The Management of Chondromalacia Patellae: A Long Term ...The Management of Chondromalacia Patellae:...
Transcript of The Management of Chondromalacia Patellae: A Long Term ...The Management of Chondromalacia Patellae:...
The Management of Chondromalacia Patellae: A LongTerm Solution
Patellofemoral pain syndrome can be a difficult condition to manage effectively. The success rate of most treatment regimes has beenpoor and in the long term the condition frequently recurs.
The author has developed a treatment programme 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 components: a thorough understanding of the mechanics 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 presenting to physiotherapists and other practitioners. The incidence in the generalpopulation is reported to be as high asone in four with this proportion increasing in the athletic population(Levine 1979, Outerbridge 1964). Thecondition, which generally has an insidious onset, is characterized by a diffuse 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 undersurface of the patella has been visualized either directly during surgeryor arthroscopy or indirectly by meansof an arthrogram (Devereaux andLachmann 1984, Ficat and Hungerford1977). In fact, many patients with severe pain and functional disability donot have any pathological findings(Andrish 1985). Their pain, which isoften exacerbated by sporting activities, stair climbing and prolonged sitting 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 diminishing the patient's symptoms sothat sporting and other recreationalpursuits can be resumed as quickly aspossible.
InitiallY, patients are managed conservatively. This often involves a combination 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, isokinetic 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 symptoms made during the treatment periodis, in many cases, only temporary, because several investigators have foundat a twelve month follow up that only300/0 of patients have remained symtom 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 compromised 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 decrease 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 patellofemoral pressures and unpredictable patterns of cartilage unloading at differentlocations on the patella. They concluded 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 inmanaging patellofemoral pain and thesuccessful identification of certain biomechanical factors which predispose anadolescent to patellofemoral pain(McConnell 1984), prompted the author to implement a quite differentmanagement programme.
Mechanics of thePatellofemoral Joint
For effective management of patellofemoral pain an understanding of themechanics of the patellofemoral jointis required. The function of the patellais to link the divergent quadriceps muscle to a common tendon, so increasingthe quadriceps lever arm and thus itsmechanical advantage (Ficat and Hungerford 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 patellofemoral pain and possibly articular cartilage breakdown (Goodfellow et al1976, Insall 1979). The individual withpatellofemoral pain will then experience 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 (Ficat 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 tightness, 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 tendon 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 lateral pull of the patella (Ficat and Hungerford 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, affects
patellar movement during knee flexion.
• iliotibial band which, if tight, willpull the patella laterally during kneeflexion (McNicol 1981, Nobel 1980).
• hamstrings which, if tight, will during 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 talocrural joint so that the subtalar jointassists, resulting in compensatorypronation (Root et al 1977).
• gastrocnemius which, if tight, willalso result in a compensatory pronation because dorsiflexion at the talocrural joint cannot occur and themovement is translated to the subtalar 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 internal rotation of the femur. The quadriceps, therefore will pull the patellalaterally (Buchbinder et al 1979, Subotnik 1980). In adolescent boys, subtalar pronation, not Q angle, was foundto be the single most significant predicator 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 consequent high sitting of the patella predisposes the individual to patellar subluxation (Insall 1979).
Vastus Medialis Obliquus(VMO) Insufficiency
The function of vastus medialis obliquus is to realign the patella duringextension of the knee (Basmajian 1970,Lieb and Perry 1968). It is the onlydynamic medial stabilizer; any insufficiency of this muscle will increase thelateral drift of the patella (Gruber 1979,LeVeau and Rogers 1980).
As there is increasing debate overthe relative merit of physiotherapeuticmanagement which includes straight legraise with and without weights (Bohannon 1983, Kramer and Sample1983, LeVeau and Rogers 1980, Micheli and Stanitski 1981, Pevsner et af1979, Soderberg and Cook 1983, Smillie 1978, Wild and Franklin 1982) andthe relative ability of exercise to specifically influence vastus medialis activity (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 participating in the study, twenty females andfifteen males (see Table 1). Twentythree have been referred by a medicalpractitioner, nine were word of mouthreferrals and three from other sources(Table 2).
