Chondromalacia - Cause of Anterior Knee Pain in Middle Aged Women in India

Middle aged women in India commonly experience Anterior knee pain. Chondromalacia patella was an old synonym for pain in the front of the knee. Technically, chondromalacia patella means a softening of the cartilage of the knee-cap.

Symptoms

Pain in the front of the knee, which is worse on sitting for prolonged periods, descending or ascending stairs and rising from a squatting position. Crunching or grating in the knee. The pain can radiate to the back of the knee. Repeated swelling with out any significant injury may pose a diagnostic challenge to the clinician. There is no pain at rest.

Risks-

Certain sports like athletics especially running, sailing, fencing, soccer, and football. Trauma. Anatomical factor include a high kneecap, which makes it easily dislocatable, a low knee cap which increases the stresses to which it is subjected and muscle weakness. Increased inward twisting of the thigh bone (ante version) and outward twisting of the leg bone (external tibial torsion) alter the line of pull of the quadriceps tendon and subject the knee cap to stresses. Increased Q angle. This is the angle between the line of pull of the thigh muscle tendon and the ligament patella. The normal angle is 12-18°. Muscle pull of the inner thigh muscle. This muscle can be congenitally weak or it may waste from disuse.

Causes

Four theories exist:
a)Malalignment of the patella due to an increased Q angle, increased femoral anteversion,increased tibial torsion.
b)a tight lateral retinaculum
c)Dysplasia of the medial musculature.
d)a biochemical cause precipitated by mechanical damage to the proteoglycan matrix.

Prevention

Avoidance of the precipitating sport. Restriction of the activity responsible for an increase in symptoms.

Treatment

R I C E (Rest, Ice, compression and elevation) are the common measures advised. Muscle building activities under the guidance of a physiotherapist. Use of patella curout braces to support the patella. Non-steroidal anti-inflammatory drug are used to neutralize the prostaglandins leading to articular cartilage breakdown. Further investigations like skyline views or a CT or MRI scan will reveal the status of the kneecap and the presence of maltracking of the kneecap.

Knee surgery in India is available to alleviate symptoms. An arthroscopic assessment may be advised to study the degree of damage to the cartilage. Simultaneously, the damaged cartilage can be debrided. If there is a clear cut evidence of maltracking of the patella then a lateral release can be done. Open operations involve decreasing the load on the joint by elevating the tibial tubercle.

Realignment procedures restore the alignment of the patella proximally or distally. In tibial tuberle transfers the bony attachment of the patellar tendon is moved medially or anteriorly. Patello femoral joint replacement is the last resort in the knee surgeon's armamentarium.

A tibial tubercle transfer is a good procedure to relieve pain on stair climbing and squatting.