CHONDROMALACIA

PATELLAE

ICD 9 – 717.7

DEFINITION & DISCUSSION

•  RETROPATELLAR CHONDROPATHY

•  -MALACIA = Softening

•  SOFTENING, EROSION, FRAGMENTATION OF PATELLOFEMORAL JOINT SURFACES

•  MAY LEAD TO D.J.D. OF THE PATELLO-FEMORAL & _Tibiofemoral___JOINTS

•  THICKEST ARTICULAR CARTILAGE IN THE BODY

•  VERY HIGH COMPRESSION FORCES (sometimes > 10x Body weight)

TYPES

•  TYPES

•  PRIMARY (IDIOPATHIC) ADOLESCENT

•  SECONDARY ADOLESCENT (TRAUMATIC) falling on knees

•  OSTEOARTHRITIC(715.96) 50-60 onset

•  OVER UTILIZED DX at lot of people are diagnosed that don't have it

ETIOLOGY / MECHANISM

•  DIRECT TRAUMA

•  BIOMECHANICAL /ANATOMICAL

•  SIZE & SHAPE OF PATELLAE

•  POSITION OF PATELLAE baja, alta unstable

•  ­ Q ANGLE(genu valgum)

•  PATELLOFEMORAL & TIBIOFEMORAL STABILITY (squeal to ACL tear)

•  MUSCLE IMBALANCE weak quads , tight hams, weak hip flexors, weak tib. ant. => pronation syndrome => chondromalicia

•  PRONATION / SHOES

•  PLICA OR LOOSE BODY (pt. With lots of knee poping or snaping)

•  OVERUSE & HIGH IMPACT ACTIVITIES

•  AGING

•  IATROGENIC wrong knee brace, postoperative, removal of synovial fluid

SIZE & SHAPE

•  DISPLASTIC PATELLAE

•  PATELLA PARVA smaller

•  WIRBERG III odd shaped

POSITION OF PATELLA

•  PT / P = PATELLOFEMORAL RATIO

•  1.2 =Alta ; 0.8=Baja to determine Alta Baja length of infrapateler tendon / patella

Q - ANGLE

•  13-18 DEGREES just a range

•  ¯ Q angle GENU VARUM-, ­ Q angle VALGUM – more lateral pressure, ¯ knee stability

•  VALGUM FAVORS LAT. PATELLAR TRACKING

•  VALGUM & ¯ STABILITY

•  FEM. ANTEVERSION (squinting patella)& GENU VALGUM

•  SQUINTING PATELLA

INSTABILITY

•  PATELLOFEMORAL

•  USUALLY EXCESSIVE LATERAL GLIDE & LATERAL _Tilt

•  TIBIOFEMORAL

•  MEDIAL COLLATERAL LAXITY

•  ANTERIOR CRUCIATE LAXITY

•  2ndary to MENISCECTOMY

•  ANTEROMED. & ANTEROLAT. INSTAB.

Any rotational instability => chondromalacia

MUSCLE IMBALANCE

•  WEAK

•  VMO start after core muscles have been strengthened

•  ABDOMINALS & HIP FLEXORS

•  GLUTEAL

•  FOOT SUPINATORS / PLANTAR FLEXORS

•  TIGHT

•  VASTUS LATERALIS / RECTUS FEMORIS

•  HAMSTRINGS

•  ITB

•  HIP ADDUCTORS

HISTORY

•  TRAUMA? OVERUSE? Idiopathic in children, Restrict activities, both RICE

•  USUALLY GRADUAL INSIDIOUS ONSET bugging me for years its just getting worse

•  USUALLY VAGUE PAIN “kinda behind kneecap”

•  ANTERIOR KNEE PAIN WORSENED BY:

•  RUNNING OR JUMPING

•  UP & DOWN HILLS OR STAIRS

•  KNEE EXTENSION EXERCISES overdone

•  “THEATER SIGN”- (GELLING PERIOD (period it takes to feel better)) stiff and sore post prolonged sitting and bothers them for a short time

•  LOCKING? (meniscus, OD, joint mouse) May say locking, but might actually be giving away which could be instability or pain

•  SOMETIMES GRINDING SENSATION esp. when walking stairs

Sequale to ACL tear

 

