Chondromalacia Patella – Knee Pain – Patellar Tracking Dysfunction

Chondromalacia patellaChondromalacia patella, also known as ”Runners Knee” is one of the most common causes of knee pain in runners. The condition results from irritation of the cartilage on the under-surface of the kneecap. This cartilage is smooth and the kneecap normally glides effortlessly across it during bending of the knee joint. In some individuals however the kneecap does not track so smoothly due to poor alignment and the cartilage surface becomes irritated, resulting in inflammation and knee pain. In more severe cases there can be breakdown of the cartilage. Chondromalacia patella can affect athletes of any age but tends to be more common in women, most likely due to anatomical differences between the sexes ie. wider hips in females which results in a greater angulation between hip and knee, thus resulting in increased lateral forces on the patella.

 

Chondromalacia Patella – Causes

There are several causes both structural and dynamic which are linked to the condition. These include excessive foot pronation(feet turn out when running etc.), tight IT band, tight vastus lateralis(basically outer lower quad), weak or slow firing vastus medialis (basically lower inner quad), increased Q angle (simply put the angle between the outer hip and centre of the knee), a lateral femoral condyle that is not sufficiently prominent anteriorly (simply put the knee joint does not fit together properly),and a small or high riding patella(knee cap).(McConnell, 2002)

 

Chondromalacia Patella – Symptoms

The most common symptom is a dull, aching pain in the front of the knee, behind the kneecap. This pain is often worse when you go up or down stairs. It also can flare up after you have been sitting in one position for a long time. For example, your knee may be painful and stiff when you stand up after watching a movie or after a long trip in a car or plane. In some cases, the painful knee also can appear puffy or swollen. Chondromalacia can sometimes cause a creaky sound or grinding sensation known as ”crepitus” when you move your knee.

 

Chondromalacia Patella – Physio Treatment 

Suitable treatment may involve 1. Soft tissue work to loosen tightened structures such as vastus lateralis muscle, IT band, lateral retinaculum etc., 2.Strengthening of weak structures such as vastus medialis, glutes , hip abductors etc., 3. Correction of overpronation using orthotics, 4. Non steroidal anti-inflammatories such as ibuprofen to reduce pain and inflammation, 5. Rest with gradual return to exercise, 6. Taping to correct tracking can be a short term solution.(Hertling and Kessler, 2006) while you strengthen the vastus medialis muscle. Also there are supports you can purchase to help correct patella tracking while exercising. These are a good short term solution while you correct the problems referred to above. Here is a good example.

If nonsurgical treatments fail, or if you have severe symptoms, your doctor may recommend arthroscopy to check the cartilage inside your knee. If the cartilage is softened or shredded, damaged layers can be removed during the surgery, leaving healthy cartilage in place .

 

References

Hertling, D., Kessler, R.M. ”Management of Common Musculoskeletal Disorders : Physical Therapy Principles and Methods.” Lippincott, Philidelphia 524-533, 2006.

Mc Connell, J. ”The physical therapist’s approach to patellofemoral disorders.” Clinical Sports Medicine 21:363-387, 2002.

 

 

For more information on chondromalacia patella see this video.

 

If  you would like to get in touch to discuss your condition or make an appointment for physio in Tralee, please click

here for details.

Regards Eddie.

Meniscus Injuries  – Knee Pain

Meniscus injuries are a relatively common knee injury. Cartilage within the knee joint provides cushioning between the bones at this joint. This protects them from the stresses of walking, jumping, running etc. There is articular cartilage which is the smooth, white tissue that covers the ends of bones(Femur, tibia) where they come together to form the knee joint. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction. Articular meniscus injuriescartilage can be damaged by injury or normal wear and tear.

Within the knee you also have fibrocartilage in the form of the medial and lateral meniscii. These are two thick wedge-shaped pads of cartilage attached to top of the tibia (tibial plateau) and under the femur bone. They  allow the femur to glide when the knee joint moves. Each meniscus is curved in a C-shape, with the front part of the cartilage called the anterior horn and the back part called the posterior horn. Meniscal tears are usually described by where they are located anatomically in the C shape and by their appearance (for example, “bucket handle” tear, longitudinal, parrot beak, and transverse).

