By Dr. Yoon Jeon, MChiro, MB, BSc, Dip.TCM, PGCert.
Case Presentation
A 63-year-old female presented to the clinic with a primary complaint of anterior right-sided knee pain, localised over the patella.
The symptoms had an insidious onset approximately 2 years prior and had progressively worsened over time.
The patient had a relevant past history of left ankle fusion surgery, following which she was immobilised in a cast for 5 months. No structured rehabilitation programme was provided post-operatively.
Clinical Examination
On observation and physical examination:
-
Mild swelling of the right knee joint was noted
-
The right patella appeared elevated compared to the left
-
Crepitus (grinding sensation) was present during knee movement
Palpation revealed tenderness in:
-
Hip adductors and abductors
-
Gastrocnemius and soleus
-
Rectus femoris
-
Popliteus
-
Tensor fascia lata (TFL / IT band)
Range of motion assessment showed:
-
Knee extension was full but significantly painful
-
Knee rotational movements were restricted
-
Fibular head mobility was restricted
Orthopaedic testing findings:
-
Waldron’s test: unable to complete due to pain
-
Wilson’s test: no abnormality detected
-
Clarke’s test: sharp pain at the superior aspect of the patella
-
Anterior drawer test: negative
-
Posterior drawer test: reproduced lateral pain from mid-fibula to thigh
-
Patellar mobility: reduced on the right compared to the left
Imaging Findings
X-ray findings demonstrated:
-
Significant reduction in patellofemoral joint space
-
Reduced tibiofemoral joint space
-
Mild osteoporosis (likely secondary to prolonged Prednisolone use)
-
Presence of a small loose fragment in the posterior aspect of the knee joint
Clinical Impression
The overall presentation was consistent with:
-
Patellofemoral pain syndrome (PFPS)
-
Chondromalacia patella
These conditions are commonly associated with abnormal patellar tracking, cartilage degeneration, and muscular imbalance.
Treatment
A structured conservative treatment plan was implemented, including:
Chiropractic Extra-Spinal Manipulation
Targeted manipulation techniques were applied to improve joint mechanics of the knee and associated structures.
Knee and Hip Joint Mobilisation
Mobilisation techniques were used to restore movement, particularly addressing patellar tracking and fibular restriction.
Electro-Acupuncture
High-frequency electro-acupuncture was applied to reduce pain, improve circulation, and promote tissue healing.
Kinesiology Taping & Strapping
Supportive taping techniques were used to improve patellar alignment and reduce mechanical stress.
Rehabilitation Exercises
A personalised home programme including stretching and strengthening exercises was prescribed, focusing on correcting muscular imbalance.
Outcome
The patient reported significant symptomatic and functional improvement after two treatment sessions.
By the third visit:
-
Further reduction in pain
-
Improved ability to walk and negotiate stairs
After a course of six treatments:
-
Only mild discomfort remained when ascending stairs
At 3-month follow-up:
-
The patient was asymptomatic
-
Full functional recovery was achieved
Discussion
The articular cartilage on the posterior surface of the patella is in constant contact with the femoral condyles during normal knee movement.
When movement becomes abnormal due to:
-
Muscular imbalance
-
Biomechanical misalignment
-
Repetitive microtrauma
this may lead to softening, degeneration, and irritation of the cartilage (chondromalacia), resulting in pain and inflammation.
Common contributing factors include:
-
Altered patellar tracking
-
Increased Q-angle
-
Weakness or imbalance in surrounding musculature
Treatment Considerations
Conservative Management
-
Anti-inflammatory approaches (e.g. ice, medication) may reduce inflammation
-
Taping and strapping can provide short-term symptom relief
-
Orthotics may help in cases involving biomechanical alignment issues
-
Soft tissue therapy and mobilisation improve muscular and joint function
-
Strengthening of the quadriceps, particularly the VMO, is essential
-
Low-impact exercise such as swimming can support rehabilitation
Surgical Options
In selected cases:
-
Debridement (shaving) of damaged cartilage may be considered
-
Micro-drilling techniques may stimulate cartilage repair in localised lesions
Conclusion
This case demonstrates that a structured conservative approach — combining joint manipulation, mobilisation, acupuncture, taping, and rehabilitation — can be highly effective in the management of patellofemoral pain syndrome and chondromalacia patella.
Such an approach is particularly beneficial in chronic cases or when symptoms persist despite initial medical management.
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
