Chondromalacia patella is usually described as an overload injury, caused by malalignment of the femur to the patella and the tibia. [17]

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 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.

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.[18]

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.[19]

Degenerative changes of the articular cartilage can be caused by [20]:

  • Trauma: instability caused by a previous trauma or overuse during recovery
  • Repetitive micro trauma 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 coordination exercises may be useful in the treatment program of patellofemoral pain syndrome.[14]

Some authors use the term “patellar pain syndrome” instead of “chondromalacia” in order to describe “anterior knee pain”. [21]

Stages of disease
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. [22]
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. [23]

  • 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. [7] 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  [24]

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, [25] with excised patellas show localised softening and degeneration of the articular cartilage. [26] The main symptom of chondromalacia patellae is anterior knee pain,[15] 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 [27]. The pain often causes disability affecting the short term participation of daily and physical activities.[28] Other symptoms are tenderness on palpating under the medial or lateral border of the patella [29]; crepitation, this may be demonstrated with motion [30]; minor swelling [29]; a weak vastus medialis muscle, and a high Q-angle [31]. 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. [8] 


This condition [29] can cause a deficit in quadricep srength, 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. [32] 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. [22]

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.[33]

The primary diagnostic approach for chondromalacia patellae is radiography with added arthrography. Pinhole scintigraphy is a part of arthrography which is also used to diagnose the condition. [34] MRI is an effective, non-invasive method with the ability to increase the sensitivity and specificity of the diagnosis .[35]

Outcome Measures[edit | edit source]

There are different measurements: [36][37]

  • 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.[38]
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 grating underneath the patella, especially if the articular surfaces are pressed together. 
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. 
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.

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 pattern may also be affected. [9]
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: [30]

  • Patellar grind test or Clarke’s sign: This test detects the presence of patellofemoral joint disorder. A positive sign on this test is 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 to 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 is able to 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.[39]

It is possible to diagnose incorrectly and these test may help in determining chondromalacia, but it is also worth ruling out other possible conditions.

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 focuse is on stretching and strengthening appropriate structures, such as: stretching the hamstrings, quadriceps and gastrocnemius and strengthening the gluteal muscles.[40] Fire needling and acupuncture may also relieve clinical symptoms of chondromalacia patellae and recovers the biodynamical structure of patellae. [41]

If conservative measures fail, there are a number of possible surgical procedures. [23]

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 the 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 were helpful, but a significant consequence is that the quadriceps will become weak.

Two other treatments that may be successful: [20]

  • Replacement of the damaged cartilage : 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.
  • Autologous chondrocyte transplantation under a tibial periosteal patch. [20]


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 general consensus is that the best treatment is a non-surgical one.[42]

Physical Therapy Management[edit | edit source]

Exercise Program

Conservative treatment of chondromalacia patellae is both physical and highly advised. Short-wave diathermy helps to relieve pain and to increase the blood supply to the area, improving nutrition supply to the articular cartilage. Care must be taken when planning an exercise programme. [40]
Conservative therapeutic interventions include the following: [52]

  • Isometric quadriceps strengthening and stretching exercises [1]– restoration of good quadriceps strength and function is an important 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.[40] 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.[9][19]
  • Hamstring stretching exercises
  • Temporary modification of activity
  • Patellar taping
  • Foot orthoses
  • NSAIDS
  • Hip strength and coordination training, as hip positioning and strength has a significant influence on anterior knee pain.
  • Hip abductors strengthening as an increased hip adduction angle is associated with weakened hip abductors. [43]


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[44]:

Coordination Exercises

  • Sit with the IL on a rolled towel under the fossa popliteum with no weight on the leg.
    1.JPG
    Extend the leg fast an relax slowly 50x


  • stand on one leg (IL) with the knee slightly bent. Tap the foot of the HL
    2.JPG
    in front, left, right and behind you on the floor



  • Jumping: from left to right, from the back to the front, in a square and
    3.JPG
    in a diamond.



