Anterior Knee Pain
The term "chondromalacia patella" means damage to the cartilage behind the kneecap. Because this cartilage has no pain fibers, the pain produced by chondromalacia tends to be some what vague, but is usually felt in the front of the knee. A better term for chondromalacia patella is chondrosis. It has also been called patellofemoral pain syndrome, excess lateral pressure syndrome, lateral patella compression syndrome and anterior knee pain.
Causes of Chondromalacia Patella
Malalignment of the Patella - The most common cause is malalignment of the patella. Alignment refers to the way that the patella (kneecap) sits in the groove in the bottom of the femur (thigh).
Symptoms
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Pain in front of the knee
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Pain made worse by going up or down stairs
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Running, sports, cheerleading make pain worse
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Pain on sitting with the knee bent
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Giving out of the knee (buckling)
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Locking of the knee (feeling it won't move)
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Grinding or popping
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Feeling kneecap goes in and out of joint
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Swelling
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Sometimes a sudden sharp pain
Normal Alignment
If the patella is out of alignment, it causes pain by creating excess tension on the surrounding ligaments and nerves. If this gets severe and leads to chondrosis (cartilage breakdown), more pain and swelling occur due to irritation in the synovium (lining membrane of the knee) by torn pieces of cartilage. Malalignment happens because the muscles and tendons holding the kneecap are out of balance or are out of alignment. In severe cases, the kneecap dislocates (comes out of joint completely) or subluxes (partially dislocates).
Dislocating Patella
If left untreated, not only will you continue to suffer pain, restriction of work, sporting and daily activities, but it can lead to arthritis.
Arthritic Patella
Normal Alignment
Abnormal Alignment
Treatment
Nonoperative
Many patients get relief through a program of stretching, strengthening, and physical therapy. Sometimes a brace and/or anti-inflammatory pills (such as Advil or Naprosyn) are used. Temporarily decreasing activities can help. Occasionally, building up a shoe will help. Also, completely alleviating pain-inducing activities (such as breaststroke style kicking) helps to promote relief.
Operative
In very severe cases or in cases that don't respond to nonoperative measures, surgery is the best treatment. Before doing surgery, generally a CAT Scan is done to find out the exact type of malalignment and the severity. The type of surgery performed depends on the findings of the CAT Scan and also on the degree of cartilage damage (which is evident at the time of surgery when the arthroscope is introduced into the knee). Many corrective procedures can be performed with the aid of arthroscopy.
Surgical options include
- Arthroscopy and Lateral Release
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Arthroscopy Lateral Release, Tibial Tubercle Osteotomy with Medialization. This is cutting the bone where the tendon from the kneecap goes into the shin and moving it over to the inside to restore normal alignment. An incision is required.
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Arthroscopy Lateral Release, Tibial Tubercle Osteotomy, and Anteriorization. This is where the piece of bone where the kneecap tendon attaches is moved forward to decrease pressure on the cartilage on the back of the kneecap. This is to try and relieve pain if the cartilage is severely damaged. An incision is required. This leaves a bump at the top of the shin bone.
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Medial Plication is very occasionally required to tighten the muscle on the inside of the kneecap. When this has to be done, rehabilitation is more prolonged.
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If necessary, the damaged cartilage is shaved.
Recovery
Some of these surgeries can be done as an outpatient, but generally it is best to stay in the hospital for a night when it is necessary to do a tibial tubercle osteotomy. You can walk on the leg right away, but for tibial turbercle osteotomy it's helpful to use crutches in the beginning. Generally, it takes about 6 weeks to get 70% of the total healing. During this time, exercises and therapy will be necessary. In a recent research project done on patients who required surgery for malalignment and subluxation, 83% obtained good or excellent results.
Check these links for more information concerning specific types of knee problems:
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Chondromalacia patella
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Other causes of knee pain
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Anterior cruciate ligament
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Other ligament injuries
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Advantages of arthroscopic surgery
