Do you struggle with a nagging , deep aching pain in the front of your knee? Do you feel as if every time after you’ve enjoyed a run or playing sport – there’s suddenly a dull ache in front of your knee cap? These are signs an symptoms linked to Chondromalacia patella. Chondromalaica is defined as the breakdown of a smoothening gel-like structure that layers your the bones inside your body.

Also known as runners knee , Chrondromalacia patella makes up to 25% of all visits seen. Chondromalacia can affect any joint in your body but when it happens to your knee cap , it is known as chondromalaicia patella. Chondromalacia patella affects young adults more than any other age group and is especially common in women. Runners, joggers, soccer players, cyclists and other athletes who repeatedly stress their knees are more likely to develop this problem.

Care should be taken to get a correct diagnoses as chondromalacia patella can be present in anterior knee pain but not everyone with anterior knee pain will have chondromalacia patella therefore making treatment challenging.

How does cartilage fit into your knee joint?

The knee joint is made up of four bones namely:

  • Femur (Thigh)
  • Tibia (Shin)
  • Fibula (Shin)
  • Patella (Knee-cap)

Bones

  • The knee cap is given it’s stability through multi structures which work together to allow the smooth gliding of the patella. The patella itself is a small bone which moves a lot during the movement of your knee. It sits in a boney groove known as the intercondylar groove. Think of the intercondylar groove as being a track with the knee cap being a sled that moves and slides on the track when bending or straightening the leg.

Cartilage

  • As the patella needs to glide and move on this track when we bend or straighten the knee , it is lubricated by articular cartilage on the backside of the bone. This is a special type of cartilage that helps the patella to glide on the intercondylar groove (it’s track) similar to water on a water slide which allows you to slide down.
  • When you have chondromalacia patella , there is a degenerative break down of the lubricating gel behind the patella. As the patella slides up and down on it’s track , there will be further damage to the intercondylar groove as there will be an increase on bone to bone erosion.

The main cell types in cartilage are:

  • Chondrocytes.

    These are formed by cells called chrondroblasts and makes up the cell matrix of cartilage as well.

  • Chondroitin sulfate. These mix with proteins in the cartilage , forming a proteoglycan. Together they form the ground substance of cartilage.
  • Perichondrium which is the fibrous sheath around the cartilage and separates the cartilage from surrounding structures. The perichondrium is further separated into two layers , the outer fibrous layer which provides support and protection and the inner cellular structure which is responsible for the growth and maintenance of the cartilage.

There are three types of cartilage we find in our body:

  • Hyaline cartilage is most common and has a smooth surface. It is tough and flexible to a certain degree. Due to it’s smooth surfaces it allows the tissues or bones to move freely while still being able to provide support such as when you bend and extend your knee.
  • Fibrous cartilage is the strongest type of cartilage. Due to it not having a outter sheath and the way it’s fibres are aligned it allows it to be tough and rigid while still providing support. These types of cartilage can be found in the intervertebral discs of our spine.
  • Elastic cartilage is springy and yellow. It has a outta sheath and it has an abundance of elastic fibres in it’s DNA. This allows it to be flexible and strong as well as to be able to shape around a specific structure. These types of cartilage can be found in the lobes of your ear.

Muscles , ligaments and soft tissue
There are further structures that give the patella it’s strength and stability. These are provided by passive and active structures surrounding the knee joint which helps keep the patella in it’s groove as it’s sliding. More information on the passive and active structures of the knee joint and patella can be found in the patella dislocation section.

What does cartilage do and how does it affect the patella?

Cartilage is made up out of collagen and elastic fibres. It’s a dense firm gel like structure which covers the surface of the joints in our body.

Function

Cartilage is considered to be a non-vascular (Low blood supply) type of connecting tissue. Lets have a look at some of the brilliant functions of cartilage in our body:

  • Cartilage is a flexible type of connective tissue as it covers the joints and aids in the ease of movement of the joint.
  • The cells (chondrocytes) are scattered and lie firmly fixed in the middle (matrix) of the cartilage. They are supported by collagen and elastic fibres.
  • Cartilage gets their nutrients via a process of diffusion across the cell borders.
  • As it is poorly supplied by blood , cartilage heals very slowly.

Articular cartilage is a highly important connective tissue is your knee. Providing a smooth , lubricated boney surface for the patella to glide when you perform a task such as jumping it also aids in the even balancing of force coming through your knee. This eases up the amount of force coming through your joint. Due to the special make up of the cartilage , treatment and repair can be found to be a challenge if not diagnosed correctly or treated before it gets worse.

 

The Patella

Your knee cap cannot function correctly if your cartilage is damaged or degenerated. Likewise , your patella has a massive impact on your cartilage. Due to the patella gliding up and down when you bend or extend your leg , repetitive motion of the patella gliding can cause the cartilage to wear and tear , hence Chondromalicia patella is also referred to as runners knee.

