The Management of Chondromalacia Patellae: A LongTerm Solution

Patellofemoral pain syndrome can be a dif-ficult condition to manage effectively. The suc-cess rate of most treatment regimes has beenpoor and in the long term the condition fre-quently recurs.The author has developed a treatment pro-

gramme which has a ninety-six percent successrate. Long term follow up of patients, aftertwelve months demonstrated that all patientsreviewed have remained pain free.The programme involves two major compo-

nents: a thorough understanding of the me-chanics of the patellofemoral joint so that anadequate assessment of the patient's lower limbcan be made, and context specific training ofcertain muscles which contribute to patellaralignment. This training must be relatively painfree so that muscle control can be enhanced.

JENNY McCONNELL

Jenny McConnell, B.App. Sc.(Phty), Grad. Dip. Man.Ther., is a private practitioner, Sports Sciences andResearch Centre, Cumberland College, Lidcome, NewSouth Wales.

This article IS based on a paper given at the MTAA IVth NationalConference held In Bnsbane In May, 1985.

Patellofemoral pain is a common,yet poorly managed condition present-ing to physiotherapists and other prac-titioners. The incidence in the generalpopulation is reported to be as high asone in four with this proportion in-creasing in the athletic population(Levine 1979, Outerbridge 1964). Thecondition, which generally has an in-sidious onset, is characterized by a dif-fuse ache in the vicinity of the patella(Levine 1979, Malek and Magine 1981,Outerbridge 1964). It is often given thediagnosis of chondromalacia patellae,but this diagnosis is only appropriateif softening and fissuring of the un-dersurface of the patella has been vis-ualized either directly during surgeryor arthroscopy or indirectly by meansof an arthrogram (Devereaux andLachmann 1984, Ficat and Hungerford1977). In fact, many patients with se-vere pain and functional disability donot have any pathological findings(Andrish 1985). Their pain, which isoften exacerbated by sporting activi-ties, stair climbing and prolonged sit-ting with flexed knees ('movie goers

knee') can be extremely difficult to treat(Levine 1979, Micheli and Stanitski1981). Thus results of management,whether it be conservative or surgical,are equivocal and much confusionabounds for the practitioner as to themost expedient method/methods of di-minishing the patient's symptoms sothat sporting and other recreationalpursuits can be resumed as quickly aspossible.InitiallY, patients are managed con-

servatively. This often involves a com-bination of the following measures -quadriceps strengthening exercises (thisincludes quadriceps setting, straight legraises, isotonic exercises in the last 30°of extension), ice or heat, ultrasound,patellar mobilizations, nonsteroidalanti-inflammatory drugs, faradicstimulation of vastus medialis, isoki-netic exercise for quadriceps andhamstrings, hamstring stretches, castimmobilization, shoe orthotics and/orwalking aids (Gruber 1979, Insalll979,LeVeau and Rogers 1980, Levine 1979,Malek and Magine 1981, Micheli andStanitski 1981, Outerbridge 1964, Smil-

lie 1978, Soderberg and Cook 1983,Wild and Franklin 1982). It seems,however, that the decrease in symp-toms made during the treatment periodis, in many cases, only temporary, be-cause several investigators have foundat a twelve month follow up that only300/0 of patients have remained sym-tom free (Devereaux and LachJnann1984).If conservative management fails,

then surgery is the next option, butsurgical management is fraught withdifficulties because of the complexnature of the extensor mechanism andthe problems resulting from compro-mised knee function. Fortunately. moreradical surgery such as patellectomy, arelatively common procedure five yearsago and having extremely detrimentaleffects on knee joint mechanics, israrely performed today (O'Donoghue1981). Recent evidence has cast doubton the efficacy of more conservativeoperative procedures such as medialalignment of the tibial tubercle to de-crease the Q angle (see the definitionbelow). Huberti and Hayes (1984),

The Australian Journal of Physiotherapy. Vol. 32, No.4, 1986 215

The Management of Chondromalacia Patellae

working on cadaveric knees, found thatboth increased and decreased Q angleswere associated with peak patellofe-moral pressures and unpredictable pat-terns of cartilage unloading at differentlocations on the patella. They con-cluded that a decreased as well as anincreased Q angle could be a potentialaetiological factor in chondromalacia.This may help to explain why somepatients who are initially symptom freefollowing surgery have a return ofsymptoms later.The overall poor results achieved in

managing patellofemoral pain and thesuccessful identification of certain bio-mechanical factors which predispose anadolescent to patellofemoral pain(McConnell 1984), prompted the au-thor to implement a quite differentmanagement programme.

