pathology: chondropathia patellae

yogabook / pathologie / chondropathia patellae

Chondropathia patellae (femoropatellar pain syndrome, PFPS patellofemoral pain syndrome), chondromalacia patellae

Definition of

Depending on the author, a distinction is made between chondromalacia patellae and chondropathia patellae. Authors who make a distinction use the term chondromalacia patellae as a synonym for PFPS and use chondropathia patellae to refer to parapatellar pain syndrome or patellar tendinopathy. In the following, the most common use of the term will be followed and PFPS will be referred to as chondropathia patellae. Other entities are named accordingly and the term chondromalacia patellae is avoided. Chondropathia patellae is a retropatellar pain phenomenon often occurring in adolescence or early adulthood, more frequently in women, which causes the affected person to fear developing retropatellar arthrosis, although chondropathia patellae, especially when treated, does not necessarily lead to this, but can heal spontaneously. However, if left untreated and if the causes persist, it can lead to retropatellar arthrosis. PFPS is present in 10% of all cases where patients present with knee pain, 25% of cases in young women, and is the most common sports medicine cause of knee pain. It is probably multifactorial in origin, which is also reflected in the poor results of conservative monotherapies. There are many therapeutic approaches, but there is almost unanimous agreement that treatment should be conservative. Only 1/3 of patients are symptom-free after 1 year, and after 4 years 91% of the remaining 2/3 still have pain or dysfunction. A precise analysis and multifactorial approach is therefore obligatory. The causes are local (in the knee joint), distal (in the ankle joint), but also proximal (pelvis and hip joint). It is often an overuse syndrome, but this is often only the trigger due to suboptimal structures, malformations and malpositions of the patella play a role, as well as hypertonus of the quadriceps or muscular imbalances (weakness of the vastus medialis, weakness of the inner hamstrings), which lead to unphysiological guidance of the patella, can also be the cause. To make matters worse, the medial vastus is not innervated until approx. 5 ms after the lateral vastus. The retropatellar cartilage is not without reason – at approx. 7 mm it is the thickest in the entire human body and is nourished by diffusion through the walking process under load, but this requires suitable (not too high, not too low) pressures. However, the quadriceps responsible for this dystrophies within a few weeks of inactivity or rest, resulting in inadequate walking and supply. A tone that is too high causes more wear and tear than supply, while a tone that is too low simply leads to inadequate supply of the retropatellar cartilage, which has few cells anyway and is mainly connective tissue and therefore does not regenerate well. Nutritional disorders lead to cartilage dystrophy and exposure of the cartilage fibers. Contrary to earlier opinions, hyperpronation alone is not a risk factor for PFPS. Girls and women are more frequently affected by PFPS. One risk factor for them is their greater tendency to adduct in the stance phase, which can lead to a medial collapse and thus to PFPS. The therapeutic factor of strengthening the abductors is particularly important for them. In addition to the typical causes mentioned above, such as overloading of the extensor apparatus or axial misalignments, in children and adolescents or the physiologically changing statics with growth, muscular imbalances and a lack of proprioception or coordination can also play a role. Other causes, including in adults, include changes in the synovium, a dysplastic (malformed) patella or incorrect ligamentous guidance of the patella. An MRI should largely reveal the causes of the disorder, unless they consist of muscular imbalances or other easily recognizable clinical disorders of the musculoskeletal system. However, if the MRI is without findings, this does not indicate arthroscopic clarification, although in some cases this can show a plica syndrome, which can be treated during arthroscopy. However, the suspicion of a plica syndrome should have been confirmed by history and functional tests beforehand. If chondropathia patellae is present, all relevant muscles including their antagonists and more distal structures must be checked, both statically and kinetically. Sufficiently strong muscles with a sufficient degree of flexibility are considered a prerequisite for the health of the retropatellar cartilage. Chondropathia patellae that occurs in adolescence and childhood in particular has a good prognosis, which is why surgical intervention is generally not indicated. For realignment osteotomies, there must be a clear indication that proves the given pathomechanism of chondropathia patellae.

Cause

  1. Malformations or malpositions of the kneecap
  2. Unphysiological guidance of the patella in the event of muscular imbalances (weakness of the vastus medialis, weakness of the /inner hamstrings)
  3. traumatic
  4. sporting or occupational overload(overuse), as well as prolonged pressure (kneeling activities)