Below are a few risk factors of the patella which leads to the development of Chondromalacia patella:

  • Abnormal gliding of the patella.
  • Boney deformity or mal-alignement of the knee and leg.
  • History of patella dislocations.
  • Trauma or infection to the knee cap.

I have chondromalacia patella … How did it happen?

Lets say you’re an avid runner that has been running for the past few years. You enjoy running on different surfaces, like roads, grass and rocky trials. However, recently you notice that you have a dull localised pain behind your knee cap. It’s getting worse every time you run and you also notice some swelling and puffiness around your knee.

These symptoms form part of what people commonly call runner’s knee. Running involves repetitive movement of the knee cap over the knee joint, much like jumping or climbing stairs or squatting down would. All of these activities require your knee to have the necessary stability to maintain normal patella movement. In a normal knee with healthy cartilage the amount of exercise or load coming through the structures are optimally loaded. This enable the knee joint as well the the cartilage to stay healthy , preventing it rom degenerating and getting damaged.

So what happens to my knee?

When you have chondromalacia patellae , the repetitive forces on your knee joint results in inflammation of the cartilage behind the patella. The gel-like cartilage that coats the backside of the patella beging in an inflammatory process. As we continue to use our leg (Even by walking normally) , the knee is now in a constant state of inflammation.

By being in this constant inflammatory state , the cartilage begins to get weaker and starts being damaged. Following this , it then gets abnormally soft and starts a phase of fissuring. This means that due to it being abnormally soft , it will now begin to develop micro-tears in the cell itself. As we know cartilage is poorly supplied by blood , it will be unable to fix itself , therefore leads to the next step whereby the cartilage begins to erode and irreversibly degenerate.

We are experts at finding the correct types of movements and exercises for your Chondromalacia patella. If you aren’t using it , you’ll lose it.

 

Causes of chondromalacia patella

When you have chondromalacia of the patella the gel-like coating flares-up. The friction that’s developed from the patella gliding up and down it’s track results in symptoms of inflammation , pain and instability.

Trauma or micro-trauma is the leading cause of chondromalacia patella. Micro-trauma is small trauma that the cartilage undergoes every time you go for a run. This lead to an imbalance of forces being translated through your knee.

Chondromalacia can affect any joint in the body but it’s most commonly found to affect the knee cap (patella). There are no distinct causes of chondromalacia but it has been found that a combination of factors often contribute to cause this condition.

  • Trauma: A fracture , dislocation or repeated subluxation of the patella will cause the hyaline cartilage to wear down faster than usual and leads to chondromalacia patella.
  • Overuse: Repetitive knee movements and incorrect jumping. squatting and running technique can all contribute to increased friction of the knee cap over the knee.
  • Muscles: Muscle imbalances of the muscles around the knee (especially the quadriceps) will lead to abnormal patella movement. This makes you more prone to developing chondromalacia.
  • Alignment: The alignment of your hips, knees and ankles form the Q-angle. People with a bigger Q-angle usually have what we call “knock knees” and people with a smaller Q-angle have what we call “bow legs”. Either of these abnormalities result in an abnormal pull of the patella. With time, it leads to more wear and tear of the cartilage around the patella, and can make you more prone to chondromalacia patella.
  • Patella: A patella that has a flatter shape or that is hypermobile can cause chondromalacia.
  • Rheumatoid or oesteoarthrits: Arthritis is a condition that degenerates cartilage and stimulates inflammation. It makes you more prone to chondromalacia patella.

 

Symptoms of chondromalacia patella

Tests that you can do to see if you have a chondromalacia patella

  • Stand on top of a step of at least 30cm.
  • With your injured knee placed , step down slowly and controlled with your unaffected leg.
  • Repeat the movement by stepping down with your injured leg as well.
  • Repeat this test 3 times.
  • The test is positive for Chondromalacia patella if you have knee pain while stepping down or unable to perform the step down.
  • Stand comfortably with your legs shoulder width apart.
  • Start by doing a squat or crouching down low.
  • Then jump up as high as you can. Repeat this jump 5 times within 10 seconds.
  • If you have knee pain or even worse are unable to jump at all, the test is positive for Chondromalacia patella.
  • Kneel down on a soft yoga mat or carpet.
  • Firstly, compare what the pressure feels like when you put your knees down on the carpet/yoga mat.
  • Sit down with the aim being your buttocks on your feet.
  • Repeat this hunch movement 5 times in 20 seconds.
  • If your knee feels painful or unable to handle the pressure of kneeling down – the test is positive for Chondromalacia patella.
  • Sitting upright on a chair or on the bed.
  • Straighten your injured knee as far out as you can.
  • As you straighten it, tighten your thigh muscle as much as you can. Repeat this 3 times in 30seconds.
  • Once you have it straightened, use the web of your hand to put extra pressure onto the front of your patella.
  • If you have knee pain , or limited range when straightening your knee or with the added pressure, the test is positive Chondromalacia patella.

