Case Studies:

Knee Pain, Chondromalacia Patella

By Dr. Yoon Jeon, MChiro, MB, BSc, Dip.TCM, PGCert.

CASE PRESENTATION

A 63 year old lady presented to the clinic with a main complaint of anterior right sided knee pain, located over the patella. Onset 2 years ago, started insidiously with a progressing course. The patient had to wear a cast for 5 month, after a left sided ankle fusion and was offered no rehab post-surgery.

On observation and physical examination, a slightly swollen knee joint with the patella raised on right side compared to the Left side, grinding Sound on movement of the knee. Tender points are over Hip Adductors / Abductors, Gastroc/soleus, Rec.fem, popliteus and TFL (ITB).

The Knee extension is not restricted but very painful and Knee joint rotations are restricted as well as Fibula movement. Orthopaedic tests shows Waldrons test could not be completed due to pain, Wilsons - NAD for pain, Clarks - sharp pain at the superior aspect of the patella, Anterior Drawer - NAD for pain, Posterior drawer - Sharp pain from mid fibula to the thigh (lateral aspect), Patella movement - right patella more restricted than the Left.

X-Ray findings are great reduction in patellofemoral joint space, mild osteoporosis (2nd to prolonged Prednisolone use), reduced joint space between the tibia and femur, small loose fragment at the posterior aspect of the knee joint.

Overall, the knee pain most likely come from Patello Femoral Arthralgia / Chondromalacia Patella.

TREATMENTS

  • Chiropractic Extra-spinal Manipulation.

  • Knee / Hip joints Mobilization.

  • Electric Acupuncture (high frequency).

  • Kinesiology typing & strapping.

  • Self-home Stretching / Strengthening Exercises.

OUTCOME

The patient has both symptomatic and functional improvement significantly after two visits. On the third visit, she still reported improvement and demonstrated better ability to walk & up/down stairs. After a course of 6 treatments, reported only an mild aching when going up stairs. Her last visit was 3 months after onset and was asymptomatic & fully functioned.

DISCUSSION

The articular cartilage on the posterior aspect of the patella comes in constant contact with the articular surfaces of the femur during normal knee motion. When knee motion is repetitively abnormal due to muscle imbalance or biomechanical misalignment, softening or degeneration and cracking of the articular cartilage, may cause the patella to rub irregularly on the femoral surfaces causing the patellar articular cartilage to become irritated, resulting inpain and inflammation. Predisposing factors are muscular imbalance as a direct cause of the patellar misalignment, repetitive micro-trauma & Increased Q-angle.

Treatment options

Conservative treatments:

Icing or anti-inflammatory drugs or to reduce inflammation has been shown effective.

Various taping and strappingtechniques can provide pain relief,but do not act to facilitate healing of the injury.

Orthotic inserts can provide relief if the symptoms result from tibial torsion or femoral anteversion.

Mobilisation and STW of surrounding muscles.

Quadriceps and VMO strengthening may be the most important treatment once the pain has calmed down. Swimming is agood alternative as a non-weight bearing strengthening regimen.

Surgical Treatment:

If there is a diffuse area of involved articular cartilage with irregular degenerative changes that are still ina fairly early stage, an appropriate surgical option might be to SHAVE the damaged cartilage down to thenormal cartilage underneath in aneffort to smooth the gliding surface.

An area of more localised degeneration might better respond to DRILLING small holes through the damaged cartilage to facilitate growth of healthy tissue up throughthe holes from the layersunderneath.

CONCLUSION

A conservative tratments consisting of specific manipulation and mobilisaition of knee joints, cross friction massage, Electric Acupuncture and Kinesiological typing provided excellent care for Chondromalacai Patella, especially when the condition is chronic or not responding to initial medical treatment.

REFERENCES

Cowan, S, et al (2003). ‘Simultaneous feeaforward recruitment of the vasti in untrained postural tasks can be restored by physical therapy.’ Journal of Orthopaedic Research, 21, 553-558

Crossley, K, et al (2002). ‘Physical therapy for patellofemoral pain: a randomized, double-blinded, placebocontrolled trial.’ American Journal of Sports Medicine, 30(6), 857-865.

http ://www. iasm.com/kneepat.html

http://orthopedics.about.com/cs/patelladisorders/a/chondromalacia.htm