Knee & Shoulder Surgeon - Orthopedic Specialist
Knee & Shoulder Surgeon - Dr. Amyn Rajani
M.S Orth (Gold Medallist), D-Orth, MBBS
Knee and Shoulder Surgeon
(Arthroscopy & Joint Reconstruction)
Orthopaedic Arthroscopy Knee & Shoulder Clinic (OAKS)

Chondromalacia Patella

chondromalatio patellae» Introduction
Chondromalacia patella is the softening and breakdown of the tissue (cartilage) that lines the underside of the kneecap (patella). It is a common cause of anterior knee pain.

» Related Anatomy
Your knee cap (patella) sits over the front of your knee joint. During the bending or straightening of the knee, the underside of the patella glides over femur.
> Strong tendons help attach the patella to the bones & muscles that surround the knee.
These tendons are called:
> The patellar tendon (where the knee cap attaches to the shin bone)
> The quadriceps tendon (where the thigh muscles attach to the top of the knee cap)

chondrosis of the patella
» Pathophysiology
Problems begin when the knee cap does not glide properly and rubs against the lower part of the thigh bone. This could happen because of the following:
> The knee cap is in an abnormal position
> There is tightness or weakness of the muscles on the front and back of your thigh
> The knee is subjected to too much activity that places extra stress on the knee cap (such as running, jumping or twisting, skiing, or playing soccer)
> Presence of flat feet

» Other predisposing factors
> Arthritis
> Previous fracture
> Previous dislocation of the patella

» Symptoms
> A grating or grinding sensation when the knee is flexed (moved so that the ankle is brought closer to the back of the thigh)
> Knee pain in the front of the knee that occurs when you get up after sitting for a long period of time
> Knee pain that worsens when you use stairs or get out of a chair
> Knee tenderness

» Signs and tests
> Tenderness over patella
> Swelling
> Crepitations felt over knee cap on flexion and extension of knee
> Special tests
> Patello-femoral grinding: pressing the patella over femur produces pain
> Theatre sign: long sitting hours with knee flexed at 90 degrees (as in movie theatre) produces pain
» Investigations
X-rays:are usually normal, although a special x-ray view of the knee cap may show signs of arthritis or tilting.
MRI:shows evidence of fraying of the articular cartilage

normal alignment patella
Normal Alignment
lateral subluxation of patella
Lateral Sublaxation
» Treatment :
Temporarily resting the knee and taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or aspirin may help relieve pain. Physical therapy, especially quadriceps strengthening and hamstring stretching, may be helpful.
If you need to lose weight, find out the correct means to do it.

Changing the way you exercise may help :
> Avoid running straight down hills; walk down instead.
> Bicycle or swim, instead of running.
> Reduce the amount of exercise you do.
> Run on a smooth, soft surface such as a track, rather than on cement.

Other techniques are :
> Special shoe inserts and support devices (orthotics) may help people with flat feet.
> Taping to realign the knee cap may help prevent symptoms.

Make sure your running shoes :
> Are made well
> Fit well
> Have good cushion

» Surgical Management
If the pain does not improve and there are signs of arthritis developing around the knee cap, surgery may be an option. Surgery may be done using arthroscopy.

During the surgery, knee cap cartilage that has been damaged may be removed. Changes may be made to the tendons to help the knee cap move more evenly.

Cartilage Procedure
In more advanced cases of patellar arthritis, surgeons may operate to repair or restore the damaged cartilage. The type of surgery needed for articular cartilage is based on the size, type and location of the damage.

Lateral Release
If the cause of chondromalacia is due to malalignment of patella with femur a procedure called a lateral release is suggested. This procedure is done to allow the patella to shift back to a more normal position and relieve pressure on the articular cartilage. In this operation, the tight ligaments on the outside (lateral side) of the patella are cut, or released, to allow the patella to slide more towards the center of the femoral groove. These ligaments eventually heal with scar tissue that fills in the gap created by the surgery, but they no longer pull the patella to the outside as strongly as before the surgery. This helps to balance the quadriceps mechanism and equalize the pressure on the articular cartilage behind the patella.

Ligament Tightening Procedure
In some cases of severe patellar malalignment, a lateral release alone may not be enough. For problems of repeated patellar dislocations, the surgeon may also need to realign the quadriceps mechanism. In addition to the lateral release, the tendons on the inside edge of the knee (the medial side) may have to be tightened as well. This can be done by a mini-open incision on the medial (inner) side.

Bony Realignment
If there is no soft-tissue component to the malalignment and only a bony component then the bony attachment of the patellar tendon may also have to be shifted to a new spot on the tibia bone. By moving a section of bone where the patellar tendon attaches to the tibia, surgeons can change the way the tendon pulls the patella through the femoral groove. This section of bone is then reattached on the tibia closer to the other knee by using screws. This will shift the patella on the medial side and offer a better patella tracking.

Expectations (prognosis)
Chondromalacia patella usually improves with therapy and use of NSAIDs. For the few people who need it, surgery is successful most of the time.

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