How severe is my chondromalacia patella?

Chondromalacia patella is graded into four stages. Lets have a look at the different stages and how they differ in their presentation:

Stage 1
Due to the repeated wear and tear of the hyaline cartilage on the underside of your knee, it begins to be more spongy instead of smooth. Due to the degeneration , the hyaline cartilage will also be softer. Below are some factors that can be expected in stage 1:

  • Frequency: Pain will come and go depending on how you move your knee.
  • Intensity: The intensity of the pain will make sit – standing uncomfortable and you’ll have a feeling of your knee being heavy and painful especially when climbing stairs.
  • Duration: The pain lasting will depend on the type of activities that you do. The pain will not be constant and will last for at least 5-10minutes after climbing stairs.
  • Range of motion: Your knee will be uncomfortable and stiff. If you try to stand up after sitting for long , it will be discomforting for an initial time then ease up.
  • Swelling: There will be swelling and a slight redness around knee cap , lasting anywhere between 4 – 10 days.

Stage 2 & 3

Stage 2 is confirmed by blisters forming in the cartilage. This is a progression of damage to the cartilage compared to stage 1. Blister’s form due to the separation of the cartilage fibres , with no effect yet on the underlying bone.
Stage 3 is further progression and worsening of the cartilage. In this stage , cartilage pieces have entered the underlying surface of the patella (Less than 50%) and have now reached and affected the bone of your thigh.

Lets have a look at the differences in how you will experience this:

  • Frequency: Pain will be more constant than before , with relief coming with rest.
  • Intensity: The intensity of the pain will be heightened. Activities such as getting in and out of your car will be difficult and painful.
  • Duration: The pain lasting will be longer as the bone is affected. Despite the activities , something as simple as sitting at your desk will bring pain lasting up to 45 minutes.
  • Range of motion: Your knee will be very uncomfortable and stiff. Your range will be limited as the swelling and pain will also be of a larger area and will not allow you to achieve full range of motion.
  • Swelling: There will be swelling as well as a constant redness around your knee cap , lasting anywhere between 10 days – 6 weeks.

Stage 4
Stage 4 is the last stage and by now is has affected more than 50% of the underlying bone surface.
There is now complete erosion and degeneration of the cartilage as well as the formation of extra boney structures known as osteophytes occurring on the underlying bone. As you try to walk , your patella has now lost its lubrication of the cartilage and now slides on the boney surface which is extremely painful.

Lets have a look at how you will experience a stage 4 chondromalacia patella:

  • Frequency: Pain is now constant. Relief is minimal without the use of pain medication.
  • Intensity: The intensity of the pain will be severe and keep you from doing normal tasks such as walking.
  • Duration: The pain does not go away. No matter whether you walking , climbing stairs or turning in bed – the pain just does not seem to go away.
  • Range of motion: Your knee will struggle to bend or extend. You will have little to no range in your knee as it’ll be extremely painful to move , stiff and limited.
  • Swelling: There will be constant swelling around the knee joint whether you are using it or not. A blue discolouration is also not uncommon in this phase as well as swelling and pain radiating down the entire leg.

Diagnosis

Physiotherapy diagnosis

Diagnosing chondromalacia patella can be challenging, because you can experience a variety of symptoms. Luckily, our physiotherapists are experts in anatomy and movement and can easily identify dysfunctional structures around your knee. We have experience and understanding of how to approach a knee examination, so you will be in good hands.

Subjective Assessment

A subjective assessment will include a conversation about your physical history and any past injuries relating to your knee. This will give us an indication of any red-flags to pick up on as well as to give us an idea of how your symptoms has been presenting. Some of things that are important to us in the subjective assessment are:

  • Any previous ligament or bone fractures.
  • Any previous surgeries that you may have had in the knee or hip.
  • Medical history such as medication , infections or trauma within the knee such as bleeding inside the joint.
  • General health , such as arthritis , bone density complications or congenital issue.
  • Recreational and activities that may put you at risk of developing chondromalacia patella such as running.

Objective Assessment

An objective or physical examination is the next step in diagnosing your chondromalacia patella. By listening to your case , we can approach this next step with the confidence and guide you through our approach as to find the root cause of your chondromalacia patella.

A physical examination will allow us to stress and test your knee joint. We use a hands-on approach , making sure that we do not miss any structure associated in diagnosing your chondromalacia patella.

