Description of Patellofemoral Chondromalacia
In the past, any type of pain over the anterior aspect of the knee was commonly called patellofemoral chondromalacia. However, patellofemoral chondromalacia is a specific term describing a particular pathology/injury that should only be used in cases with this problem.
Chondromalacia, or damage to the cartilage, is the formation of early arthritis. Any type of damage to the cartilage surface itself results in an early onset of arthritis. Thus, any grinding with translation of the patella in the trochlea groove, or evidence of pain or swelling with activities, could be indicative of some underlying patellofemoral chondromalacia. This chondromalacia can occur both on the patella (the kneecap) or the trochlea groove (the end of the femur where the kneecap articulates).
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(Please keep reading below for more information on this condition.)
Treatment for Patellofemoral Chondromalacia
The treatment of patellofemoral chondromalacia depends upon its location, the symptoms, and whether it is localized or more diffuse. A good physical exam with radiographs and an MRI may be necessary to best differentiate this.
In the vast majority of cases, we commonly recommend starting out with a patellofemoral-strengthening program. In addition, it has been well demonstrated that strengthening the hip muscles is very important to help to alleviate some of the pain associated with patellofemoral chondromalacia. The use of a stabilizing knee brace, such as a neoprene sleeve, and injections may also be indicated in some patients.
In those patients who have a localized area of arthritis or who have flaps of the patella or trochlea groove that are catching when the knee bends and extends, there may be an indication for surgery. The most common surgical procedure is to smooth down the unstable articular cartilage flaps. While this does not cure the arthritis, it may prevent further rapid progression of the arthritis by preventing these articular cartilage flaps from peeling back and becoming deeper lesions. In patients who may have a patellar dislocation or other causes of a small, localized area of arthritis, patellar articular cartilage resurfacing procedures may be indicated. These are much more rare and the results are not as good as cartilage resurfacing procedures for the rest of the knee. Thus, a complete evaluation must be performed on those patients to determine what necessary steps may be indicated.
Patients who have a trimming of the rough cartilage areas of the patella or trochlea (a chondroplasty) initiate physical therapy the day after surgery. It is important to work on reactivation of the quadriceps muscles, to minimize knee swelling after surgery, and to work on full knee motion. In addition, it is essential that patients work on patellar mobility after surgery to minimize the chance of scar tissue adhesions of the patellofemoral joint. This is especially important because the formation or reformation of these scar tissue adhesions increase the stress on the patellofemoral joint cartilage, which in the presence of arthritis increases the chance of recurrent pain. In many instances, patients should avoid lunges and deep squatting because of the extra stress this places on the patellofemoral joint cartilage. Low impact activities are stressed, such as the use of a stationary bike, an elliptical machine, swimming and walking. Activities which cause recurrent or postoperative knee swelling should be avoided because this swelling can lead to atrophy of the quadriceps muscles and recurrent pain.
Patellofemoral Chondromalacia Injury FAQ
The kneecap joint is one of the most mobile in the body and allows one to have increased strength to be able to strengthen their knee out. The cartilage on the kneecap joint is the thickest in the body, but when it is damaged or overused, it can have some breakdown. Any breakdown of the cartilage surface on the kneecap is an effect an area of arthritis, which is commonly called chondromalacia patella. The following questions and answered have been posed to us in an attempt to provide some answers about how to treat patella chondromalacia and to decrease one’s overall symptoms when one does have it.
1. What is patella chondromalacia?
It is important that one have a true diagnosis of patella chondromalacia rather than to be labeled with a diagnosis of patella chondromalacia due to some anterior knee pain. Patella chondromalacia is some breakdown of a cartilage surface on the kneecap and it is basically a kind term for arthritis of the kneecap. It starts with a breakdown of the surface layer of the cartilage, which is the strongest, and progressively leads to further wearing and cracking of the underlying cartilage due to overuse, genetics, or an injury. Once the surface layer of the cartilage is broken, the progression of chondromalacia patella is irreversible and one needs to work on an exercise program or avoid the activities which could make it progress further.