Blood supply

Because the blood supply is different to each part of the meniscus. Knowing where the tear is located may help decide how easily an injury might heal (with or without surgery). The better the blood supply, the better the potential for recovery. The outside rim of cartilage has better blood supply than the central part of the “C.” Blood supply to knee cartilage also decreases with age, with up to 20% of normal blood supply  lost by age 40.

What causes a meniscus to tear?

A forceful twist or sudden stop can cause the end of the femur to grind into the top of the tibia, pinching and potentially tearing the cartilage of the meniscus. These meniscus injuries can also occur with deep squatting or kneeling, especially when lifting a heavy weight. Meniscus tear injuries often occur during athletic activities, especially in contact sports like football and hockey. Motions that require pivoting and sudden stops, in sports like tennis, basketball, and golf, can also cause meniscus damage.

 

Meniscus injuries  – Increasing risk with age

The risk of developing a torn meniscus increases with age. This is  because cartilage begins to gradually wear out, losing its blood supply and its resilience. Being overweight also puts more stress on the meniscii. This means that routine daily activities like walking and climbing stairs increase the potential for wear, degeneration, and tearing. It is estimated that six out of 10 patients older than 65 years have a degenerative meniscus tear. Many of these tears may never cause problems.

Some of the fibers of the cartilage are interconnected with those of the ligaments that surround the knee. Thus, meniscus injuries may also be associated with tears of the collateral and cruciate ligaments, depending upon the mechanism of injury.

Symptoms of meniscus injuries can include some or all of the following:

  • Pain with running or walking longer distances
  • Intermittent swelling of the knee joint: Many times, the knee with a torn meniscus feels “tight.”
  • Popping, especially when climbing up or down stairs
  • Giving way or buckling (the sensation that the knee is unstable and the feeling that the knee will give way): Less commonly, the knee actually will give way and cause the patient to fall.
  • Locking (a mechanical block where the knee cannot be fully extended or straightened): This occurs when a piece of torn meniscus folds on itself and blocks full range of motion of the knee joint. The knee gets “stuck,” usually flexed between 15 and 30 degrees and cannot bend or straighten from that position.  

Diagnosis

The diagnosis of a knee injury begins with a history of the injury etc. and physical examination. There have been many tests described to assess the internal structures of the knee. The McMurray test is one long used orthopedic test . The health-care professional flexes the knee and rotates the tibia while feeling along the joint. The test is positive for a potential tear if a click is felt or noticeable pain is felt while circumducting the knee in full flexion.

Physiotherapy in Tralee – referral for MRI

(MRI) is the test of choice to confirm the diagnosis of a torn meniscus. It also allows a radiographer to visualize the inner structures of the knee. These structure include; the cartilage and ligaments, the surface of the bones, and the muscles and tendons that surround the knee joint. Plain X-rays cannot be used to identify meniscal tears but may be helpful in looking for bony changes, including fractures, arthritis, and loose bony fragments within the joint. In older patients, X-rays may be taken of both knees while the patient is standing. This allows the joint spaces to be compared to assess the degree of cartilage wear. Cartilage takes up space within the joint and if the joint space is narrowed, it may be an indicator that there is less cartilage present, likely from degenerative disease.

Treatment of Meniscal Tears

Sometimes conservative measures such as physical therapy, NSAIDs and rest can be enough to settle the condition. When conservative measures are ineffective the next step may be surgery to repair or remove the damaged cartilage.

 

Here is a little video explaining more.

 

For physiotherapy in Tralee phone 086-7700191, click here for website homepage

Osgood Schlatter disease : Knee Pain in Adolescents

Osgood Schlatter disease is an inflammation of the bone, cartilage and/or tendon at the top of the tibia (shinbone ie. just under the knee), where the tendon from the kneecap(patella) attaches. It presents as a painful lump below the kneecap. It usually strikes active adolescents during growth spurts which can begin any time between the ages of 8 and 13 in girls, 10 and 15 years  in boys, basically during puberty.  Growth spurts make kids vulnerable because their bones, muscles, and tendons are growing quickly and not always at the same time. With exercise, these differences in size and strength between the muscle groups place unusual stress on the growth plate at the top of the shinbone (A growth plate is a layer of cartilage near the end of a bone where most of the bone’s growth occurs. It is weaker and more vulnerable to injury than the rest of the bone).

