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Chondromalacia of the patella is a condition in which the cartilage of the kneecap (patella) becomes worn from age or is damaged from injury. In a healthy knee, the undersurface of the patella is covered with articular cartilage that is smooth and slick. This surface allows the patella to slide easily in the groove of the femur as the knee bends and straightens (flexes, extends). With chondromalacia patella, the undersurface of the patella becomes rough and then wears away (thins). This loss or damage of articular cartilage is an early finding in osteoarthritis. Chondromalacia patella is thus an arthritis involvement of the patella.
Some individuals are born with natural anatomic variations that make them more prone to developing chondromalacia patella. Chondromalacia may also be caused by trauma, such as a twisting injury in which the patella is pulled out of the femoral groove and the cartilage surface is bruised, scratched, or chipped. Individuals who have previously had a fracture or dislocation of the patella are more prone to develop chondromalacia patella. Most cases of chondromalacia patella develop from our upright posture that stresses the patellofemoral joint. It is most often a wear and tear condition rather than a specific injury.
Risk: Chondromalacia patella is a condition that tends to affect teenagers (especially females) and individuals over 40 years of age (Tidy). Certain sports (e.g., football, soccer, running, sailing, fencing) are also commonly associated with this disorder. Incidence and Prevalence: Knee pain is reported by about 20% of adult Americans and accounts for nearly 3 million outpatient and emergency room visits in the US annually (Levy). Chondromalacia patella may be the source of the knee pain, but it more frequently is seen concomitantly with other conditions. |
Source: Medical Disability Advisor
History: Individuals may complain of knee pain with walking, running, squatting, and ascending or descending stairs. However, knee pain is not always present, and is not an indicator of the severity of chondromalacia patella. The individual may report a feeling of grating, catching, or locking of the knee with motion. Some individuals will have a sensation that the knee is giving out. Many individuals report pain after sitting with the knee bent for long periods (e.g., during movies, car rides, plane trips). Physical exam: Chondromalacia patella may be evaluated by placing manual pressure on the patella while the individual contracts the quadriceps muscle. Pain during this maneuver is suggestive of chondromalacia patella. A crackling sound in the knee (crepitus) is often noticeable with passive range of motion (PROM). Active range of motion (AROM) against resistance is usually painful. Alignment of the patella may be evaluated by measuring the quadriceps angle (Q-angle) although this is difficult to interpret. Tests: Routine knee x-rays will include special views of the patella (Merchant view) to evaluate its position in the femoral groove. MRI or CT scans can be used to evaluate the articular surface. |
Source: Medical Disability Advisor
Nonsurgical (conservative) treatment involves rest and decreasing the frequency of activities that aggravate the condition, such as squatting, ascending or descending stairs, kneeling, lunging, and sitting with bent knees. Use of oral and topical nonsteroidal anti-inflammatory medications (NSAIDs) and cold therapy (cryotherapy) followed by heat packs (thermotherapy) may provide relief of pain and swelling. In some cases, shoe orthotics or a brace to stabilize the patella may be recommended as both treatment and prevention. Taping or bandaging of the affected knee may provide some pain relief.
Physical therapy to increase quadriceps strength and decrease swelling and pain may be helpful. Patient education is an important part of treatment because chondromalacia patella is a chronic condition.
For severe cases in which symptoms do not respond to conservative treatment, arthroscopic surgery may be recommended to smooth (débride) the undersurface of the patella. This procedure involves removing (shaving) the damaged cartilage down to the less damaged cartilage underneath. In more severe cases, the damaged cartilage may be removed entirely (chondrectomy); however, these procedures on the damaged cartilage rarely produce lasting beneficial results. If the problem is aggravated by malalignment of the patella, various surgical procedures can be performed to realign the patella and relieve pressure on the cartilage surface. These include tightening of the medial capsule of the knee and lateral capsular release to relieve excessive tightness of the lateral capsule. In very severe cases patellectomy, patella arthroplasty with patella replacement, total knee replacement, or tibial osteotomy to displace the patella anteriorly (Maquet or Fulkerson procedure) may be indicated. |
Source: Medical Disability Advisor
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| ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.* |
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| Knee Disorders |
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| * The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence. |
Source: ACOEM Practice Guidelines
Acute, painful episodes usually resolve with rest and a period of avoidance of aggravating activities. Complete resolution of symptoms is rare.