2. Is patella chondromalacia reversible?
Patella chondromalacia, once it starts, is irreversible. This is because it involves a breakdown of the surface layer of the cartilage surface and once that happens, it is always progressive. One can definitively slow down the progression of chondromalacia patella by changing their exercise program or avoiding those activities which could cause it to wear out faster.
3. Can chondromalacia patella be cured?
True chondromalacia patella, which involves a breakdown of the cartilage surface, cannot be cured. However, a program of weight loss, avoidance of those activities which make it worse, exercise, and/or injections may help one to make it become asymptomatic. Surgery to trim down the frayed or fissured cartilage surfaces can also sometimes take away the symptoms, but it does not cure the underlying chondromalacia patella.
4. Is chondromalacia patella permanent?
Yes, chondromalacia patella is permanent. This is because it involves an irreversible breakdown of the cartilage surface which can progress over time.
5. Is chondromalacia patella arthritis?
Yes, chondromalacia patella is arthritis. It is easy for physicians to call problems with the cartilage chondromalacia rather than to tell the patients directly that they have arthritis.
6. Can chondromalacia patella get worse?
Chondromalacia patella can always get worse. This is because it can be a progressive problem. Avoidance of the reason why it happened in the first place, which is commonly overuse due to repeated squatting or lunging-type activities, is a good way to slow down the progression of chondromalacia patella.
7. Is chondromalacia patella the same as osteoarthritis?
Yes, chondromalacia patella can be the same as either degenerative or traumatic osteoarthritis. This is because it involves an irreversible breakdown of the cartilage surface.
8. Is chondromalacia patella painful?
Not all patients with chondromalacia of their patella cartilage surface have pain. Often times, the chondromalacia has been present for years and a certain event, such as overuse or repetitive activities, can make the symptoms come to light.
9. Is chondromalacia patella hereditary?
Since chondromalacia patella is a form of arthritis, it is believed that there is a genetic component to some cases. Therefore, it would be hereditary in some cases.
10. Can chondromalacia patella get better?
While chondromalacia patella itself is irreversible, the symptoms from chondromalacia patella can get better.
11. Does chondromalacia patella show up on an MRI?
The diagnosis of chondromalacia patella on MRI can be definitive, but it can be directly correlated to the strength of the magnet for the MRI. Low-field strength MRIs, such as those with 1.0 or 1.5 Tesla magnets, may not show chondromalacia as well as higher-field strength Tesla magnets such as a 3.0 Tesla MRI scan. In addition, patients who have swelling of their knee can often have the MRI more definitively show the area of chondromalacia because fluid can leak into the crevices and cracks that are present with the chondromalacia patella.
12. What is chondromalacia patella?
Chondromalacia patella involves the breakdown of the cartilage surface of the kneecap. Over time, this can result in deeper cartilage damage, even to the point where there can be bare bone arthritis present.
13. Does chondromalacia patella occur with a joint effusion (swelling)?
One of the more common ways that chondromalacia patella can present for the first time is in patients who have swelling with activities. Because chondromalacia patella is arthritis and arthritis symptoms are pain and swelling with activities, those who may overuse their knees with a long day of skiing, hiking, or doing other activities may develop swelling of their knee. These patients may have had chondromalacia patella for a while, but the overuse problem triggered the swelling to make it become more symptomatic.
14. Can I run with chondromalacia patella?
Many patients with chondromalacia patella can run. It is important to make sure that one has done the most that they can possible to decrease the symptoms of chondromalacia patella and ensure that one does not have pain and swelling with running to ensure that one is not causing the chondromalacia patella to progress further.
15. Can patella taping work for chondromalacia?
Patella taping can possibly work for chondromalacia, but it needs to be integrated with a strengthening program of the knee with a special emphasis on quadriceps strengthening.