SIGNS & SYMPTOMS

•  VMO WASTING (VISIBLE/PALPABLE?) yes

•  SWELLING? Bakers cyst, or generalized swelling

•  PALPABLE CREPITIS, maybe with step-up test

•  TENDER FACETS most sensitive of all the tests

•  PASSIVE ROM USUALLY PAINLESS

•  ACTIVE RESISTED ROM PAINFUL

•  QUADRICEPS WEAKNESS

•  CLARKE'S TEST? Not very good, leads to over-diagagnoses

•  GRINDING TEST? More specific, unless you tip the patella, it needs to remain flat

QUADRICEPS WASTING PHOTO

Loses definition

SPECIAL IMAGING

•  PATELLAR X-RAYS what you see is the tip of the iceberg, DJD, spurring, arthritis, position, asymmetric spacing,

•  AP

•  LAT.

•  Patellar, or sunrise view

•  MRI, if you need for insurance or lawsuit

•  ARTHROGRAM

•  ARTHROSCOPE, GOLD STANDARD

X-RAY

TREATMENT-ACUTE

•  R. – REDUCE OR ELIMINATE HIGH IMPACT & REPETITIVE IMPACT; AVOID HARD SURFACES

•  I. – ICE, ICE MASSAGE, AFTER ACTIVITY

•  C. – ELASTIC BRACE – HOW LONG? Might have to wear forever

•  MANIPULATE FOOT, KNEE, & BACK, & hip, adjusting patella has little effect

•  MASSAGE THIGH Deep tissue

•  NUTRITION – BROMALAIN, GAGS (this is an arthritic condition), CA, MG, VIT. C, B6, NIACINAMIDE(related to niacin more effects on joints, side effects is liver damage,

TREATMENT – PATELLAR BRACES

•  CHOPAT – COUNTER FORCE STRAP

•  DONUT SLEEVE, hole over kneecap

•  HORSE SHOE SLEEVE, for top or bottom

•  MULTIPURPURPOSE

TREATMENT POST ACUTE

•  LIMIT / AVOID - JUMPING, SPRINTS, HILLS, STAIRS, HARD SURFACES, STOP & GO, REPETITIVE HIGH IMPACT, HIGH MILEAGE, maybe after a couple of months of inactivity, can start back on low impact sports

•  KNEE BRACE – TRY TO WEAN BUT?

•  TAPE – SEE PAGES 383-389 IN REID

•  SHOE CHANGES & PRONATION CONTROL

•  EXERCISES type is extreamly important

•  MANIPULATE, MASSAGE, HOT & COLD

•  ICE AFTER EXERCISE

•  SURGERY? Wash it out

EXCERCISES

•  STRETCH

•  QUADRICEPS

•  ILIOPSOAS hip flexors and flexors

•  HAMSTRINGS

•  HIP ADDUCTORS

•  STRENGTHEN

•  GLUTEALS, HIP FLEXORS, first & ABS. FIRST

•  QUADRICEPS – ESPECIALLY VMO

STRENGTHENING HIP ABDUCTORS PHYS SPS MED , JAN '96 P16X

QUADRICEPS EXERCISES

•  ISOMETRIC (BEFORE ISOTONIC)

•  SITTING PUSH highest amount on EMG

•  SLR SETTING

•  PILLOW QUAD SETS smash pillow under knee

•  WALL SIT SETTING

•  ISOTONIC – CAREFUL THEY CAN AGGRAV.

•  WALL SQUATS on door (smooth)

•  LUNGES, don't touch knee to floor

•  SQUATS OR LEG PRESS

•  OPEN CHAIN – LEG EXTENSIONS LAST

AT HOME KNEE REHAB . PHYS SPS MED, MAY ‘96, P36

PROGNOSIS

•  AGE & MOTIVATION?

•  CARTILAGE IS A SLOW HEALER

•  IN YOUNG USUALLY SELF LIMITING

•  RE EVALUATE 4-6 WKS

•  REFER? If you think severe or not responding to treatment

•  STAGE 1 – 4-6 WKS FOR RECOVERY

•  STAGE 2 (deeper erosions)– 8-12 WKS RECOVERY; RECURRANCE COMMON

•  STAGE 3-4 (deeper still into bone)– SYMPYOMATIC IMPROVEMENT IN SOME; NO PROMISES

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