 

While  Osgood Schlatter disease  is more common in boys, the gender gap is narrowing as more girls become involved in sports.  Osgood Schlatter disease  affects as many as 1 in 5 adolescent athletes. Teens increase their risk if they play sports involving running, twisting, and jumping, such as basketball, football, volleyball, soccer, tennis, figure skating, and gymnastics etc. Doctors disagree about the mechanics that cause the injury but agree that both overuse and physical stress are involved. Most parents call the doctor after their child complains of intermittent pain over several months.

Signs and symptoms of  Osgood Schlatter disease

  • pain that worsens with exercise
  • relief  from pain with rest
  • swelling or tenderness at the bony prominence under the knee and over the shinbone
  • limping after exercise
  • tightness of the muscles surrounding the knee (the hamstring sometimes but particularly the quadriceps muscles)

 

The pain varies from person to person. Some have only mild pain while performing certain activities. For others, the pain is nearly constant and can be debilitating. The good news is that Osgood Schlatter disease (OSD) is far less serious than its name suggests. Though it is one of the most common causes of knee pain in adolescents, it is really not a disease, but an overuse injury. The condition is self limiting and usually resolves itself within 12 to 24 months. A similar condition, ”Sever’s disease” occurs in children of the same age group down at the achilles tendon attachment and presents as heel pain. Again the condition is self limiting and the same treatment protocols apply.

While there is no evidence that rest accelerates the healing process, a reduction in activity usually reduces the pain. There is no need to rest completely. Pain should be the main guide as to limitation of activity. Tightness in  the quadriceps muscles may predispose to this condition. The athlete should commence a stretching program. Some massage therapy on the quadriceps  can be tried. Pain also can sometimes be relieved by icing the painful area(ice in wet towel) for 10 minutes at a time. Correction of any biomechanical abnormality, such as excessive subtalar pronation(feet turn out while running) should also be considered.

Summary

To sum up, this is basically a self limiting condition that adolescents generally grow out of (Brukner and Khan, 2011). Some stretching exercises  and modification of activities is generally the best and most cost effective course of treatment.

References

Brukner P, Khan K. Clinical Sports Medicine. 4th ed. Sydney: McGraw-Hill, 897-898, 2011

 

 

For more information or to make an appointment phone 086-7700191. Physiotherapists in Tralee, Co. Kerry.

Common Knee Injuries

1. Chondromalacia Patella

knee injuriesKnee injuries like Chondromalacia patella result from degeneration of cartilage on the underside the kneecap (patella)due to poor alignment of the kneecap (patella) as it slides over the lower end of the thighbone (femur). This condition can also be referred to as patellofemoral syndrome.  It usually presents as pain in the front of the knee aggravated by activities such as running, jumping, climbing or descending stairs etc., or by prolonged sitting with knees in a moderately bent position. Patients with chondromalacia patella frequently have abnormal patellar “tracking” toward the lateral (outer) side of the femur. Some patients may also have a vague sense of “tightness” or “fullness” in the knee area with the condition. Mild swelling of the knee area may also occur.

2. Meniscus TearKnee injuries

knee injuriesAny activity that causes you to forcefully twist or rotate your knee, especially when putting your full weight on it, can lead to a torn meniscus. Each of your knees has two menisci — C-shaped pieces of cartilage that act like a cushion between your shinbone and your thighbone. A torn meniscus causes pain, swelling and stiffness. You might also feel your knee lock and have trouble extending it fully. Conservative treatment — such as rest, ice and medication — is sometimes enough to relieve the pain of a torn meniscus and allow the injury time to settle down on its own. In other cases, however, a torn meniscus requires surgical repair.

The meniscus weakens with age. Tears are more common in people over the age of 30. If you have osteoarthritis, you’re at higher risk of injuring your knee or tearing your meniscus. When an older person experiences a meniscus tear, it’s more likely to be related to degeneration. This is when the cartilage in the knee becomes weaker and thinner.

 

3. Cruciate ligament rupture

knee injuriesThese ligaments are found inside your knee joint. They cross each other to form an “X” with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments stabilize the knee. About half of all injuries to the anterior cruciate ligament occur along with damage to other structures of the knee, such as articular cartilage, meniscus, or other ligaments. Partial tears of the anterior cruciate ligament are rare; most ACL injuries are complete or near complete tears.