16. What is the orthopaedic test for chondromalacia patella?
Having a patient relax with their knee out straight and then moving the kneecap in the end of the femur (the trochlear groove) is a good way to assess for any crunching or pain with moving of the patella. In some cases, the patients may also have some chondromalacia of the opposing surface of the femur and it may not be definitive as to whether the chondromalacia is at the patella or the femur. In addition, having a patient stand up and lunge or squat to the point where they hurt can also be definitive as to the presence of chondromalacia being symptomatic when one does feel this crepitation with moving the patella in the trochlear groove.
17. How does one differentiate between patellar tendinitis or chondromalacia?
Sometimes it can be difficult to differentiate between patellar tendinitis and patellar chondromalacia. Patellar tendinitis occurs when there is an overuse injury and the patellar tendon attachment at the kneecap is degenerative on its deeper surface. This usually means that when one pushes on the tendon when the knee is out straight it will be painful. In most cases, when the knee is then bent to 90 degrees and one pushes on the patellar tendon, there will be less pain or no pain, which can often be a definitive diagnosis for patellar tendinitis. Patellar chondromalacia usually hurts with the kneecap being moved on the end of the femur (the trochlear groove) and one can feel crunching (crepitation), which often reproduces the patient’s symptoms. When one does move the patella in the trochlear groove and there is painful crunching, it is usually definitive for patellar chondromalacia.
18. Can one cycle with chondromalacia patella?
One of the best exercises for the treatment of patellar chondromalacia is to use a stationary bike. This is because it can often be a low-impact exercise regimen which will allow one to build up one’s strength so you have better absorption and have less symptoms with patellar chondromalacia. However, there are times when patients may have big cracks in their patellar cartilage where a cycling program can exacerbate the symptoms. If one does have more symptoms with cycling, then one should consult a physician because this may indicate that an arthroscopy may need to be performed sooner rather than later.
19. Does chondromalacia patella hurt with squats?
Yes, chondromalacia patella often hurts with squats. This is because squatting and lunging put extra stress across the kneecap joint. Because chondromalacia patella is arthritis, one can be causing further breakdown of the cartilage when one does squats or causes an exacerbation of the cartilage problem, which can be manifested by pain or swelling with the squatting activities.
20. Does chondromalacia patella happen with a Baker’s cyst?
A Baker’s cyst is formed when fluid leaks from the front of the knee to the back of the knee between the direct arm of the semimembranosus and the medial head of the gastrocnemius. It is almost always directly correlated with the amount of swelling within the knee joint itself. Therefore, if one does have swelling in their knee develop because of chondromalacia patella, this can often present as a painful Baker’s cyst in the back of the knee. The usual treatment for this is to treat the patella chondromalacia and try to decrease the swelling in the knee to make the Baker’s cyst become less noticeable.
21. Is obesity associated with patellar chondromalacia?
In patients who are overweight or obese, when they squat, lunge or generally put extra stress on the front of their knee, they can exacerbate or cause chondromalacia patella. Therefore, losing weight can be a good way to decrease some of the symptoms with chondromalacia patella because it will decrease the forces over the front of the knee and potentially lead to a slowing down of the breakdown of the cartilage surface.
22. Which weightlifting exercises should be avoided with chondromalacia patella?
The kneecap joint sees some of the highest forces in the knee. These forces are expressively increased when one is squatting or lunging. Therefore, exercises which involve squatting and lunging can either exacerbate underlying chondromalacia patella or potentially lead to a breakdown of the cartilage surface due to the excessive force and cause chondromalacia patella.
23. Why can chondromalacia patella pain be worse at night?
The reason that chondromalacia patella pain can be worse at night is because of the fact that it is arthritis. Arthritis can often cause inflammation, which can develop hours after one causes tissues to be overloaded. Therefore, when one is lying down in bed at night with not so many distractions, the pain from chondromalacia patella and the arthritis can be increased.