Some of the structures we will have a look at include:

  • Knee joint range of motion: By assessing how well your knee joint bends and extends , we are able to identify any limitations in your range. This , coupled with the ability of your patella to glide effectively is an important aspect of diagnosing your Chondromalacia patella. The alignment of your patella as well as your Q-angle is further indicative if you have any uneven weight distribution which is imperative to an successful functioning knee.
  • Muscles: Your muscular strength play an important role on your knee and knee-cap. We will assess for any imbalances or weakness in your glutes , quadricep and hamstring muscles. If they are over-powering one another , it is a sign of a knee dysfunction and can relate to the cause of your chrondomalacia patella.
  • Ligament Stability: Any previous ligament injuries to the knee joint ligaments will certainly have a hand in the development of a chondromalacia patella. Your ACL , PCL , MCL , LCL and meniscus are responsible for the stability of you knee joint. If one of these structures have been injured before or just not doing their job , it will certainly have an effect on your knee.

Patients between the ages of 15 – 35 years old are the ones affected by chondromalacia patella. If you are highly active , and have a considerable dull ache behind your knee – cap , it is best you have it assessed before it progresses into stage 4 chondromalacia patella.

X-rays

X-rays will not be useful in the early stages on Chondromalacia patella as imaging will only pick up severe boney deformities. Standard x-rays should include:

  • Anterior – posterior view
  • Lateral view
  • Axial View

These views enables us to assess patella height , how deep it sits in it’s groove and any boney deformities on the surface of the knee bone.

Your physiotherapist can refer you to get x-rays taken if necessary.

Computerized Tomography

A CT scan is another type of radiographic intervention that enables us to assess for any boney abnormalities such as fractures , patella tilt or a trochlear dysplasia.

A CT scan can be used in ongoing pain but is not recommended in favour of a MRI scan.

If you need an CT scan, your physio will refer you.

MRI

An MRI remains one of the best tools in diagnosing Chondromalacia patella. By allowing a in depth look at the patella , trochlear groove , patella alignment as well as the ligaments , tendons and more importantly cartilage.

The degeneration as well as the secondary bone damaging will aid us in the diagnoses by identifying any space loss and surface loss between the knee cap and underlying bone. An MRI will also detect any early signs of degeneration.

If your physiotherapist suspects anything further than what has been assessed , you will be referred to the right specialist.

Why is the pain not going away?

Why is it not going away?

It is not uncommon for your symptoms and functional capacity to worsen over time. Chondromalacia is the degeneration of your cartilage under your knee-cap , this process can worsen over time – especially if you continue activities such as running , walking long distances or going to the gym. You should NOT ignore the symptoms if they continue. We have years of expertise in these types of conditions , so rather get it assessed before it worsens.

Why is my knee pain worsening?

When you bend and extend your knee , your patella glides up and down. Aided by the cartilage and fluid which lubricates the track on which your patella glides on. When you have Chondromalacia patella , it is these lubricating structures that are affected and undergoing a degenerative process. As the cartilage does not have a good blood supply , it will not heal on it’s own.

As you continue running or even performing “normal” activities such as walking – the patella is required to glide up and down on it’s track , even though there’s degeneration. The repetitiveness of this movement that the patella does , causes an inflammatory response as the cartilage is being weaned down , leaving more bone on bone irritation. This is the repeated , becoming a cycle of pain and discomfort that you will experience. The more severe your cartilage degeneration, the higher stage of Chondromalacia patella you will have – directly affecting your recovery time.

I’m resting but the pain is still there?

The more you walk or run through the pain, the longer it will take to heal. If the pain returns every time you return from a run , it is an indicator that you have missed the most vital aspect of the healing process. Resting comes with optimal loading of your chondromalacia patella , this means that while you are not doing your normal activities , attention should be paid to the rehabilitation of your knee cap. We are skilled to deal with the loading and phases of healing , do not hesitate getting in contact with us so you can rather be safe than sorry.

What NOT to do

  • Continuous use of anti-inflammatory medication without a prescription.

  • Manage the pain through medication alone. You are only masking the symptoms of something more serious.

  • Walk, run or gym through the pain.

  • Wear a knee brace continuously without the necessary rehabilitation.

What you SHOULD do

  • Rest as needed.

  • Do safe movements and exercise within limits of your pain.

  • Make an appointment to confirm the diagnosis and determine how severe the tissue damage is.

  • Finish your treatment and rehabilitation programme for better long-term results

Making it worse

  • Running

  • Jumping

  • Walking far

  • Climbing stairs

  • Driving for long hours

  • Wearing unsupportive shoes

  • Crouching down

  • Squats and lunges

  • Hiking

  • Trail running

  • Getting up from sitting after a long meeting

  • Kicking a ball

Problems we see when patients come to us with chondromalacia patella

There are various complications that can arise if you do not get the correct management and treatment following your Chondromalacia knee cap. We are able to prevent and mitigate these complications from happening or getting worse.

Below are some general complications and how we are able to manage and prevent it from getting worse:

Waiting too long

  • The longer you wait, the bigger your chances of causing permanent damage to your knee-cap. Treatment and rehabilitation can start within the early stage 1 of chondromalacia patella. We aid the healing process by performing techniques that allows the pain and swelling to decrease. We also prescribe exercises that aims at the smooth gliding of your patella without causing a flare up of the degenerating cartilage. The longer you continue to avoid treating it , the more damage and degeneration will occur. This brings up challenges in the treatment process that can be avoided if rehabilitation starts immediately.

