Conservative treatment may be best for most chondromalacia cases
1st on the web (January 12, 2010)
KOHALA COAST, Hawaii — Chondromalacia, or soft cartilage, is a cause of anterior knee pain that in most cases will best respond to conservative treatment, according to an orthopedic researcher.
In a presentation at Orthopedics Hawaii 2010, here, John D. Kelly IV, MD, told the attendees, “When patients have it, they have anterior knee pain that is usually worse going downstairs more than up, squatting, getting out of a chair, etc.”
Kelly, who is the editor of the Your Practice/Your Life column for Orthopedics Today, said that data suggest that ischemia resultant from excessive pressure from the patella may be the culprit to this pain.
“[Scott F.] Dye reported that it was an overload to patella, perhaps caused by excessive weight, excessive stress, malalignment or trauma which causes the pain,” he said.
Tests for chondromalacia include: the Kolowich Test, for lateral retinacular tightness; lateral glide, for medial laxity; J sign, for tracking; and Q angle at 30° flexion.
John D. Kelly IV
Treatments that work include: physiotherapy, nutraceuticals/hyaluronic acid, braces/orthotics, and surgery, Kelly said.
“For physiotherapy, if it hurts, do not do it,” Kelly said. “Quad stretching helps, they should address weak abductors (valgus).” Surgeons should also consider straight leg raises in slight external rotation.
“Surgery has very narrow indications,” he said. “You should only address only what has deviated from the norm.” Indiscriminate lateral release will only worsen the pain.
“Indications for surgery include failed physical therapy for at least 6 months and a tight retinaculum,” he said. Others include a softening of the lateral facet and an absence of central or medial trochlear/patellar disease.”
“Shea and Fulkerson have shown that if you choose your patients carefully, 98% of your patients will do well with a limited lateral release for chondral lesions grade 1 and 2, and evidence of lateral tilt on computed tomography,” he said.
Other options are medial retinacular tightening, when lateral subluxation is present, and medial imbrication in rare instance where medial laxity contributes to the malalignment.
Kelly IV, MD. Chondromalacia: What is painful and what works. Presented at Orthopedics Today Hawaii 2010. Jan. 10-13, 2010. Kohala Coast, Hawaii.