24. What should one do to work out when one has chondromalacia patella?
One of the important things to do when one does have chondromalacia patella is to build one’s lower body strength so you have better absorption when you load your joint. Avoiding the activities which cause it to be painful are important as part of this. In addition to working on low-impact strengthening programs, which can include the use of a stationary bike, an elliptical machine, swimming, or walking, one should also work on strengthening their hip muscles to ensure their kneecap joint is tracking properly.
25. Can one use viscosupplementation for chondromalacia patella?
Viscosupplementation with some of the hyaluronic injections can be useful for cases of chondromalacia patella. As in all cases of viscosupplementation, the effects are generally better when one has less arthritis than there is more arthritis. Therefore, if one does have bone-on-bone arthritis of the kneecap joint, it would be expected that viscosupplementation may not be as beneficial as with those who have mild arthritis of their kneecap.
26. Does chondromalacia patella lead to patellar tilt?
Many cases of patella chondromalacia involve a wearing away of the cartilage on the outside part of the kneecap joint. Therefore on x-ray, it can appear that the patella is tilting because the cartilage space is less than it should be normally. In these cases, the patella is not truly tilting and the regular treatment for patellar chondromalacia should be followed. A lateral release in this indication would have little chance of benefiting these symptoms.
27. What type of injections would be useful for patellar chondromalacia?
For patients with mild symptoms of chondromalacia patella, injections may or may not be indicated. For patients who do have a lot of pain and swelling with their chondromalacia patella, which could inhibit them participating in exercise program, use of a corticosteroid injection may be beneficial to quiet down the knee sufficiently so that one could initiate a strengthening program. In general, injections for patellar chondromalacia will make the symptoms go away for a few weeks, so it is important to get set up with a physical therapy or home exercise program to treat the long-term symptoms of their chondromalacia patella.
28. What is the MRI grading for patellar chondromalacia?
The MRI grading for chondromalacia patella is similar to the arthroscopic grading. Those patients who have some very mild cartilage surface changes or show evidence of softening on an MRI scan have grade 1 chondromalacia. Those patients who have some breakdown of the surface cartilage to the point that it is less than 50% of the total width of the cartilage in the kneecap have grade 2 chondromalacia. Grade 3 chondromalacia is where there is deeper cartilage wear, but there is no significant bone exposed. Grade 4 chondromalacia is where the cartilage is completely worn out down to bone.
29. Is a microfracture useful for patellar chondromalacia?
In general, most cartilage replacement surgeries do not do as well in the kneecap joint as they do in other places in the knee. It is important to make sure that the kneecap is not unstable, that the edges around the cartilage defect are not worn down (have good “shoulders”), and that the size of the defect is generally small, usually less than 1 cm 2. In these circumstances, a microfracture of the patella could be indicated. It is especially important because of the poor outcomes in kneecap cartilage surgery that one have a complete workup to determine if this is what is best for the pathology.
30. When should a lateral release be performed for chondromalacia patella?
There are a few indications when a lateral release would be useful for chondromalacia patella. Most cases of lateral releases are performed because it is wrongly assumed that there is patella tilt causing the symptoms, when in effect the kneecap cartilage is worn out on the lateral side and it is not true patellar tilt that is present.
31. Can one do lunges when they have chondromalacia patella?
Lunges are one of the activities that put the most stress on the front part of the knee, especially the patellofemoral joint. Therefore, lunges are one of the exercises that can most exacerbate symptoms for chondromalacia patella.
32. Can one have chondromalacia patella and have no pain?
Many cases of chondromalacia patella are asymptomatic. It is very common for surgeons to perform knee arthroscopies for meniscus tears or anterior cruciate ligament tears and to find that there is some underlying cartilage wear of the kneecap joint for which the patient has no symptoms. If there are no symptoms, one should ensure that they are on a regular exercise program so that the knee does not become symptomatic.
33. What type of rehabilitation program should be followed for chondromalacia patella?
In general, one should follow a rehabilitation program which does not exacerbate the underlying symptoms and also works on lower-impact strengthening for that affected knee. These exercises include the use of a stationary bike, pool therapy to include swimming, the use of an elliptical machine, and walking. Working on strengthening one’s hips has also been found to be beneficial for helping anterior knee pain. In general, lunges, squats, and knee extension exercises on machines at the gym can exacerbate underlying chondromalacia symptoms.