Mechanics of thePatellofemoral JointFor effective management of patel-

lofemoral pain an understanding of themechanics of the patellofemoral jointis required. The function of the patellais to link the divergent quadriceps mus-cle to a common tendon, so increasingthe quadriceps lever arm and thus itsmechanical advantage (Ficat and Hun-gerford 1977). For efficient functioningof this mechanism the patella must bealigned so it remains in the trochlearnotch of the femur. Malalignment ofthe patella from altered mechanics willpredispose an individual to patellofe-moral pain and possibly articular car-tilage breakdown (Goodfellow et al1976, Insall 1979). The individual withpatellofemoral pain will then experi-ence increased pain when the knee isflexed because the patellofemoral jointreaction force (PFJRF) increases withflexion of the knee from 0.5 times bodyweight during level walking to three tofour times body weight when ascendingor descending stairs and seven to eighttimes body weight during squatting (Fi-cat and Hungerford 1977, Reilly andMartens 1972).

Factors Affecting Patellar AlignmentMany parameters have been cited in

the literature as causing malalignmentof the patella and hence pain. Theseare increased Q angle, muscle tight-ness, excessive pronation, patella altaand vastus medialis insufficiency.

Q AngleThis is regarded by many investiga-

tors as the single most important factorcontributing to patellofemoral kneepain. The Q angle is the angle formedby the intersection of the line of pullof the quadriceps and the patellar ten-don measured through the centre ofthe patella. The outer limit for normalQ angle is 13-15 0

• An increase in Qangle which may be associated withincreased femoral anteversion, externaltibial torsion and lateral displacementof the tibial tubercle increases the lat-eral pull of the patella (Ficat and Hun-gerford 1977, Gruber 1979, Insa1l1979,Malek and Magine 1981).

Muscle TightnessThere are structures which, when

tight, are reported to have an effect onpatellar alignment. These are:• rectus femoris which, if tight, affectspatellar movement during knee flex-ion.

• iliotibial band which, if tight, willpull the patella laterally during kneeflexion (McNicol 1981, Nobel 1980).

• hamstrings which, if tight, will dur-ing running cause increased flexionof the knee thus increasing thePFJRF in stance (Winter 1983). Ithas been suggested that the increasedknee flexion will cause an increasein ankle dorsiflexion which cannotbe adequately fulfilled by the talo-crural joint so that the subtalar jointassists, resulting in compensatorypronation (Root et al 1977).

• gastrocnemius which, if tight, willalso result in a compensatory pron-ation because dorsiflexion at the tal-ocrural joint cannot occur and themovement is translated to the sub-talar joint (Root et al 1977).

ExceSSive PronationProlonged pronation of the subtalar

joint is accompanied by a prolongedinternal rotation of the leg resulting inmalalignment of the patella and inter-nal rotation of the femur. The quad-riceps, therefore will pull the patellalaterally (Buchbinder et al 1979, Su-botnik 1980). In adolescent boys, sub-talar pronation, not Q angle, was foundto be the single most significant pre-dicator of patellofemoral pain (.003level of significance) (McConnell 1984).

Patella A ItaThis is measured by means of a lat-

eral roentgenogram where the heightof the patella and the distance fromthe inferior pole of the patella to thetibial tubercle (ie the patellar tendonlength) are determined. Patella alta ispresent when the measurement of thelength of the patella tendon is twentyper cent greater than the measurementof the height of the patella. The con-sequent high sitting of the patella pre-disposes the individual to patellar sub-luxation (Insall 1979).