In severe cases in which surgery is required, outcome depends on the severity of the cartilage damage and the type of surgery performed. Individuals who undergo a full patellectomy usually experience persistent weakness of the knee. Individuals who undergo insertion of a patellar prosthesis may eventually experience wearing of the opposing articular surface of the femur, causing further symptoms. This procedure is still being refined and final results are not known. Total knee replacement is more aggressive but gives satisfactory results in more than 80% of cases (Palmer). The outcomes for the Maquet and Fulkerson procedures are variable. |
Source: Medical Disability Advisor
The aim of rehabilitation for patellar chondromalacia is to control symptoms and increase function. Rehabilitation of the knee will vary depending on the underlying origins and causes (etiology) of the excess pressure on the undersurface of the patella.
In general, rehabilitation of patellar chondromalacia focuses on strengthening the knee musculature and on proprioceptive exercises. If knee mobility is limited by pain, the physical therapist may initially use modalities, such as electrical stimulation and cold, for pain control.
Once pain has decreased, the individual may progress with an exercise program. Quadriceps stretches become a vital part of the recovery program because of the force this muscle group exerts on the patella (Bizzini). Strengthening exercises should also be included, including isometrics as well as open and closed chain activities (Heintjes). Individuals should be instructed in a home exercise program to complement the supervised rehabilitation program and to be continued after discharge from therapy.
Additional information may provide insight into the rehabilitation needs of these individuals (D'hondt). |
FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical Therapist | | Up to 12 visits within 6 weeks | | | | | | | | Surgical | |
| Physical Therapist | | Up to 12 visits within 6 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| The most common complication is continued discomfort; this may persist with or without surgical intervention. |
Source: Medical Disability Advisor
| Individuals whose job requirements include frequent or prolonged periods of walking, lifting or carrying heavy items, ascending and descending stairs or ramps, or squatting may need to restrict or eliminate these activities until symptoms subside. Until pain subsides, individuals should be allowed frequent rest breaks to avoid prolonged standing. The work environment may need to be modified to permit sitting with the knee in extension rather than in flexion. Depending upon the type of surgery performed, the individual may be treated as an outpatient and may return to work within a few days, or, with more involved surgeries, the individual may require 1 to 2 nights in the hospital and a more extended break from work. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has diagnosis of patella chondromalacia been confirmed?
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Has an x-ray or CT scan been done to assess patellar alignment?
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Has a bone scan been done to rule out other diagnoses?
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Has individual experienced any aggravating conditions such as patella malalignment, recurrent patella subluxation, dislocation, or osteoarthritis?
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Does individual have an underlying condition that may affect recovery?
Regarding treatment:
- Were conservative methods effective in resolving symptoms?
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Did the individual receive sufficient physical therapy?
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Is the individual compliant in following an exercise program to strengthen the quadriceps muscle?
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Has a 6-month period of conservative therapy been unsuccessful?
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Was surgical intervention required? If so, what procedure was performed?
Regarding prognosis:
- If a 6-month period of conservative therapy been unsuccessful, could symptoms be expected to resolve with additional time and therapy?
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If surgical intervention was required, did procedure achieve expected results?
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Have symptoms recurred?
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Have other problems occurred as a result of the procedure?
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What further treatment options are available?
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Source: Medical Disability Advisor
| CitedServi, Jane T. "Patellofemoral Joint Syndromes." eMedicine. Eds. Andrew L. Sherman, et al. 22 May. 2008. Medscape. 18 Feb. 2009 <http://emedicine.medscape.com/article/90286-overview>. "Question and Answers about Knee Problems." WebMD.com. WebMD Inc. 26 Nov. 2004 <http://www.webmd.com>. |
| RehabilitationBizzini, M., et al. "Systematic Review of the Quality of Randomized Controlled Trials for Patellofemoral Pain Syndrome." Orthopedic and Sports Physical Therapy 33 1 (2003): 4-20. National Center for Biotechnology Information. National Library of Medicine. 26 Nov. 2004 <PMID: 12570282>.D'hondt, N. E., et al. "Orthotic Devices for Treating Patellofemoral Pain Syndrome." Cochrane Database System Review 2 (2002): CD002267. National Center for Biotechnology Information. National Library of Medicine. 21 Jan. 2009 <PMID: 12076444>. Heintjes, E., et al. "Exercise Therapy for Patellofemoral Pain Syndrome." Cochrane Database System Review 4 (2003): CD003472. National Center for Biotechnology Information. National Library of Medicine. 21 Jan. 2009 <PMID: 14583980>. |
Source: Medical Disability Advisor
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