chondromalacia patellae


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chondromalacia patellae

  2. 2. Literal translation - “Soft Cartilage”AKA:• Patellofemoral overload syndrome• Patellar Pain syndrome• Anterior knee pain syndrome• Runners Knee
  3. 3. CAUSES:Mechanical overload of the patellofemoraljoint.a) Malcongruence - patellofemoral surfacesb) Malalignment – extensor mechanism- weakness of vastus medialisSingle injury – damage to articular surface
  4. 4. PATHOLOGYDegeneration of articular cartilage-PrecipitantChanges in articular cartilage + subchondral bone1.Cartilage N appearance with only biochemical changes but boneshows reactive vascular congestionOR2.Cartilage softening/fibrillation with or without subarticularintraosseous hypertensionFibrillation usually on undersurface of the patella at the jn. of medialand odd patellar facet /median ridge confined to superficial zonesand heals spontaneously.NOT A PRECURSOR OF OA!
  5. 5. Lateral Articular surface involvement-usuallycongenital tightness of lateral quadricepsexpansion„Ficat’s hyperpression zone syndrome’OrExcessive Lateral Pressure SyndromePredisposes to OALateral Release for prophylaxis
  6. 6. CLINICAL FEATURES• Introspective teenage girl or athletic young adult• Flat foot / Knock kneed athletes• Spontaneous Pain in front of knee/ beneath the kneecap• Maybe h/o recurrent displacements/injury• Aggravated by activity/climbing downstairs/standing after prolonged sitting with kneesflexed• Both knees• Swelling-give way-catching(not true locking)• Grating/grinding sensation when knee is extended
  7. 7. SignsAppears N kneeMalalignment/tilting of patellaQuadriceps wastingEffusionCrepitus on moving the kneeTenderness under the edge of the patellaSmall high patellaIn severe cases a/w Patella Alta“Theatre sign”
  8. 8. Press patella against femur to elicit pain and asking patientto contract the quadriceps first with central pressure thencompressing the medial facet and then the lateral facetApprehension test + implies previoussubluxation/dislocation.Patellar tracking with pt seated at edge of the couch, flexingand extending knee against resistancePatellar alignment gauged by Q angle-angle subtended bythe line of quadriceps pull and the line of patellar ligament.Should not exceed 20 degreesStructures around knee and hip examined r/o referred pain
  9. 9. STAGESI: swelling and softening of the cartilageII: fissuring within the softened areasIII: fasciculation of articular cartilage almost tolevel of subchondral bone;IV: destruction of cartilage with subchondral boneexposed
  10. 10. Grading (Bentley 1992)• Grade I: area <0.5 cm diameter• Grade II: Area 0.5 – 1.0 cm diameter• Grade III: area 1.0 – 2.0 cm diameter• Grade IV: area >2 cm diametera: softening, swelling/fibrillation of cartilageb: Full thickness cartilage loss to bone
  11. 11. IMAGING• X Rays- skyline viewlateral view with knee half flexedTangential views at 30, 60 and 90 degrees offlexionBest seen on slightly overexposed lateral X rayAxillary radiograph determines which facet is involvedMost accurate to measure malpositon CT/MRI with knee infull extension and varying degrees of flexion.
  12. 12. • Diagnosis made only on Arthroscopy or surgery• Arthroscopy is useful to r/o other causes of anteriorknee pain. Also to know presence and extent of thelesion and probing of patella with soft probe• Gauge patellofemoral congruence, tracking andalignment
  13. 13. DIFFERENTIAL DIAGNOSIS• Patellofemoral overload- maltrackingoveruse• Patellar instability-subluxation/tilt• Intraarticular pathology-plica syndromemeniscal disordersOsteochondriotis dissecansPatellofemoral arthritisPeripatellar disorders-bursitis/tendinitis/apophysitisBipartite patella bone tumoursHip disorders- slipped capital femoral epiphysis
  14. 14. TREATMENT• Conservative• Operative
  15. 15.
  16. 16. Conservative Rx• Reassurance• Ice Application• Physiotherapy• Avoid stressful activities• Stretching and strengthening medial quadriceps15 mins 4 times/day – Quad sets (bicycling, poolrunning, swimming flutter kick)• Aspirin / Ibuprofen / Naproxen• Support for a valgus footSTEROIDS BEST AVOIDED
  17. 17. Knee brace
  18. 18. Operative RxIndications:1. Abnormality correctable by operation2. Conservative Rx tried for at least 6months3. Pt genuinely incapacitated
  19. 19. Surgical Options1. Lateral Release2. Proximal Realignment3. Distal Realignment4. Distal elevation of Patellar ligament5. Chondroplasty6. Patellectomy
  20. 20. Preventive MeasuresShort-arc extensionsDone sitting up or lying down.Rolled-up towel to support the thighkeep leg and foot in the air for 5 seconds.Lower foot as knee is bent slowly.Repeat 10 times for each leg, twice a day.
  21. 21. Straight-leg raisesDone lying down.Lift whole lower limb at the hip with the knee extendedkeep it up in the air for 5 seconds. Then lower slowly.Repeat 10 times for each leg, twice a day.
  22. 22. Quadriceps isometric exercisesDone sitting up, with legs extended in frontTighten quadriceps muscles by pushing the kneesdown onto the floor.Hold for 5 seconds.Repeat 10 times each leg, twice a day.
  23. 23. Stationary bicyclinglow tension setting improves exercisetolerance without stressing the knee.Seat should be high enough so that the leg isstraight on the down stroke.Start with 15 minutes a day and work up to 30minutes a day.
  24. 24. THANK YOU