Vastus Medialis Obliquus(VMO) InsufficiencyThe function of vastus medialis ob-

liquus is to realign the patella duringextension of the knee (Basmajian 1970,Lieb and Perry 1968). It is the onlydynamic medial stabilizer; any insuf-ficiency of this muscle will increase thelateral drift of the patella (Gruber 1979,LeVeau and Rogers 1980).As there is increasing debate over

the relative merit of physiotherapeuticmanagement which includes straight legraise with and without weights (Bo-hannon 1983, Kramer and Sample1983, LeVeau and Rogers 1980, Mich-eli and Stanitski 1981, Pevsner et af1979, Soderberg and Cook 1983, Smil-lie 1978, Wild and Franklin 1982) andthe relative ability of exercise to spe-cifically influence vastus medialis ac-tivity (LeVeau and Rogers 1980, Reillyand Martens 1972, Reynolds et af1983)the author undertook a clinical trial

216 The Australian Journal of PhysIOtherapy Vol. 32, No 4, 1986

The Management of Chondromalacia Patellae

Table 1:Age range and sex of trial subjects

Clinical TrialThirty-five patients from the ages of

12 to 37 years are currently participat-ing in the study, twenty females andfifteen males (see Table 1). Twenty-three have been referred by a medicalpractitioner, nine were word of mouthreferrals and three from other sources(Table 2).The mean duration of symptoms was

4.9 years with a range from one monthto a nineteen year history of symptoms(Table 3). Eighteen of the patients hadbilateral symptoms, the rest had uni-lateral symptoms. A summary of areaand region of pain is in Tables 4 and5.

Referrals Number %

Sports Medicine 15 43General Practitioner 5 14Rheumatologists 3 8.5Word of Mouth 9 26Other 3 8.5

Table 3:Duration of symptoms

Months/Years Nurnber of %patients

1-3 months 4 11.53-6 months 6 176-12 months 9 261-2 years 8 232-5 years 2 5.7>5 years 6 17

Table 2:Method of referral

5 149 264 11.51 31 3

Female %%

8.511.5175.7o

3462o

MaleAges

12-1618-2224-2830-3436-38

5. Feedforward adjustmentsAdjustment occurs in a muscle so

that it is 'set' in advance for a par-ticular activity. The feedback mecha-nism is too slow to fine tune for anyerror because by the time the infor-mation is received the muscle is alreadyin a new position (Krebs et al 1983,Tuller et af 1982). However, it may bepossible to train a muscle to respondto a new length/tension ratio, that is,to retune this feedforward mechanism.So, consider an individual who ex-

periences patellofemoral pain when as-cending and descending stairs or squat-ting while gardening or jogging downhills. Given the above factors, how ef-fective would a regime of straight legraises with or without weights, or iso-kinetic exercises be in achieving a rapidsymptom free status for this individ-ual?

3. The effect of pain on musclecontractionPain has an inhibitory effect on

quadriceps muscle contraction partic-ularly if it is accompanied by knee jointeffusion (de Andrade et al 1965, Spen-cer et af 1984, Stratford 1981). Con-sequently, extreme care should be takennot to exacerbate the pain with exer-cises because this exacerbation will onlybe detrimental to the patient's reha-bilitation and rather than enhancingmuscle activity with exercise, muscleinhibition and subsequent atrophy willoccur (Stratford 1981). However, it hasbeen found that isometric quadricepscontractions are inhibited less with theknee in a flexed position (Stokes andYoung 1984).

4. Specificity of trainingTraining of a muscle should be spe-

cifically tailored for the demands placedon that muscle (Sale and MacDougall1981) Training effects are specific tolimb position, joint angle, limb velocityand type of contraction (Moffroid andWhipple 1970, Sale and MacDougall1981, Winter 1983).

1. The position of the femurWhen the femur is internally rotated,

knee extension is assisted by the tensorfascia lata muscle through its attach-ment into the iliotibial band (Kaplan1958). This increases the lateral pull onthe patella and thus decreases the ef-fectiveness of the vastus medialis ob-liquus (McNichol 1981).