Wearing a brace or knee guard for too long

  • Wearing a knee brace or guard can be an important management tool when treating chondromalacia patella. Usually worn between 2 days to one week , a brace restricts the knee cap by not allowing too much movement when walking. It also protects the patella as it’s still required to perform even though it is undergoing a degenerative process. We have seen individuals who “get used” to wearing a knee brace as it feels good and potentially limits pain. However , this only makes you reliant on a knee brace which is not good as it does not fix your root cause.

Not completing treatment or trying out different treatment strategies

  • A common trend amongst patients is once they’re feeling a bit better , they stop doing rehabilitation or treatment. Healing a cartilage is a process and there will be complications that arises further down the line. Once you stop doing treatment , you have let your knee cap down by stopping. As you all feel much better , you will do a lot more. Gradually as your activity levels increase , your knee cap is required to do more to cope with these demands and stresses placed on it. We aim to design your rehabilitation program , not only to cope with your normal activities but to also cope with the extraordinary activities.

Medication

  • Taking medication has a place in your road to recovery. During the initial treatment phase , medication is useful to manage the inflammatory process of your chondromalacia patella. However , medication is not going to regenerate your cartilage or provide the strength and ease of movement required to fix your knee. Taking it for long periods of time is certainly not recommended as this will bring up complications such as stomach ulcers , drowsiness and give you a false sense of recovery as your pain levels will be masked.

Incorrect diagnoses

  • Alternative diagnoses can be found later in the section , although getting a clear and correct diagnoses is important. This gives us a clear indication as what exactly is the issue and aids us in treating the root cause of your patella pain. If you are worsening or do not get the results we anticipate – a re-assessment will be done to ensure that all structures of the knee has been thoroughly assessed.

Physiotherapy treatment

We can deliver the best clinically suited program and protocol for your Chondromalacia patella. Through our thorough approach we can provide the necessary guidance, education and answers to make sure we give you the ability to confidently return to the activities that means the most to you.

Research has shown that apart from severe late stage 4 chondromalacia patella , a conservative approach and rehabilitation program of at least 12 weeks is vital for the first step in the recovery from chondromalacia patella. Physiotherapy is therefore a vital component on your road to recovery. There’s a variety of different forms of treatment we use which not only focuses on your knee, but on the surrounding structures as well.

Muscles

  • These include your quadricep , hamstring , calves and glutes.

Knee joint and patella

  • Patella ligaments and their stability is an important aspect of rehabilitation. We are able to isolate and strengthen these structures to equip them to be extra strong again.
  • Knee joint range of motion. We aim to confidently get your knee bending and extending without pain as well as not inflicting further irritation to your patella.

The specific physiotherapy treatment interventions will consist of:

Improving daily function

  • Assessing your daily tasks and functional capacity is important to us as this will guide us in advising you on what to do and what to avoid. Perhaps you’ve been aggravating your symptoms and you not aware of it! Allow us to confidently assess these tasks and give you the best direction in your road to recovery.

Prevent further degeneration

  • Techniques such as taping or strapping allows the patella to move within it’s pain-less range. If your patella continues to slide into a degenerative zone , it causes further damage. Correct application of tapping will avoid this from happening as well as give you pain-relief.
  • Heat and ice therapy to control the affects of the inflammation. We will provide you with the answers and guidance needed as to when to use heat or ice on your knee joint.

    Combination therapy

    • Best evidence recommends that a combination of strengthening , manual therapy and laser therapy is best suited for the rehabilitation of a Chondromalacia patella. We are skilled at performing and finding this balance in order to optimally give your patella the care it needs while still respecting the degeneration and not allowing it to flare up.

    Proprioception and Balance

    • Improve balance and proprioception of the knee. Being aware of your knee is essential for your body to know. Following nay type of injury , these factors play a major role in your response to treatment.

    Phases of rehabilitation

    1st Phase: (Week 0 – 2)

    Protect and Educate

    • The main focus in the initial phase is to rest and protect the patella. Due to the previous repetitive trauma that the cartilage , patella and knee joint has sustained , rest and unloading from weight-oriented activities such as running is essential during this phase. These activities are not allowed in this phase as to allow the knee joint to settle from being inflamed.
    • Another important point in this phase is to educate you on the do’s and dont’s regarding your chondromalacia patella. This is to get you to understand what changes are happening in your patella and why. We feel that the better you understand your body. The better you are informed about the process ahead , what to expect and what objectives need to be met before progressing to the next phase.