The mean duration of symptoms was4.9 years with a range from one monthto a nineteen year history of symptoms(Table 3). Eighteen of the patients hadbilateral symptoms, the rest had unilateral 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 particular activity. The feedback mechanism is too slow to fine tune for anyerror because by the time the information 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 experiences patellofemoral pain when ascending and descending stairs or squatting while gardening or jogging downhills. Given the above factors, how effective would a regime of straight legraises with or without weights, or isokinetic exercises be in achieving a rapidsymptom free status for this individual?
3. The effect of pain on musclecontraction
Pain has an inhibitory effect onquadriceps muscle contraction particularly if it is accompanied by knee jointeffusion (de Andrade et al 1965, Spencer et af 1984, Stratford 1981). Consequently, extreme care should be takennot to exacerbate the pain with exercises because this exacerbation will onlybe detrimental to the patient's rehabilitation 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 attachment into the iliotibial band (Kaplan1958). This increases the lateral pull onthe patella and thus decreases the effectiveness of the vastus medialis obliquus (McNichol 1981).
2. The origin of the VMO fibresBose (1980) found after dissecting
the quadriceps muscle, that the maximum amount of VMO fibres originatefrom the tendon of the adductor magnus, therefore the addition of adduction 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 symptoms were a result of poor mechanicalalignment, then alteration of this alignment 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 difference 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 throughout the full range of extension and theentire quadriceps muscle needs to generate 60070 more tension in the last 15 0
of extension to complete the movement(Lieb and Perry 1968), how is it possible to more selectively train vastusmedialis? There are fi ve aspects whichneed to be considered before decidinghow a patient should perform quadriceps exercises.
The Australian Journal of PhySiotherapy Vol 32, No 4, 1986 217
The Management of Chondromalacia Patellae
seconds because often the pain is delayed in onset. It has been found inpreliminary investigations that theVMO has phasic rather than tonic activity in patellofemoral pain suffererswhereas VMO activity is tonic in subjects with no patellofemoral pain(Richardson 1985).
If pain is reproduced during any ofthe 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 patient's lower leg is supported on thetherapist's knee so that the patient canfully relax the quadriceps muscle, thusenabling the therapist to glide the patella medially. The glide is performedusing both thumbs flattened against thelateral border of the patella (Figure 1).
This glide is maintained while thepatient 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 delighted 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 increased Qanglewere 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 contractions 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 gymnastics or jumping in netball beforetheir pain was reproduced. Objectively,pain was reproduced in eighteen patients by squatting, in eleven by ascending and descending stairs, and insix by other means such as one legsquat, duck walk or jumping (Table6).
Twenty-seven of the thirty-five patients had received previous treatmentwith little success, the majority havingreceived physiotherapy treatment iestraight leg raise with weights, and isokinetics; four had undergone surgery.
The following information was obtained 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 length
decreasedLeg 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
%
11.526o3
2017
311.5
38.5
Patella alonePatella + fern/tibFemur/tibNone
Number
3162010
%
846
728.5
Electromyographic activity of theVM0 and VL was investigated in twosubjects while they performed a maximal quadriceps contraction in standing. Both subjects demonstrated an increase in VMO activity during a medialpatellar glide whereas VL activity didnot change. A medial glide of the patella may therefore increase the efficiency of the VMO in these patients.Further work needs to be done in thisarea to fully investigate the implications of these findings.
Sixteen patients had positive jointsigns on patellofemoral and tibiofemoral passive movements, three had
positive signs on patellar movementsalone and seven on only tibiofemoralmovements. Interestingly, if the patellawas held medially while the tibiofemoral movements were being tested thepreviously positive joint signs disappeared. 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 manoeuvre facilitated VMO training, as patellar movement was no longer restricted.