The  cruciate ligaments can be injured in several ways such as : changing direction rapidly ; Stopping suddenly ; Slowing down while running ; Landing from a jump incorrectly ; Direct contact or collision to the knee.

When you tear a  cruciate ligament, you might hear a “popping” noise and you may feel your knee give way under you. Other typical symptoms include:

  • Pain with swelling. Within 24 hours, your knee will swell. If ignored, the swelling and pain may resolve on its own. However, if you attempt to return to sports, your knee will probably be unstable and you risk causing further damage to the cushioning cartilage (meniscus) of your knee.
  • Loss of full range of motion
  • Tenderness along the joint line
  • Discomfort while walking

Treatment for a cruciate ligament tear varies depending on the patient’s individual needs. For example, the young athlete involved in agility sports will need surgery to return safely to sports. Less active, older individuals may be able to return to a quieter lifestyle without surgery.

 

4. Collateral ligament strain/ruptureKnee injuries

physiotherapists in DingleThe collateral ligaments of the knee are located one on either side of your knee joint. They help connect the bones of your upper and lower leg, inside your knee joint. The collateral ligaments help keep your knee stable. They keep your leg bones in place and keep your knee from moving too far sideways. A collateral ligament injury occurs when the ligaments are stretched or torn. A partial tear occurs when only part of the ligament is torn. A complete tear occurs when the entire ligament is torn into two pieces. A collateral ligament injury can occur if you get hit very hard on the inside or outside of your knee, or when you have a twisting injury. Sometimes the ligaments just sprain and this is easier to recover from and requires no surgery.

With a collateral ligament injury, you may notice:

  • Your knee is unstable and can shift side to side as if it “gives way”
  • Locking or catching of the knee with movement
  • Knee swelling
  • Knee pain along the inside or outside of your knee

Various orthopedic tests can help diagnose  collateral ligament damage. More detailed knowledge of the injury can be obtained by MRI. Injured ligaments are considered “sprains” and are graded on a severity scale.

 

If you have a collateral ligament injury, you may need:

  • Crutches to walk until the swelling and pain get better
  • A brace to support and stabilize your knee
  • Physical therapy to help improve joint motion and leg strength

A lot of the time people don’t need surgery for collateral ligament damage  but more serious cases may.

 

5. Baker’s Cyst – Knee injuries

 knee injuries

Baker’s cyst is a fluid-filled swelling that causes a lump at the back of the knee, leading to tightness and restricted movement. Usually, this condition is due to an underlying problem affecting the knee joint, such as arthritis or a cartilage injury.

 

6. Patella Tendinopathy

knee injuriesPatellar tendinopathy(also known as Jumper’s knee) is an overuse injury affecting this knee tendon. There are a number of factors which can contribute to the development of patellar tendinopathies. These include:

  • Rapid increase in amount of training
  • Sudden increase in training intensity
  • Playing/training on rigid surfaces
  • Tight quadriceps and hamstring muscles
  • Poor foot posture, knee or hip control.

Tendinopathies usually causes pain, stiffness, and loss of strength in the affected area. The pain may get worse when you use the tendon. An experienced practitioner will be able to diagnose a tendinopathy from both palpation and history of the condition.   Tendinopathies can be confirmed by MRI which will give a clearer picture of the level of damage. Treatment for patellar tendinopathies varies depending on the level of injury and can vary from conservative treatment combining rest / eccentric training  to surgical intervention in more serious cases.

7. Osgood Schlatter’s Disease(Kids)

 physiotherapists in DingleOsgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia) called the tibial tuberosity. The condition gets worse with activity and better with rest. Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics — especially running and jumping sports – are at an increased risk for this condition. However, less active adolescents may also experience this problem. The condition normally resolves over time but can be anything from a few weeks/months to two years. It is nothing to worry about. A child can remain active but pain from the condition itself will limit that activity. Icing the area of pain and stretching leg muscles especially quads can help. NSAIDs can be used to relief the pain and inflammation but should be used sparingly and under doctors supervision.

 

Article by Eddie O Grady Physiotherapist.

