What treatment options are available?
Nonsurgical Rehabilitation and Treatment
Non-operative treatment is the usual treatment for this problem. You may require 4-6 weeks of physiotherapy treatment, and then several more months of a home stretching and strengthening program to treat your chondromalacia patella. Getting the pain and inflammation under control is the first step. The overall goals for a rehab plan are to provide pain relief or pain control, improve muscle function and flexibility, improve knee alignment, and avoid further wear and tear.
The initial treatment for chondromalacia patella at Parkway Physiotherapy will aim to decrease the inflammation and pain in your knee. Simply icing the knee can often assist with the inflammation and relieve a great deal of the pain. In cases of chronic pain (lasting longer than 3 months), heat may be more useful in decreasing pain. Your physiotherapist may also use electrical modalities such as ultrasound or interferential current to decrease the pain and inflammation. Massage, particularly for the quadriceps muscle, may also be helpful. During the initial stages of treatment, where the knee is still quite painful, a relative rest from activity may be required. This means that those activities that bother your knee the most may need to be stopped or decreased for a specific amount of time to allow your knee pain to settle down. In many cases, however, you may still be able to partake in a moderate amount of activity. Your physiotherapist will advise you on the appropriate amount of rest from activity that will be needed in your specific case. For some patients a complete cessation of all activities is required in order to get the pain and inflammation under control.
Your physician may suggest anti-inflammatory medications, such as aspirin or ibuprofen, as another means of combating the inflammation and pain. Acetaminophen or paracetamol may be suggested for pain control if you can't take anti-inflammatory medications for any reason.
Once the initial pain and inflammation has calmed down, your physiotherapist will focus on improving the flexibility, strength, and alignment around the knee joint and entire lower extremity. Static stretches for the muscles and tissues around the knee (particularly the quadriceps and iliotibial band on the outside of the knee) will be prescribed by your physiotherapist early on in your treatment to improve flexibility. Again, any tightness in the muscles or tissues around the knee can increase the pull on the patella and affect alignment during walking, running or jumping so it is important to address this immediately.
Strength imbalances will also affect the alignment of the knee and can cause muscles to tighten which put more pressure on the knee and can contribute to the cause of chondromalacia patella. Your physiotherapist will determine which muscles in your individual case require the most strengthening. Strength in both the knee and the hip (which controls the knee position) are very important. In most cases your physiotherapist will prescribe exercises that strengthen the medial quadriceps muscle (VMO) as this muscle is prone to weakness around the knee, and as described above, when it is not strong enough, the pressure behind the kneecap increases. Your physiotherapist will also focus on the particular timing of contraction of this muscle to ensure that it fires when needed to guide the patella properly along the femoral groove.
The muscles of the hip (gluteals) that work to align the knee over top of the foot also have a tendency to be weak so specific attention will be paid to them in the rehabilitation process.
When you have gained enough strength in the knee and hip muscles, your physiotherapist will incorporate advanced exercises that force the knee and hip to recruit the correct muscles while under tension and at a quicker rate. When bending the knee in activities such as running, jumping or stair climbing and descending, the knee muscles and ligaments are placed under load while they are stretching (eccentric load.) This load can be tremendous and translates to heavy loads on the back of the kneecap. In order to prepare the patella to take this load once you return to activity your physiotherapist will prescribe ‘eccentric’ muscle strengthening. Bending the knee quickly into a squatting position and then stopping rapidly (drop squats) encourages the patella (and entire knee joint) to adapt to the force that will eventually be needed to return to physical activity, and to recruit the proper muscles with the proper timing. When appropriate, weights can be added to simulate the increased body weight that the knee endures during running and jumping. Your physiotherapist may ask you to do this exercise on a board slanting downwards (approximately 25 degrees) which has been shown to improve the recruitment of the required knee muscles. In addition, an electrical muscle stimulator may be used on the quadriceps muscle during the activity, which encourages improved recruitment of the muscle, particularly the VMO. All exercises should be completed with minimal or no pain and advancing the exercises should be done only at the discretion of your physiotherapist. Once these exercise are mastered, your physiotherapist may add even more advanced jumping and landing exercises from a height or on different surfaces.
As part of your treatment your physiotherapist may use a hands-on technique to mobilize your kneecap and improve its flexibility if it is stiff. In cases where the patella does not move well, improved movement can assist in decreasing the resistance that the VMO needs to work against and make tracking of the patella easier to control.
Taping the kneecap may also help you to do exercises and activities with less pain. Your physiotherapist may even teach your how to tape your own knee so you can do it for sporting activities that you are still engaging in. Taping over a longer time frame will cause irritation to the skin and can be cumbersome, therefore if the taping helps, a brace, which performs a similar function, may be suggested. Braces used for chondromalacia patella are made of soft fabric, such as cloth or neoprene, and work to encourage proper alignment of the patella as it glides down the knee. There are small buttress pads in the brace that sit on the side of the patella to keep it lined up within the groove of the femur. Patients commonly report less pain and improved function with both taping and bracing.
As mentioned above, proper alignment of your entire lower extremity is paramount to decreasing the overall stress that is placed on the patella and knee in general. In addition to strengthening, stretching, hands-on treatment, and taping, foot orthotics may be useful to assist with alignment. Strengthening of the muscles of the shin and foot can help with the foot alignment, but often this is not enough to fully correct the problem, and foot orthotics are required. Alignment of the foot in turn then encourages proper alignment up the lower extremity chain. Your physiotherapist can advise you on whether orthotics would be useful for you, and also on where to purchase them.
A critical part of our treatment for chondromalacia patella at Parkway Physiotherapy includes specific education on returning to full physical activity. Bending and straightening the knee occurs often even in everyday activities such as walking or stair climbing so a patella that is recovering from injury can easily be aggravated. Returning you back to normal physical activity at a graduated pace is crucial to avoid repetitive pain or a chronic injury. Your physiotherapist will advise you on the acceptable level of activity at each stage of your rehabilitation process and assist you in returning to your activities as quickly but as safely as possible.
With a well-planned rehabilitation program and adherence to suggested levels of rest and activity modification, most people respond very well to the treatment we provide for chondromalacia patella at Parkway Physiotherapy. If, however, your knee pain is not responding to the treatment then we may suggest that you consult an orthopaedic surgeon as surgery may be necessary in your case to resolve your pain.
Parkway Physiotherapy provides services for physiotherapy in Victoria, Westshore, Langford, Sooke.