Predisposing

– Musculoskeletal system

  1. Dysfunction of the thigh muscles and the ligamentous apparatus, especially shortened quadriceps with relative weakness of the vastus medialis
  2. Tractus iliotibialis too tight
  3. Axial and rotational misalignments: Rotations in the knee joint lead to load peaks
  4. Foot deformities, especially flat feet
  5. X-legs
  6. Weakness of the hip abductors and the exorotators of the hip joint, as both tend to endorotate the knee joint during movement, which has little effect as long as the leg is a free leg, but does have a significant effect when the foot is in contact with the ground again (when running) and the leg becomes a standing leg.
  7. Hyperpronation of the ankle joint with simultaneous endorotation of the femur(endorotation in the hip joint) and tibia(endorotation in the knee joint)
  8. Tendency to hip dorsotation with overactive tensor fasciae latae
  9. Overtension of the hamstrings and calf muscles
  10. Lateral retinaculum of the patella too tight

– Behavior

  1. Unphysiological (not leg-axis appropriate) loads
  2. Exorotated lower legs in the free leg phase when running

Diagnosis

  1. Patella pressure pain, patella displacement pain
  2. X-ray, MRI if necessary
  3. Palpatory and auscultatory rubbing and crunching
  4. Increased contact pressure
  5. Tests and signs: Glide test, sole sign, facet pressure pain, McConnell test, Clarke (patella grind) test

Symptoms

  1. Pain when walking downhill or uphill, climbing stairs or sitting for long periods with bent knees, squatting
  2. Start-up pain if necessary
  3. Swelling if necessary
  4. Pain after prolonged sitting

Complications

  1. Arthrosis of the femoropatellar sliding bearing (retropatellar arthrosis)

Therapy

  1. Avoid bending at 90° under load, e.g. squatting
  2. as far as possible, avoid prolonged sitting
  3. No knee supports, as they increase the pressure!
  4. Cryotherapy, electrotherapy, ultrasound,
  5. Rest, if necessary local anti-inflammatory drugs, orally only in exceptional cases
  6. Elimination of known causes
  7. Flexibility/proprioception and endurance training
  8. PT, depending on the cause: stretching the quadriceps, strengthening the quadriceps, especially the vastus medialis, strengthening the hip abductors and hip exorotators, stretching the hamstrings
  9. In case of changes to the retropatellar cartilage or the gliding bearing, infiltration therapy (hyaluron,..) if necessary
  10. If conservative treatment options fail: Arthroscopy or lateral release of the lateral retinaculum and retraction of the medial retinaculum
  11. Adolescent onset of chondropathia patellae usually has a good prognosis, but in adulthood the cartilage damage is often progressive and develops into retropatellar arthrosis.

Asana practice and movement therapy

Here, the quadriceps in particular must be brought into a healthy, not excessive, but also not too low tone. Its four heads attach to different areas of the upper patellar pole, the vastus medialis more on the inside, the vastus intermedius approximately in the middle and the rectus femoris and vastus lateralis from the middle to the outside. If their tension is unbalanced, the guidance of the patella becomes unphysiological. Even if the guidance in the intercondylar sulcus prevents the patella from dislocating, the petropatellar cartilage is still unevenly and therefore excessively loaded in some places. Although the patella runs on the femur in the femoropatellar sliding bearing, the force is transferred to the attachment on the tibial tuberosity, i.e. to the lower leg. As the rotational position of the lower leg in the knee joint plays a role in cyclical movements such as running, it is also a potentially significant factor. As the outer hamstrings, the biceps femoris, is usually stronger than the inner, the lower leg will tend to exorotate. This rotation will have a detrimental effect on the knee joint, especially as when running the knee joint first performs an eccentric contraction after the foot touches down to absorb the body weight and then a concentric contraction to push the body forward before the foot leaves the ground. There are therefore two movements that take place in the knee joint with every step. What’s more, they are in the range close to full extension, in which the collateral ligaments force the lower leg to straighten, i.e. to stop any rotation. The tendency ofthe lower leg to exorotateis countered by strengthening the inner hamstrings. If the abductors and exorotators of the hip joint are too weak (in relation to other muscles), this leads to an endorotation of the thigh in cyclical movements such as running, which must be compensated for abruptly when the foot touches down, with the quadriceps taking on the body weight in eccentric contraction and transferring a correspondingly large load to the patella and the femoropatellar sliding bearing, which must lead to increased wear in view of the resulting dyskinesia.

Asanas

  1. Asanas in 811: Stretching the quadriceps
  2. Asanas in 812: Strengthening the quadriceps
  3. Asanas in 816: Stretching the rectus femoris
  4. Asanas in 817: Strengthening the rectus femoris
  5. Asanas in 742: Strengthening the abductors
  6. Asanas in 751: Stretching the adductors
  7. Asanas in 737: Strengthening the exorotators
  8. Asanas in 731: Stretching the endorotators
  9. Asanas in 813: Strengthening the Vastus medialis
    1. 1. warrior pose
    2. 1. hip opening
    3. 2. hip opening
    4. 3. hip opening
  10. Asanas in 827: Strengthening the end rotators of the knee joint
    1. Deadlift
    2. 3rd warrior pose
    3. 3rd warriorpose backwards against the wall