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Kneecap pain, Patellar Maltracking, Chondromalacia

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Published on Sunday, 04 October 2009 23:14

Written by Vic Goradia, M.D.

Chondromalacia or Patellar Tracking Knee Problems -by Vic Goradia, M.D.

Chondromalacia means damaged articular* cartilage. This cartilage is normally a hard, smooth layer that cushions bone and allows the joint to move easily. When the cartilage is damaged from injury or years of use, pain can occur. Uneven areas of damaged cartilage can cause swelling and a feeling of 'catching', 'locking',' and 'giving-way'. If these uneven areas continue to catch over time, the area of damage can get bigger.

Initial treatment for chondromalacia

This may include anti-inflammatory medications such as ibuprofen, an exercise program to strengthen the muscles on top of your thigh, and recommendations to limit stair climbing, squatting and kneeling. If this treatment fails, arthroscopic surgery may be recommended to help smooth uneven areas of cartilage. It is impossible to make the cartilage completely smooth, and currently there isn’t any technology to replace lost cartilage. The goal of the procedure is to slow down the progression of the damage and to reduce pain and catching by removing unstable flaps and uneven areas of cartilage.

Maintaining strength in the thigh muscles and limiting activities that involve squatting, kneeling and climbing stairs will help to improve symptoms. If the damage is severe or if the chondromalacia is associated with mal alignment or mal tracking, then a Fulkerson osteotomy may be recommended.

Malalignment and Maltracking

The kneecap normally slides in a groove (trochlea) in the thighbone (femur) as the knee bends and straightens. If the kneecap is improperly tilted or malaligned in the groove, pain can occur.

Maltracking occurs if the kneecap partially comes out of the groove as the knee is bent and straightened. This is called subluxation, and it can cause pain and a sense of “giving-way.” Some people are born predisposed to developing these conditions, while others develop it as a result of injury or muscular weakness.

Treatment Options for Patellar Pain and Misalignment

Typically the initial treatment for malalignment is physical therapy for specific stretching and strengthening exercises, along with trials of selective taping and/or bracing. If symptoms continue, arthroscopic surgery can be performed to release the tight structures on the outside of the kneecap that cause this condition. This surgery is known as a lateral release. This procedure will cause the knee to swell and become weak for several weeks after surgery.  Physical therapy will be needed to decrease swelling and increase strength. The full beneficial effects of surgery usually take six to eight weeks, but for some patients it can take as long as three months.

Maltracking often requires something in addition to arthroscopic lateral release. This usually includes a Fulkerson osteotomy – a procedure in which the bone at the end of the kneecap tendon (patellar tendon) is moved. Once the bone is repositioned, it is held in place with screws. Sometimes the tissues on the inside of the kneecap must be tightened with stitches, called medial imbrication.

After surgery, a brace is needed for six weeks while the bone heals. Crutches will be needed for several weeks until muscle strength improves to allow walking in a brace. Two to three months of rehabilitation may be necessary before symptoms resolve.

Dislocation

A dislocation occurs when the kneecap completely comes out of the groove. This stretches or tears the ligaments that normally keep the kneecap in its proper location. Occasionally, as the kneecap dislocates, an area of cartilage or bone can become chipped. In these cases, arthroscopic surgery is necessary to remove or replace this loose piece. If there is not a loose piece, then the dislocation can often be treated with a brace that keeps the knee straight for several weeks, which allows the ligaments to heal.

This is followed by an exercise program to strengthen the muscles, which further stabilizes the kneecap. If the kneecap continues to dislocate, then surgical reconstruction can be performed to prevent further pain and injury. This reconstruction would include a lateral release, medial imbrication and Fulkerson osteotomy.