    Inflammation and medication

    • Anti-inflammatory’s in patients with chondromalacia patella are always taken long before you’ve seen us. This is generally not good as we want to wean you off medication as soon as possible. Treatment of swelling and pain via ice is proven to be as efficient in the initial phase. Anti-inflammatories will not fix the underlying issue , as it delays healing. Pain medication can be taken , provided it does not have any adverse effects.

    Strapping

    • Compression strapping in this phase provides the management of pain and swelling. There are a variety of different strapping techniques we use to achieve optimal healing within phase 1.

    Exercises

    • Isometric exercises are the mainstay type of muscular contractions in the first phase. Focus will be paid to your quadricep , hamstring and glute muscles. Isometric activation involves a contraction without moving your joint through range. This is the perfect setup to build upon as we progress through your phases of rehabilitation.

    To progress to the next phase , we want to see a increase in your functional capacity. Goals to be met at the end of this phase includes:

    • Walking at a comfortable pace and pain no more than a 3/10.
    • Pain free isometric contraction.
    • Able to get from sit-stand with ease and no discomfort.

    2nd Phase: (Week 2 – 4)

    Once we have objectively met the criteria of phase 1 we are now able to progress to phase 2.

    The main objectives set out in phase 2 are as follows:

    • Increasing load on the patella femoral joint
    • Establishing pain-free range of motion in the knee joint
    • Establishing good isometric & isotonic co-contraction of the surrounding muscles
    • Increasing functional capacity

    Load

    • Increasing the amount of stress load through the knee joint and patella is essential in this phase. By stopping all weight bearing activities in phase 1 , we are not able to start getting the patella ready for activities such as running again. Exercises will be progressed to mimic the effect of weighted activities. We will not start running in this phase , but merely perform exercises such as a simple step-down within your pain-free range. The step is no higher than 5cm , and as you get stronger – we go higher. This allows us to load just the right amount of force , sufficient enough to stimulate the patella femoral joint.

    Range

    • Range exercises will be commenced in this phase , as phase 1 objectives will allow for more pain-free movement without causing too much inflammation on the underside of the patella. Due to the repetitive wear and tear of the cartilage , the quality of movement is important as our aim is to promote flexion and extension while avoiding a flare up of cartilage inflammation.

    Strength

    • Isometric exercises will continue in this phase. Starting at 10seconds holds in the first phase , this phase will be directed to 20-30 seconds of contracting. Isometric exercises has great benefits , as proved by research which has shown a reduction in pain as well as stimulating muscle fibres in a safe way.
    • Isotonic exercises will also be introduced in this phase. These are exercises which require you to contract your muscle while moving your joint through range. Simple movements such as a straight leg raise can be used as you have now achieved a pain-free contraction as well as being able to hold your muscular contraction for longer.

    Modalities

    • Using modalities such as laser therapy , dry needling and strapping will be used from this phase onwards. This is to aid optimal healing in your chondromalacia patella.

    To progress to the next phase , we want to see a increase and progression in your functional capacity. Goals to be met at the end of this phase includes:

    • Walking stairs comfortably
    • Driving your car for longer periods with no discomfort
    • Able to get from sit-stand no discomfort.
    • Able to sit on your hunches

    3rd Phase: (Week 4 – 6)

    As we approach phase 3 , you should be able to:

    • Walk with little to no pain at all
    • Only a slight sudden discomfort when performing certain activities such as stair climbing
    • No inflammation or pain on resting or after activity
    • Able to comfortably contract your muscles for at least 3×8 reps (20 seconds) without pain
    • Able to bend and straighten your knee without pain

    Loading

    • In phase 3 , we will progress the amount of force and load going through your patella. Cycling and swimming will be introduced int his phase as this allows for more load coming through your patella without inflicted more damage to your chondromalacia patella. Cycling within a pain-free range will be calculated as well as the type of swimming you’ll be allowed to do.
    • Walking small distances can be tolerated , as long as it is managed correctly and not over-done.

    Strength

    • Strength exercises will progress into more challenging isotonic movements like a squat , knee extensions and hamstring curls.
    • As you progress to phase 4 onwards , the strength becomes more focused , not just on your knee but on your entire body as well. This is due to your functional capacity increasing , therefore you’re patella will be able to cope with more stress.

    Stability

    • Single leg balance and proprioceptive exercises will be started in this phase. Balancing on one leg while performing a simple hands-on-hip movement is the type of movement that allows targeted stress coming through your patella , but also works your neurological structures.

    Modalities will continue to be used in this phase to mitigate any flare-ups that may occur. This is not uncommon as from phase 3 on , the rehabilitation becomes more targeted , meaning you will do more but still within your patella’s limitations.

    To progress to the next phase , we want to see a increase and progression in your functional capacity. Functional goals to be met at the end of this phase includes:

    • Walking stairs without pain.
    • Standing for longer periods of time (30min) without pain.
    • Cycling without pain.