Meniscus Injuries  – Knee Pain – Physiotherapy in Tralee

Cartilage within the knee joint provides cushioning between the bones at this joint. This protects them from the stresses of walking, jumping, running etc. There is articular cartilage which is the smooth, white tissue that covers the ends of bones(Femur, tibia) where they come together to form the knee joint. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction. Articular meniscus injuriescartilage can be damaged by injury or normal wear and tear.

Within the knee you also have fibrocartilage in the form of the medial and lateral meniscii. These are two thick wedge-shaped pads of cartilage attached to top of the tibia (tibial plateau) and under the femur bone. They  allow the femur to glide when the knee joint moves. Each meniscus is curved in a C-shape, with the front part of the cartilage called the anterior horn and the back part called the posterior horn. Meniscal tears are usually described by where they are located anatomically in the C shape and by their appearance (for example, “bucket handle” tear, longitudinal, parrot beak, and transverse).

Blood supply

Because the blood supply is different to each part of the meniscus. Knowing where the tear is located may help decide how easily an injury might heal (with or without surgery). The better the blood supply, the better the potential for recovery. The outside rim of cartilage has better blood supply than the central part of the “C.” Blood supply to knee cartilage also decreases with age, with up to 20% of normal blood supply  lost by age 40.

What causes a meniscus to tear?

A forceful twist or sudden stop can cause the end of the femur to grind into the top of the tibia, pinching and potentially tearing the cartilage of the meniscus. These meniscus injuries can also occur with deep squatting or kneeling, especially when lifting a heavy weight. Meniscus tear injuries often occur during athletic activities, especially in contact sports like football and hockey. Motions that require pivoting and sudden stops, in sports like tennis, basketball, and golf, can also cause meniscus damage.

Increasing risk with age

The risk of developing a torn meniscus increases with age. This is  because cartilage begins to gradually wear out, losing its blood supply and its resilience. Being overweight also puts more stress on the meniscii. This means that routine daily activities like walking and climbing stairs increase the potential for wear, degeneration, and tearing. It is estimated that six out of 10 patients older than 65 years have a degenerative meniscus tear. Many of these tears may never cause problems.

Some of the fibers of the cartilage are interconnected with those of the ligaments that surround the knee. Thus, meniscus injuries may also be associated with tears of the collateral and cruciate ligaments, depending upon the mechanism of injury.

Symptoms of a meniscus injury can include some or all of the following:

  • Pain with running or walking longer distances
  • Intermittent swelling of the knee joint: Many times, the knee with a torn meniscus feels “tight.”
  • Popping, especially when climbing up or down stairs
  • Giving way or buckling (the sensation that the knee is unstable and the feeling that the knee will give way): Less commonly, the knee actually will give way and cause the patient to fall.
  • Locking (a mechanical block where the knee cannot be fully extended or straightened): This occurs when a piece of torn meniscus folds on itself and blocks full range of motion of the knee joint. The knee gets “stuck,” usually flexed between 15 and 30 degrees and cannot bend or straighten from that position.  

Diagnosis

The diagnosis of a knee injury begins with a history of the injury etc. and physical examination. There have been many tests described to assess the internal structures of the knee. The McMurray test is one long used orthopedic test . The health-care professional flexes the knee and rotates the tibia while feeling along the joint. The test is positive for a potential tear if a click is felt or noticeable pain is felt while circumducting the knee in full flexion.

Physiotherapy in Tralee – referral for MRI

(MRI) is the test of choice to confirm the diagnosis of a torn meniscus. It also allows a radiographer to visualize the inner structures of the knee. These structure include; the cartilage and ligaments, the surface of the bones, and the muscles and tendons that surround the knee joint. Plain X-rays cannot be used to identify meniscal tears but may be helpful in looking for bony changes, including fractures, arthritis, and loose bony fragments within the joint. In older patients, X-rays may be taken of both knees while the patient is standing. This allows the joint spaces to be compared to assess the degree of cartilage wear. Cartilage takes up space within the joint and if the joint space is narrowed, it may be an indicator that there is less cartilage present, likely from degenerative disease.

Treatment of Meniscal Tears

Sometimes conservative measures such as physical therapy, NSAIDs and rest can be enough to settle the condition. When conservative measures are ineffective the next step may be surgery to repair or remove the damaged cartilage.

 

For physiotherapy in Tralee phone 086-7700191, click here for website homepage