2. The origin of the VMO fibresBose (1980) found after dissecting

the quadriceps muscle, that the maxi-mum amount of VMO fibres originatefrom the tendon of the adductor mag-nus, therefore the addition of adduc-tion while performing knee extensionmight facilitate VMO activity duringearly stages of rehabilitation (Bose etal 1980).

which emphasized specific training ofcertain muscles of the lower extremity.It was thought that if a patient's symp-toms were a result of poor mechanicalalignment, then alteration of this align-ment should decrease the symptoms.To overcome the lateral tracking of thepatella in the symptomatic individual,any tight lateral structures would haveto be elongated and the vastus medialisobliquus would have to be functioningas well as, if not better than, that ofan asymptomatic individual. It has beenfound that there is no significant dif-ference in activity of vastus medialisand vastus lateralis in asymptomaticindividuals (Reynolds et af 1983) but adecrease in VMO activity comparedwith vastus lateralis (VL) activity existsin patients with patellar subluxation(Mariani and Caruso 1979).As vastus medialis is active through-

out the full range of extension and theentire quadriceps muscle needs to gen-erate 60070 more tension in the last 15 0

of extension to complete the movement(Lieb and Perry 1968), how is it pos-sible to more selectively train vastusmedialis? There are fi ve aspects whichneed to be considered before decidinghow a patient should perform quad-riceps exercises.

The Australian Journal of PhySiotherapy Vol 32, No 4, 1986 217

The Management of Chondromalacia Patellae

seconds because often the pain is de-layed in onset. It has been found inpreliminary investigations that theVMO has phasic rather than tonic ac-tivity in patellofemoral pain suffererswhereas VMO activity is tonic in sub-jects with no patellofemoral pain(Richardson 1985).If pain is reproduced during any of

the isometric contractions the patient'sleg is brought back up to full extension.In this position the patella is no longerin contact with the femur, hence it canbe moved relatively easily. The pa-tient's lower leg is supported on thetherapist's knee so that the patient canfully relax the quadriceps muscle, thusenabling the therapist to glide the pa-tella medially. The glide is performedusing both thumbs flattened against thelateral border of the patella (Figure 1).This glide is maintained while the

patient again performs the isometriccontraction at the position which waspreviously painful. This time thereshould be a significant reduction inpain, if the pain is patellofemoral inorigin. The therapist can then be quiteconfident in predicting a favourableoutcome for the patient, provided ofcourse that the patient is prepared tobe involved in the training programme.Most patients are more than happy tobe involved because they are so de-lighted to be free of pain.

There were some marked similaritiesin the presenting biomechanicalcharacteristics of the subjects and anindividual subject could exhibit morethan one of these characteristics. Asummary of findings is presented inTable 7. The most common findingswere pronated feet, tight iliotibial bandand squinting patellae which were seenin 22, 21 and 15 subjects respectively.Tight hamstrings and increasedQanglewere found in only ten subjects. Anumber of subjects had weakness ofone of their hip rotators. There wereonly three subjects who did not havepain on the critical test, developed bythe author. Their pain was reproducedon more strenuous testing.

The critical test is a test performedwith the patient in high sitting andinvolves isometric quadriceps contrac-tions at five different flexion angles,namely 120, 90, 60, 30 and 0°, whilethe femur is externally rotated. Thecontraction is sustained for at least ten

ful loading such as tumbling in gym-nastics or jumping in netball beforetheir pain was reproduced. Objectively,pain was reproduced in eighteen pa-tients by squatting, in eleven by as-cending and descending stairs, and insix by other means such as one legsquat, duck walk or jumping (Table6).

Twenty-seven of the thirty-five pa-tients had received previous treatmentwith little success, the majority havingreceived physiotherapy treatment iestraight leg raise with weights, and iso-kinetics; four had undergone surgery.The following information was ob-

tained from the patients' histories.Twenty complained of 'movie goersknee', seventeen were subjectivelysymptomatic on stairs, five felt theyhad to go into a squat position beforethey were symptomatic and six re-ported that they required more stress- Figure 1: Medial glide of the patella.

