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Chondromalacia patella refers to cartilage damage to the underneath side of the patella (the part that contacts the femur). It is often due to wear and tear over time, but can occasionally be caused by trauma, as well. Symptoms include pain with stair climbing (especially underneath the kneecap), getting stiff after sitting for long periods of time, and grinding in the knee known as crepitus. Muscle imbalances can also put you at a greater risk for this condition, the most notable being a difference between the strength of the VMO versus the strength of the more lateral muscles.
The VMO, or vastus medialis oblique, is a part of the quadriceps group of muscles. This particular muscle sits just above and medial to the kneecap, and runs on an oblique, or diagonal orientation from the adductor magnus tendon to the tibial tuberosity. This muscle plays a vital role in proper patella tracking. If it is weaker than the muscle more lateral to it, like to vastus lateralis, the patella may not track properly (may be pulled more tot he outside of the leg). The patellar groove (also known as the intercondylar fossa of the femur) allows the patella to move along the femur without much friction or interference. Should the patella be pulled out of this groove, the underneath side may encounter more friction as it tracks. This can results in more wear and tear to the underneath side of the kneecap, resulting in chondromalacia patella.
Another thing that can lead to poor patellar tracking here is something called a poor Q patella between the quadriceps muscle (from its attachment at the AIIS) and the patellar tendon/ligament (and its attachment on the tibial tuberosity). A normal Q angle is approximately 10-12 degrees for men and around 15-18 degrees for women. A higher number can indicate poor patellar tracking, which may result in degeneration to the underneath side of the patella. Those who hyperpronate at the ankle (or roll in) are at a higher risk for an increased Q angle. Muscle imbalances, such as those mentioned above, may also affect your Q angle.
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While no one (therapist or doctor) can fully reverse damage that has already been done to the cartilage underneath your patella, you can take actions to reduce pain, restore muscle balance, and keep it from progressing. Your therapist will check the biomechanics of your knee, hip, and ankle as you move and walk, climb stairs, etc., to ensure proper patella tracking. Bracing and taping can be helpful in these cases. Making sure the muscles surrounding your knee are strong and balanced is key. This will often target strengthening the VMO while ensuring muscles like vastus lateralis, your IT Band, hamstrings, and calves are not too short (ie, need stretching to improve flexibility).
Some ways to target your VMO include quad sets with your foot turned our slightly, short arc quads (SAQ’s) in parallel or turned-out, SAQ’s or long arc quads (LAQ’s) with a ball or pillow between your knees, mini squats against a wall or ball squats, single leg mini squats or heel drops off a step, stationary lunges, step-ups or step-downs. Exercises should be done in pain-free range and only done as long as you can control the movement and maintain proper alignment.
Photo credit: http://patellofemoral.completesportscare.com.au
Your therapist may also include neuromuscular re-education in your plan of care. This involves re-teaching your muscles in which ones should fire and which ones shouldn’t (or perhaps, shouldn’t fire as much) when performing certain functional tasks. This can often be very simple in concept, but difficult to master and frustrating at times, as you’ll be focusing on breaking bad habits and replacing them with good ones. When working to re-educate your muscles on the “right way” to do things, awareness and attention to detail are paramount.
Another part of your rehab regime may be agility training, which will include things like running, jumping, and landing training. The Bosu Ball can again be helpful here, as I’ve often employed doing lunges with the front leg on the Bosu Ball once a certain amount of strength and control has been met, but more challenge is needed before the patient or dancer is released from physical therapy to resume his/her normal level of activity.
This concludes our look into chondromalacia patella. Stay tuned next week as we look into patellar tendinopathy and jumper’s knee.
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