    4th Phase: (Week 6 – 8)

    As you approach phase 4 , you should be able to:

    • Bend and extend your knee to full range without any pain
    • Walking and climb stairs without pain
    • Integrating well into functional activities like cycling without pain
    • Have pain-free gliding of your knee cap
    • No swelling or resting pain after performing you exercises

    In the 4th phase , the rehabilitation will become more challenging and intensive as your patella is now more stronger , stable and pain-free. This allows for more stresses and loading to occur in the patella-femoral joint , still within your boundaries but also continuing to build for the next two phases.

    Below are some of the progressions you can expect when navigating through phase 4:

    Strength

    • Progression of exercises will be introduced that will allow for more targeted forces coming through the patella. Exercises will higher stresses placed on the patella will be used , this include: Single leg lunges , single leg step downs on a box of at least 30cm , squatting all the way through range , single leg bridging and single leg hamstring curls.
    • Also introduced towards to end of this phase are exercises that require the patella to stabilise after putting it through a tasks such as a jumping. You will not be jumping to your full capacity in this phase , but merely just introducing the movement and stress to the patella.
    • Balancing exercises will be single leg in this phase and will involve you performing a rotational movement while standing and balancing on your affected patella. This is so allow for a rotational stress to be placed on the patella as rotational forces are another type of important stress the patella needs to be able to handle.

    Cardiovascular

    • Cycling and swimming will and can continue in this phase.
    • Treadmill or road walking of no more than a 50% and not longer than 15-20min will also be started in this phase. These are bigger stresses placed on your patella so care and mindfulness will be practised when these tasks are introduced , you will not perform these tasks on the same day you do your patella exercises , so a loading plan will be calculated for you as you allow the optimal loading to occur.

    To progress to the next phase , we want to see a increase and progression in your functional capacity. Functional goals to be met at the end of this phase includes:

    • Road or treadmill walking for periods of 20 min without pain.
    • Able to perform a pain-free squat.
    • Standing for longer periods of time (45min) without pain.
    • Repetitive crouching with ease and no discomfort.

    5th Phase: (Week 8 – 10)

    As you enter phase 5 , you should be able to perform and re-integrate back into your normal daily activities with ease and confidence. You should be able to comfortably be able to:

    • Walk , stern jog of distances of up to 5km without pain

    • Drive and climb stairs effortlessly
    • Return to training within limits but comfortably able to perform training skills such as passing drills and shadow training.
    • Return to gym
    • Perform your work requirements without any pain

    We will look at the re-integration in this phase , building into your final phase. This means that we have now completed your foundation , your progressions and are now approaching the top of your pyramid. The main focus in this phase is to mimic movements and stresses that are important to you and your sport , loading your patella with these types of stresses so when you are fully fit and return to playing or gym training – it will not be a surprise to your patella.

    Focused explosive and agility movements in this phase will include:

    • Agility drills that require you to build up speed , working from slow – medium – fast pace.
    • Single leg hoping from side – side with a stick landing for stability
    • Rotational hopping while landing on one leg
    • Dynamic strengthening exercise’s such as a bear crawl , squat jumps and box jumps.
    • Drop landings from a higher box of at least 60cm
    • Movements specific to your sport such as taking a tackle to your knee , sprinting in different directions and catch passing while running.

    These types of stresses will set you up for your final phase to ensure that no stone is left unturned , as once you have been cleared – you will have the confidence and guidance to know exactly just how strong and stable your patella is.

    To progress to the next phase , we want to see a increase and progression in your functional capacity. Functional goals to be met at the end of this phase includes:

    • Return to sport training with ease and no pain.
    • Able to perform a pain-free squat of at least 0.5 x body weight
    • Able to jump or skip with no pain.
    • Able to sprint at at least 80% without pain.

    6th Phase: (Week 10 – 12)

    By stressing , re-assessing and continuing your end-stage rehabilitation on your chondromalacia patella , we are able to ensure that the injured structure is now stronger , stable and has the ability to withstand the demands you place on it.

    As in these final two weeks – we are now fine tuning your rehabilitation. This allows us to safely state that when we give you the medical clearance – we are confident that your patella has been stressed to the max and you are able to integrate fully back into your highest level of activity.

    By now you will be able to:

    • Walk , jog and sprint without issues
    • Integrated well back into training
    • Know how to mange your patella after intensive activity
    • Jump , land and take off without issues
    • Stable balancing technique which you are able to generate power and explode off , such as a single leg forward jump.

    At the end of this final phase you will be cleared based on the objectives set out and met by you. This will give you the confidence and ability to get back into the tasks you love the most , without having the anxiety and fear that kept lingering in your mind. Allow us to help you with our rehabilitation skills , knowledge and guidance to get you back in the most appropriate way possible.

    Healing time

    Healing time for a chondromalacia patella will differ amongst patients as each individual case will react differently to treatment as well as dependent on the severity or stage that you’re in. As the knee joint is responsible for weight bearing and walking , the structures that are affected when a patella has chondromalacia needs sufficient time to rest , recover and heal. It will not help continuing to walk , squat , run or climb stairs with the injured patella as the cartilage will continue to be aggravated by these movements. Rest and unloading from specific activities is a must and is recommended in the first step to recovery.