Subjective ObjectiveNo No.of % of %Pat. Pat.

Stairs 17 48.5 Stairs 11 31Squat 5 14 Squat 18 51Movie- Other 6 17goersKnee 20 57Other 6 17

Table 6:Summary of activities producingsymptoms

Table 4:Distribution of pain sites #

Site of Pain Number of %Patients

Unilateral R 9 26L 8 23

Bilateral R = L 2 5.7R > L 6 17L>R 10 28.5

Table 5:Distribution of pain areas

Area of Pain Number of %Patients

Lateral 10 28.5Medial 5 14Retro/Peri 12 34Inferior 3 8.5Superior 0 0Nonspecific 5 14

218 The Australian Journal of Physiotherapy. Vol. 32, No.4, 1986

The Management of Chondromalacia Patellae

Table 7:Biomechanical characteristics

Unilateral Problem

Greater in Greater inBoth Legs Asymptomatic SymptomaticAffected knee kneeEqually

Bilateral Problem

Greater in Greater inLess More

Symptomatic Symptomaticknee knee

Total%

Pronation increasedQ angle increasedDecreased iliotibial bandSquinting PatellaeHyperextensionHamstring lengthdecreased

Leg lengthOther

Isometric Quadriceps

8

9738

14312

4

24121

1082512

117

Passive Movements

62.828.56042.82028.5

5.762.8

Angle

All0+6060 + 900+90o306090120no pain

Number

49o1761413

%

11.526o32017311.538.5

Patella alonePatella + fern/tibFemur/tibNone

Number

3162010

%

8467

28.5

Electromyographic activity of theVM0 and VL was investigated in twosubjects while they performed a max-imal quadriceps contraction in stand-ing. Both subjects demonstrated an in-crease in VMO activity during a medialpatellar glide whereas VL activity didnot change. A medial glide of the pa-tella may therefore increase the effi-ciency of the VMO in these patients.Further work needs to be done in thisarea to fully investigate the implica-tions of these findings.Sixteen patients had positive joint

signs on patellofemoral and tibiofe-moral passive movements, three had

positive signs on patellar movementsalone and seven on only tibiofemoralmovements. Interestingly, if the patellawas held medially while the tibiofe-moral movements were being tested thepreviously positive joint signs disap-peared. Ten subjects had no positivepassive joint signs.

Treatment ProgrammeAlthough a protocol for treating pa-

tellofemoral pain was established, thespecific treatment for each patient wasdesigned according to the findings from

the examination. If a patient had anytight structures he/she was taught tostretch the tight structure first. Thisapplied particularly to the iliotibialband which frequently seemed to be aproblem. However iliotibial bandstretches seemed to affect the proximalend of the muscle, having no effect onthe distal attachment. A strong medialglide and/or medial tilt with the patientin sidelying proved to be much moreeffective at stretching the tight lateralstructures around the knee. This man-oeuvre facilitated VMO training, as pa-tellar movement was no longer re-stricted.

The Australian Journal of PhYSiotherapy. Vol. 32, No.4, 1986 219

The Management of Chondromalacia Patellae

For training to be effective, the pa-tient must not experience pain whilsttraining as pain has a strong inhibitoryeffect on muscle function (Spencer eta11984, Stokes and Young 1984). Thus,to enhance VMO activity, the patellamust be firmly taped to permit a morenormal tracking (Figure 2). However,before the patella can be taped, anassessment of its orientation must bemade, so that the tape can be appro-priately applied. There are three com-ponents of patellar orientation whichmust be examined.

1. Glide componentAlmost all patients will require a me-

dial glide of their patella. The amountof glide will vary depending on thetightness of lateral structures and therelative amount of activity in the VMOcompared with the VL.