  • 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. [45](Level 1A)
  • Manual perturbations applied against the hip musculature in side lying with one leg raised. [45] (Level 1A)
  • Performing a lunge with a twist. Perform a lunge while twisting your torso with your hands raised in front of you.[45] (Level 1A)


Strength Exercises

  • Extend the IL for 10 seconds.
    4.JPG


  • Strengthening the hip abductors begins with isometric exercises, performing prone heel squeezes will positively affect muscle recruitment of the hip abductors. [45] (Level 1A)

Resistance Exercises

  • sit at the front of a chair with both legs extended just above the floor.
    6.JPG
     Push the heel of the healthy leg(HL) against the heel of the injured leg(IL). Make sure there is no movement in both legs. Hold for 7 seconds.
  • Sit with the IL on a rolled towel under the fossa popliteum,
    7.JPG
    with a weight on the leg



  • Stand with the IL, slightly bent, in front of the extended HL. Bend the IL
    8.JPG
     slowly. Make sure the knee never passes the foot. Move your weight to the IL. When you feel pain, quit immediately.



  • stand with the IL on a step. Touch with the HL the floor by bending the
    9.JPG
    IL, first with the toes, then with the foot, then with the heel of the foot.


  • Standing abduction with a resistance band. [45] (Level 1A)


  • Side-to-side walking with a resistance band. [45] (Level 1A)



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. [7] 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. [45]


Ice & Drugs


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.[19][43]
The benefit of anti-inflammatory drugs (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[19].


Tapes and braces


Taping the patella into a certain position may be helpful, but the scientific evidence is varied. A commonly used technique is the ‘McConnell taping’. When taped properly, the McConnell tape may have a short-term pain relief.[19][46][47]

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. [21]


Foot Orthoses


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.[28][19] [21]

 

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.[54]

Key Research [edit | edit source]

Resources[edit | edit source]

http://www.tlichtpuntje.be/info/patellaafwijkingen.htm
https://en.wikipedia.org/wiki/Chondromalacia_patellae
http://www.physio-pedia.com/Patellar_Grind_Test
http://www.physio-pedia.com/Knee_Extension_Resistance_Test
http://www.medicinenet.com/patellofemoral_syndrome/article.htm

Clinical Bottom Line[edit | edit source]


Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 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
  2. ↑ 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
  3. ↑ http://www.e-radiography.net/radpath/c/chondromalaciap.htm
  4. ↑ http://www.ubsportsmed.buffalo.edu/education/patfem.html
  5. ↑ http://orthopedics.about.com/cs/patelladisorders/a/chondromalacia.htm
  6. ↑ http://emedicine.medscape.com/article/1898986-overview#aw2aab6b3 fckLR(Levels of Evidence: 5E)
  7. ↑ 7.0 7.1 7.2 ANDERSON M. K. ,Fundamentals of Sports Injury Management, second edition, Lippincott Williams & Wilkins, 2003, p. 208 (Levels of Evidence: 5F)
  8. ↑ 8.0 8.1 8.2 BEETON K. S., Manual Therapy Masterclasses, The Peripheral Joints, Churchill Livingstone, 2003, p.50-51 fckLR(Levels of Evidence: 5E)
  9. ↑ 9.0 9.1 9.2 Florence Peterson Kendall et al., Spieren : tests en functies, Bohn Stafleu van Loghum, Nederland, 469p (383)
  10. ↑ 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)
  11. ↑ 11.0 11.1 MILNER C. E., Functional Anatomy For Sport And Exercise: Quick Reference, Routledge, 2008, p. 58-60 fckLR(Levels of evidence: 5E)
  12. ↑ SINGH V., Clinical And Surgical Anatomy, second edition, Elsevier, 2007, p. 228- 230. fckLR(Levels of Evidence: 2C)
  13. ↑ 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)
  14. ↑ 14.0 14.1 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
  15. ↑ 15.0 15.1 Iraj Salehi, Shabnam Khazaeli, Parta Hatami, Mahdi Malekpour, Bone density in patients with chondromalacia patella, Springer-Verlag, 2009
  16. ↑ 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)
  17. ↑ BARTLETT R., Encyclopedia of International Sports Studies, Routledge, 2010, p. 90. (Levels of Evidence: 5F)
  18. ↑ Jenny McConnell. “The management of chondromalacia patellae: a long term solution.” Australian Journal of Physiotherapy, volume 32, issue 4, 1986, pages 215-223
  19. ↑ 19.0 19.1 19.2 19.3 19.4 19.5 http://www.aafp.org/afp/991101ap/2012.htm
  20. ↑ 20.0 20.1 20.2 LOGAN A. L., The Knee Clinical Applications, Aspen Publishers, 1994, p. 131.
  21. ↑ 21.0 21.1 21.2 MANSKE R. C., Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder, 2006, Mosby Elsevier, p. 446, 451. (Levels of Evidence: 5E)
  22. ↑ 22.0 22.1 WESSELY M., YOUNG M., Essential Musculoskeletal MRI: A Primer for the Clinician, Churchill Livingstone Elsevier, 2011, p. 115. (Levels of Evidence: 5E
  23. ↑ 23.0 23.1 MUNK P. L., RYAN A. G., Teaching Atlas of Musculoskeletal Imaging, Thieme, 2008, p. 68-70. (Levels of Evidence: 5E)
  24. ↑ 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)
  25. ↑ ELLIS H., FRENCH H., KINIRONS M. T., French’s Index of differential diagnosis, 14th edition, Hodder Arnold Publishers, 2005. (Levels of Evidence: E)
  26. ↑ ANDERSON J. R., Muir’s Textbook of Pathology, 12th edition, Lippincott Williams Wilkins, 1988 (Levels of Evidence: C)
  27. ↑ MOECKEL E., NOORI M., Textbook of Pediatric Osteopathy, Elsevier Health Sciences 2008, p. 338. (Levels of Evidence: D)
  28. ↑ 28.0 28.1 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
  29. ↑ 29.0 29.1 29.2 SHULTZ S. J., HOUGLUM P. A., PERRIN D. H., Examination of Musculoskeletal injuries, third edition, Human Kinetics, 2010, p. 453. (Levels of Evidence: E)
  30. ↑ 30.0 30.1 DEGOWIN R. L., DEGOWIN E. L., DeGowin & DeGowin’s Diagnostic Examination, 6th edition, McGraw Hill, 1994, p. 735. (Levels of Evidence: B)
  31. ↑ EBNEZAR J., Textbook of Orthopedics¸ 4th edition, JP Medical Ltd, 2010, p. 426-427. (Levels of Evidence: E)
  32. ↑ 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)
  33. ↑ George Bentley, Ian J. Lesly and David Fischer. “Effect of aspirin treatment on chondromalacia patella” Annals of the rheumatic diseases, 1981, 40, p37-41.
  34. ↑ 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 : Official Publication, Society of Nuclear Medicine 1994, 35(5):855-862
  35. ↑ Kim, H. J., Lee, S. H., Kang, C. H., Ryu, J. A., Shin, M. J., Cho, K. J., & 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
  36. ↑ 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.
  37. ↑ 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.
  38. ↑ Helen M. Gordon : 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
  39. ↑ 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
  40. ↑ 40.0 40.1 40.2 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.
  41. ↑ Huang J, Li L, Lou BD, Tan CJ, Liu Z, Ye Y, Huang A, Li X, Zhang W. [Efficacy observation on chrondromalacia patellae treated with fire needling technique at high stress points] Zhongguo Zhen Jiu. 2014 Jun;34(6):551-4.
  42. ↑ R van Linschoten et al., Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial, BMJ, 2009
  43. ↑ 43.0 43.1 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 Sport Med. 2004; 32:251-261
  44. ↑ P. van der Tas J.M. Klomp-Jacobs; Chondropathie Patellae; Maatschap voor Sport-Fysiotherapie, Manuele Therapie en Medische Trainings Therapie
  45. ↑ 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)
  46. ↑ 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
  47. ↑ 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


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