    If undergone an arthroscopy , healing time following this surgery can be expected to be anywhere between 16 – 21 weeks , depending on the individual.

    Non-Surgical approach

    • A rehabilitation program is best suited for long-term recovery. A clinically based and objectively measured program for no less than 3 – 4 months is recommended. Unless it is indicated , a non-surgical approach is the best way to recover from your chondromalacia patella.

    Surgical approach

    • If you had or are planning to have surgery for chondromalacia patella, there will still be a lengthy recovery period involved. Following your surgery, a healing time of 4 – 7 months can be anticipated. This is because the cartilage, bone and knee joint itself that needs time to heal. Exercises and loading will generally start while you are in hospital and gradually progresses over the course of your recovery journey. If you plan to return to a high-level sport, the recovery can be even longer.

    You will need to see your physiotherapist weekly, or in more severe cases twice a week. Remember, you only spend an hour at a time with your physio, so the greatest part of your recovery is up to you. Each individual are different and so are their healing times. Allow us to cater for your specific healing time while still loading your cartilage and patella in the most optimal way possible.

    Other forms of treatment

    Medication

    • A doctor can prescribe non-steriodal anti-inflammatory drugs (NSAID’s) or cortisone as a form of treatment. Unfortunately, the relief will be temporary if you don’t treat the real problem.

    Cell Therapy

    • Mesenchymal Stem Cell (MSc) treatment has gained momentum over the last two decades. Research has advocated for it to be safe and effective in the treatment of chondromalalcia patella. However, it is still an experimental and expensive form of treatment.

    Knee braces

    • A brace or knee guard is important for the management of your symptoms in the acute phase of this condition. It gives a feeling of stability and helps to decrease the strain on the knee joint. However, you need to actively strengthen muscles to get the best long-term results.

    Foot orthoses

    • Insoles and orthoses are designed to distribute your weight evenly, based on your foot arch and structure. This can help to ease your symptoms and alignment in conjunction with safe movement.

    Is surgery an option?

    Surgery for a Chondromalacia patella is the last resort once a non-surgical rehabilitation approach has failed. The type of surgeries will differ depending on how severe your Chondromalacia patella is , as there is no “best” suited surgery for a Chondromalacia patella. These different type of surgeries will have to take into account your specific history as well as your level of activity.

    Below are some of the factors that will determine which surgery is best suited for you:

    • Age
    • Level of activity and participation
    • History of trauma to the knee

    In addition , there are a few indicators that you should “qualify” for before having a surgery. These are:

    • Failed non-surgical approach.
    • Extensive cartilage and joint space loss in stages 3 & 4.
    • Low trochlear depth. This refers to the track on which your patella slides on. Research has shown that a low trochlea depth along with the angle in which your patella tilts when moving is a indictor of a potential surgery for Chondromalacia patella.
    • Boney changes in severe stages 3 and 4.
    • Displaced fractures.
    • Excessive patella mal-tracking. This refers’s to an abnormally gliding pattern of your patella.

    The types of surges that can be done once all the factors above are check through will include:

    • Patellectomy – Can be a partial or total. Only recommended for individuals who has excellent quadricep muscle strength.
    • Tibial Tuberosity surgeries – In severe stage 3 or 4 cases , your leg bones will be affected. The aim of this surgery is to restore the joint function in the knee.
    • Arthroscopy – The most common type of surgery for a Chondromalacia patella. The aim is to smooth our any rough parts of cartilage in the knee , and is used in stages 2 , 3 and 4. Research has shown that only 10% of patients with chondromalacia patella actually needs this type of surgery.

    As these surgeries aim to resort function off the knee joint , rehabilitation is still important after surgery to prevent complications.Known complications arising after surgery include:

    • Patella instability
    • Patella tendonitis
    • Pain and functional disability
    • Post traumatic arthritis

    We are experts at knowing how to navigate the rehabilitation following a patella surgery , allow us to guide you through this process whilst getting you back to your best.

    What else could it be?

    • Osteoarthritis – A degenerative disease that affects joints. This is similar to chonromalacia patella, but typically affects the tibio-femoral joint and not just the patello-femoral joint.
    • Patella Subluxation – Hypermobility or an injury that causes the patella to move/dislocate in and out of its groove. Repetitive subluxation leads to an unstable knee joint.
    • Hoffa’s fat pad syndrome – Inflammation of the fat pad which sits underneath and behind the knee cap. It it caused through repetitive trauma or injury. Causes many of the same symptoms as chondromalacia patella.

    Also known as

    • Runner’s Knee
    • Anterior knee syndrome
    • Patella-femoral pain syndrome
    • Knee-cap pain