2. Tilt ComponentThis is particularly significant if the

deep lateral retinacular fibres are tight.The amount of tilt is detected by thetherapist using his/her thumb and in-

Figure 2: Application of tape.

dex finger on the lateral and medialborders of the patella. Both digitsshould be level. If the medial bordersits higher than the lateral border whichis commonly the case, the lateral struc-tures are tight and must be stretched.Correction of the lateral tilt can bemade by firm taping from the midlineof the patella medially. This lifts thelateral border and provides a passivestretch to the lateral structures.

3. Rotation componentThe longitudinal axis of the patella

ie the superior and inferior poles shouldbe in line with the longitudinal axis ofthe femur. Any alteration in this align-ment will affect the pressure distribu-tion to the underlying articular carti-lage (Ahmed et al 1983). To correctabnormal patellar rotation, firm tapingfrom either the middle inferior poleupwards and medially (to correct ex-ternal rotation of the inferior pole), orthe middle superior pole downwardsand medially (to correct internal ro-tation of the inferior pole) is applied.A patient may have one or more of

these components, and the severity ofeach of these components will varyfrom patient to patient. Each abnormalcomponent must be corrected ade-quately if the patient is going to trainand resume all activities in a painfreemanner.As most lower limb activities occur

in weight bearing, training the VMOmust also be done in weight bearing ifa change of symptoms is to occur.However, many patients become sym-tomatic when sitting for prolonged pe-riods, so specific training can be doneduring the day whenever the patient issitting. The instruction to the patientis to tighten the medial quadriceps byusing the adductors isometrically with-out activating the VL. It is importantto emphasize to the patient that this isa skilled activity which improves withpractice.Training in a weight-bearing position

involves the patient standing in a walk-stance position with the symptomaticleg forward and the knee flexed to 300

Figure 3: Training in a weight· bearingposition: walk-stance with the symp-tomatic knee forward and in 30° flexion.

(Figure 3). The patient is instructed tocontract the VMO and to relax thelateral hamstrings and the VL as muchas possible. This position is held for aperiod of ten seconds while the patientsupinates the foot just past the mid-position and then allows the foot togo back into pronation but remainingin a more supinated position than ispresent in the resting foot position.This is repeated a number of times.The knee is then straightened and theexercise commenced again.The exercise is repeated with the knee

flexed to about 75 0• The aim is to train

the invertors of the foot so that thereis a decrease in pronation in standingand an increase in the awareness offoot posture.If the patient has difficulty achieving

a VMO contraction then it can some-times be facilitated with the knees in a'turned out' squat position (a plie). Thepatient does a quarter-bend knee bend,contracts the VMO of both legs whileat the same time relaxing his/her lateral

220 The Australian Journal of Physiotherapy. Vol. 32, No.4, 1986

The Management of Chondromalacia Patellae

Figure 4: Plie position to facilitate con-traction of the vastus medialis oblique.

hamstrings and VL as much as possi-ble. He/she then (.ommences the su-pination and pronation movements ofthe foot, repeating them a few timesbefore straightening up and starting theroutine again (Figure 4). This processcan be repeated in a half squat andwhen the patient�� pain has decreasedsignificantly, or when greater outerrange quadriceps control is required,the three-quarter squat position isadded.It must be emphasized that the ex-

ercises should only cause a minimalamount of discomfort, and that thepatient should adjust the tape if anincreased amount of pain is experi-enced. This applies particularly to pa-tients with extremely tight lateral struc-tures as the tape loses its effectivenessfairly quickly.Training a muscle eccentrically

causes a muscle to hypertrophy (Gold-berg 1967, Gutman 1971). As much ofthe quadriceps action in the uprightposition is eccentric, and hypertrophyas well as control of the quadriceps is

Figure 5: Stepping down from a stepfor eccentric quadriceps action.

desired, then eccentric training must beincluded in the patient's regime ofquadriceps exercises. Most patients withpatellofemoral pain complain of painwhen walking down stairs so this actionmust be practised. The patient is in-structed to step down from a step andthen back up while the quadriceps ofthe leg remaining on the step contractseccentrically then concentrically (Fig-ure 5). This is performed at the pa-tient's own speed to begin with, thenthe patient is requested t6 go as slowlyas possible and later, to go as fast aspossible, without sacrificing accuracyof the movement. Emphasis should beplaced on alignment and symmetry ofthe lower limb during this activity.These exercises may be progressed

by altering the height of the step and/or by providing resistance to the move-ment either during treatment by addinga weight around the ankle or at homeby either using the weight or wearinga backpack with a known amount ofweight inside. The weight of course canbe increased.