The Australian Journal of PhYSiotherapy. Vol. 32, No.4, 1986 219
The Management of Chondromalacia Patellae
For training to be effective, the patient 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 appropriately applied. There are three components 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 structures 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 alignment will affect the pressure distribution to the underlying articular cartilage (Ahmed et al 1983). To correctabnormal patellar rotation, firm tapingfrom either the middle inferior poleupwards and medially (to correct external rotation of the inferior pole), orthe middle superior pole downwardsand medially (to correct internal rotation of the inferior pole) is applied.
A patient may have one or more ofthese components, and the severity ofeach of these components will varyfrom patient to patient. Each abnormalcomponent must be corrected adequately if the patient is going to trainand resume all activities in a painfreemanner.
As most lower limb activities occurin weight bearing, training the VMOmust also be done in weight bearing ifa change of symptoms is to occur.However, many patients become symtomatic when sitting for prolonged periods, 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 without activating the VL. It is importantto emphasize to the patient that this isa skilled activity which improves withpractice.
Training in a weight-bearing positioninvolves the patient standing in a walkstance position with the symptomaticleg forward and the knee flexed to 300
Figure 3: Training in a weight· bearingposition: walk-stance with the symptomatic 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 midposition 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 kneeflexed to about 75 0
• The aim is to trainthe 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 achievinga VMO contraction then it can sometimes 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 contraction of the vastus medialis oblique.
hamstrings and VL as much as possible. He/she then (.ommences the supination 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 experienced. This applies particularly to patients with extremely tight lateral structures as the tape loses its effectivenessfairly quickly.
Training a muscle eccentricallycauses a muscle to hypertrophy (Goldberg 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 instructed to step down from a step andthen back up while the quadriceps ofthe leg remaining on the step contractseccentrically then concentrically (Figure 5). This is performed at the patient'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 progressedby altering the height of the step and/or by providing resistance to the movement 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 important 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 programme, is a thorough understandingby the patient of the underlying mechanism causing the problem and the roleexercise plays in realigning the patellaand thus decreasing the pain. The patient 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 treatment 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 treatments. Three patients reported significant decreases in pain after three treatments 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 because they left the State - one is teaching in Queensland, the other has goneoverseas. Overall, over ninety per centof patients responded quickly and favourably to the treatment (Table 8).
Interestingly, all the positive passivetibiofemoral 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 patients are still painfree and participating 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 temporarily and found that they had aslight return of symptoms. The symptoms disappeared once they resumedtheir exercise programme.
ConclusionThere are two factors which are es
sential in the managerrlent of patellofemoral pain. First, a thorough analysis of the problem must be made toidentify the contributory factors. Eachfactor must be specifically addressedto affect a change in patellofemoralalignment. Second is the context specific training of the muscles contributingto patellar alignment. Of prime importance 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 relatively 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 appropriate taping. Later, it seems that thequadriceps muscle resumes this responsibility, 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 patellofemoral pain have an imbalance between 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 thatcontext specific training of the musclescontributing to patellar alignment, particularly the quadriceps muscle, is possible. 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 patellofemoral joint.
ReferencesAhmed A, Burke D, and Yu A (1983), In vItro
measurement of statIc pressure distnbutlon msynOVIal Jomts-Part 11: retropatellar surface,Journal ofBlOmechamcal Engmeermg, lOS, 226236.
Andnsh J (1985), Knee mJuries m gymnastIcs,ClImcs m Sports Medlcme, 4 (1), 111-121.
BasmaJIan J (1970), Re-educatIOn of vastus medlabs' a misconceptIOn, Archives of PhysicalMedlcme and RehabliltatlOn, 51, 245-247.
Bohannon R (1983), Effect of electrIcal stimulatIOn to the vastus medIalIs muscle m a patIentwith chromcally dlslocatmg patellae, PhYSicalTherapy, 63 (9) 1445-1447.