34. What type of surgery is performed for chondromalacia patella?
For those patients who have significant crepitation in the front of their knee where they cannot do their desired activities or those patients who have gone through a program of injections and therapy without improvements with patellar chondromalacia, an arthroscopic chondroplasty, which smooths down the rough cartilage surfaces, may be beneficial. In these cases, it is important to minimize the amount of cartilage surface that is removed because once it is gone, there is effectively a larger area of arthritis. The success rate for patellar chondromalacia surgery can be improved by doing a proper rehabilitation program after surgery and also making sure that one avoids those activities which may have caused it in the first place.
35. Can platelet-rich plasma be used for patella chondromalacia?
There are no specific studies which have demonstrated that patients who have chondromalacia patella can benefit from platelet-rich plasma (PRP). However, there is some data to show that in patients who have knee arthritis overall, there may be an equal benefit of PRP to corticosteroid injections or the use of viscosupplementation. Further studies are needed on this to validate if PRP is more useful than other injections to treat chondromalacia patella.
36. Can a joint effusion (swelling) happen with patellar chondromalacia?
Because patellar chondromalacia is arthritis and the symptoms of arthritis are pain and swelling with activities, patellar chondromalacia is a common cause of patients who develop knee swelling without any particular injury. This is probably because most cases of chondromalacia patella may be asymptomatic until one engages in a higher level of activity than one is used to. In these circumstances, the knee may become painful and swollen with activities.
37. Can chondromalacia patella happen from trauma?
Traumatic arthritis of the kneecap due to trauma, such as in a motor vehicle accident where one hits the front of their knee, or where one falls on a flexed knee, or after a patella fracture, is a form of chondromalacia patella. This can be different than those cases of chondromalacia patella that happen with overuse or due to genetics, because it can have a direct blow to the kneecap which damages the cartilage surface. In any effect, the treatment going forward would be very similar to those patients who have other types of chondromalacia develop.
38. What exercises should be avoided with patellar chondromalacia?
Those exercises which should be avoided with patellar chondromalacia include knee extension exercises with weights, lunges, lunges with weights, and significant squatting with weights. That is because of the extra force that is put on the front of the knee with these activities which can cause a breakdown of the cartilage of the kneecap joint.
39. Should one use a stationary (exercise) bike for chondromalacia patella?
One of the most beneficial exercises for chondromalacia patella is use of a stationary bike. This is because it is a low-impact exercise which can strengthen the quadriceps and lower extremity muscles to improve one’s absorption when one loads their joint. Some patients, although rare, with patellar chondromalacia do have pain with an exercise bike. In these circumstances, these patients should see a physician to determine if an arthroscopy is needed because of the cracks and fissures of their kneecap causing this type of pain.
40. Can chondromalacia patella happen with patellar instability?
Patellar instability is usually when the kneecap slides to the outside of the joint and often times gets stuck because it is dislocated. When the kneecap slides back in the joint, it can catch on the kneecap cartilage and cause cracking or a complete slough of the cartilage. Therefore, chondromalacia patella can potentially happen with cases of patellar dislocations or subluxations.
41. Can one diagnosis patellar chondromalacia on x-ray?
While an MRI scan can be more definitive as to determining the grade and extent of patellar chondromalacia, one can often have a high index of suspicion that one has patellar chondromalacia from looking at a 45-degree patellar sunrise x-ray. When the kneecap has some mild bone spurs, there may be some mild chondromalacia present. Once the kneecap cartilage is thinned, one can assume that the thinning is both on the kneecap and on the femur and one can see it on these x-rays. Complete bone-on-bone changes of the kneecap joint can be seen and are indicative of advanced patella and trochlear chondromalacia. Many of these patients may also have large bone spurs with an overhanging lateral facet of the patella, which can make the kneecap become captured and have very little motion.