As the patient improves it is impor-tant to examine the requirements ofthe quadriceps and other lower limbmusculature during his/her sportingactivity, so that training specific to thatsport can be commenced. For example,a cyclist with knee pain who is hillclimbing has different requirements tothose of a netballer leaping to catchthe ball or a marathon runner runningdown hills.Paramount to the success of this pro-

gramme, is a thorough understandingby the patient of the underlying mech-anism causing the problem and the roleexercise plays in realigning the patellaand thus decreasing the pain. The pa-tient must, therefore, regularly practisethe exercises at home and the therapistmust check the exercises each time thepatient comes so any problems can beresolved and the effectiveness of theexercises can be evaluated.

Results of the TreatmentThe results thus far have been ex-

tremely encouraging. After two treat-ment sessions twelve patients had nopain on both subjective and objectiveevaluation. Fifteen patients had no painwithin three to five treatment sessions.Two had no pain after seven treat-ments. Three patients reported signifi-cant decreases in pain after three treat-ments but these patients are stillreceiving treatment. One patient feltthat after three treatments she had notimproved, even though objectively shehad improved. She is no longer comingfor treatment. Two patients did notattend after the initial examination be-cause they left the State - one is teach-ing in Queensland, the other has goneoverseas. Overall, over ninety per centof patients responded quickly and fa-vourably to the treatment (Table 8).Interestingly, all the positive passive

tibiofemoral joint findings disappearedafter altering the joint mechanics.To date, only fourteen patients

(40070) have not had any treatment forat least six months. All of these pa-tients are still painfree and participat-ing in sporting activities with no prob-

The Australian Journal of PhySiotherapy. Vol. 32, No 4, 1986 221

The Management of Chondromalacia Patellae

Table 8:Results of Treatment

lems. They are all doing their exercises,two had stopped their exercises tem-porarily and found that they had aslight return of symptoms. The symp-toms disappeared once they resumedtheir exercise programme.

ConclusionThere are two factors which are es-

sential in the managerrlent of patello-femoral pain. First, a thorough anal-ysis of the problem must be made toidentify the contributory factors. Eachfactor must be specifically addressedto affect a change in patellofemoralalignment. Second is the context speci-fic training of the muscles contributingto patellar alignment. Of prime im-portance is the quadriceps muscle whichafter specific training may be 'set' soit is activated in advance to preventlateral tracking of the patella. Specifictraining of the invertors and supinatorsof the foot to increase awareness offoot position may also assist in alteringlower limb position and hence patellartracking.The training must however, be rel-

atively painfree in order to enhancemuscle control. The quadriceps muscleis inhibited by pain and/or effusion inthe knee joint so that if exercises arepainful there may be a detrimentalrather than a beneficial effect on pa-

No Pain

Decreased

No ChangeUnknown

Number of Number of Patients %Treatments

<3 12 343-5 15 435-7 1 38 1 3

Total 29 83%

3 8.5

Total 32 92%

1 32 5

tellar position. Initially, maltracking ofthe patella may be altered by appro-priate taping. Later, it seems that thequadriceps muscle resumes this respon-sibility, so use of external supports suchas the Palumbo brace is not necessary.Further investigation is required tosubstantiate this claim. It does appear,however, that patients with patello-femoral pain have an imbalance be-tween the activity in the VMO and VLcomponents of the quadriceps. Tapingof the patella to enhance contractionof the VMO is critical in the initialstages of treatment.Clinical evidence to date suggests that

context specific training of the musclescontributing to patellar alignment, par-ticularly the quadriceps muscle, is pos-sible. As long as training is maintained,the effects seem to be long term andthe patient can remain asymptomaticeven when participating in activitieswhich are demanding for the patello-femoral joint.

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