Bose K, Kanagasuntherum R and Osman M (1980),Vastus medialIs oblIque: an anatomical andphySIOlogIc study, Orthopaedics, 3, 880-883
Buchbmder R, Naporo Nand Blzzo E (1979) TherelatIOnship of abnormal pronatIOn to chondromalaCia patellae m distance runners, Journalof the American Podiatric ASSOCiatIOn, 69 (2),159-161
de Anrade J, Grant C and Dixon A (1965), JomtdistenSIOn and reflex mhlbltIon m the knee, TheJournal of Bone and Jomt Surgery, 47A (2),313-322.
Devereaux M and Lachman S (1984), Patellofemoral arthralgia m athletes attendmg a sportsmJury clImc, British Journal ofSports Medlcme,18 (1), 18-21
Flcat R and Hungerford 0 (1977), DISorders ofthe Patellofemoral Jomt, WillIams and WIlkmsCo , Baltimore.
Goldberg A (1967), Work mduced growth of skeletal muscle m normal and hypo-physectomlsedrats, American Journal ofPhYSIOlogy, 312, 11931198
Goodfellow J, Hungerford DS and Zmdel M(1976), Patello-femoral Jomt mechamcs and pathology, 1 & 2, The Journal of Bone and JomtSurgery, 58B (3), 287-299.
Gruber M (1979), The conservative treatment ofchondromalacia patellae, Orthopaedic Cllmcsof North America, 10, 105-115
Gutman E, Schlaffmo Sand Hazhkova V (1971),Mechamsm of compensatory hypertrophy mskeletal muscle of the rat, Experimental Neurology, 31, 451-464.
Hubertl H and Hayes W (1984), Patellofemoralcontact pressures, The Journal of Bone andJomt Surgery, 66A (5), 715-724.
lnsall J (1979), ChondromalaCia patellae: Patellarmalahgnment syndrome, Orthopaedic Clmlcs ofNorth America, 10, 117.
Kaplan ED (1958), The IlIotibial tract, The Journalof Bone and Jomt Surgery, 40A, 817-832.
Kramer J and Sample J (1983), Companson ofselected strengthenmg techmques for normalquadnceps, PhySIOtherapy Canada, 35 (6), 300304
Krebs 0, Stables W, CuttIta 0 and Zickel R(1983), Knee Jomt angle: Its relatIOnshIp toquadnceps femons m normal and post-arthrotomy lImbs, Archives of PhySical Medlcme &RehabilitatIOn, 64, 441-447.
LeVeau B and Rogers C (1980), Selective trammgof the vastus medialIs muscle usmg EMG biOfeedback, PhYSIOtherapy, 60 (11), 1410-1415.
Levme J (19'79), Chondromalacia patellae, ThePhySICian and Sportsmedlcme 7 (8), 41-49.
Lleb F and Perry J (1968), Quadnceps functIon,The Journal of Bone and Jomt Surgery, 50A(8), 1535-1548.
McConnell J (1984), An mvestIgatIOn of certamblOmechamcal variables predIsposing an adolescent male to retropatellar pam, Paper presented at the 2nd Australasian PhySIotherapyCongress, Perth.
McNichol K (1981), Iliotibial tract fnction syndrome m athletes, Canadian Journal ofAppliedSports SCiences, 6 (2), 76-80.
Malek M and Magme R (1981), Patellofemoralpam syndromes: A comprehenSIve and con-
222 The Australian Journal of Physiotherapy. Vol 32, No 4, 1986
The Management of Chondromalacia Patellae
servatlve approach, Journal ofOrthopaedIc andSports PhysIcal Therapy, 2 (3), 108-116
Mariam P and Caruso I (1979), An electromyographlc mvestigatlOn of subluxatIOn of the patella, The Journal of Bone and JOint Surgery,618, 169-171
MIchelI Land Stamtskl C (1981), Lateral patellarrelease, AmerIcan Journal of Sports Medicine,9 (5), 330-336
MoffrOld M and Whipple R (1970), Specificity ofspeed of exerCise, Physical Therapy, 50 (12),1692-1700
Noble C (1980), IlIotibial band fnctlon syndromem runners, Amencan Journal of Sports MediCine, 8 (4), 232-234
Nordgren B, NordesJo Land Rauschmg W (1983),Isokmetlc knee extensIOn and pam before andafter advancement osteotomy of the tibial tuberoslty, Archives of Orthopaedic and TraumaticSurgery, 102, 95-101
O'Donoghue DH (1981), Treatment of chondraldamage to the patella, Amencan Journal ofSports MedICine, 9 (1), 1-10
Outerbndge RE (1964), Further studies on theaetiology of chondromalacia patellae, The Journal of Bone and Jomt Surgery, 468 (2), 179190.
Pevsner D, Johnson J and Blazma M (1979). Thepatellofemoral Jomt and Its ImphcatIons In therehabilItation of the knee, Physical Therapy, 59(7), 869-874.
Reilly D and Martens M (1972), ExpenmentalanalysIs of the quadrIceps muscle force andpatellofemoral Jomt reaction force for vanousaCtiVItIeS, Acta Orthopaedica ScandmaVlca, 43,126-137
Reynolds L, Levm T, Medeiros J, Adler NandHallum A (1983), EMG ?cttvlty of the vastusmedlahs oblIque and the vastus laterabs In thenrole In patellar alIgnment, AmerIcan Journal ofPhysical MediCine, 62 (2), 61-71.
Richardson C (1985), The role of the knee musculature m high speed OSCillatIng movements ofthe knee. MTAA 4th Blenmal Conference Proceedmgs, Bnsbane, 59-70
Root M. Onen Wand Weed J (1977), ClImcalBIOmechamcs, Vol 11, ClImcal BlOmechamcsCorporatIOn. Los Angeles.
Sale D and MacDougall D (1981), SpeCifiCity mstrength trammg: a review for the coach andathlete, CanadIan Journal of ApplIed SportsSCIence, 6 (2), 87-92
SmillIe I (1978), InjUrIes of the Knee Jomt,Churchill Llvmgstone, EdInburgh, p.56
Soderberg G and Cook T (1983), An electromyographlc analysIs of quadnceps femons musclesettIng and straight leg raIsmg, Physical Therapy, 63 (9), 1434-1438.
Spencer J, Hayes K and Alexander I (1984), KneeJomt effUSIOn and quadnceps reflex InhibitIonm man, Archives of PhySIcal MediCine andRehabllttatlOn, 65, 171-177.
Stener B (1969), Reflex mhlbltlon of the quadnceps elIcited from a subpenosteal tumour, ActaOrthopaedlcal Scandmavlca, 40, 86-91.
Stokes M and Young A (1984), InvestigatIons ofquadnceps InhibitIon: Imphcatlons for chmcalpractice, PhysIOtherapy, 70 (11), 425-428.
Stratford P (1981), Electromyography of thequadnceps femons muscles m subjects wIth normal knees and acutely effused knees, PhysicalTherapy, 62 (3), 279-283.
Subotmk S (1980), The foot and sports mediCIne,Journal of Orthopaedic and Sports PhysicalTherapy, 2 (2), 53-54.
Tuller B, Fitch H and Turvey M (1982), TheBernstem perspectIve: 11, In Human Motor BehaVIOur An IntroductIOn, edIted by J Kelso.LEA, New Jersey
WIld J and Franklm (1982), Patellar spm andquadnceps rehabilItation' an EMG study, Journal of OrthopaedIc and Sports Physical Therapy, 10 (1), 12-15
Wmter D (1983), Moments of force and mechanIcal power m JoggIng, Journal ofBlOmechamcs,16 (1), 91-97.
The Australian Journal of Physiotherapy Vol 32, No.4, 1986 223