Age Wide Knee Hindrance: a Review on Chondromalacia Patella

Home , Chondromalacia patellae

Available online at www.ijpbr.org Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 ISSN: 2394 - 3726 Int. J. Phar. & Biomedi. Rese. 201 6, 3 (2): 5-12 Review Article

Age Wide Knee Hindrance: A Review on Chondromalacia Patella

Mohammad Zeeshan Alam Khan* and Rana Paul Department of Microbiology, School of Life Sciences, Sikkim University (Central University), Gangtok, Sikkim, India *Corresponding Author E-mail: [email protected] Received: 06.04.2016 | Revised: 13.04.2016 | Accepted: 18.04.2016

ABSTRACT

Chondromalacia patella is the softening, thinning, and degradation of cartilage underneath the

patella and the inflammation of it. It is most common to young adults who are very much involved

with physical activities like sports and excersizing. Overuse or injury can lead to the degradation of intraarticular cartilage under the knee cap. This osteoarthritis can result from ligament injury, excess laxity, joint hypermobility, and clinical instability with osteoarthritis appearing in the synovial joint. With many clinical diagnosis present for Chondromalacia patella, this review brings in light why prolotherapy is among the best treatment for it. Following prolotherapy, patients experienced statistically significant decreases in pain at rest, during ADL, and exercise. Stiffness and crepitus decreased after prolotherapy, and ROM increased. Patients reported improved walking ability and exercise ability after prolotherapy. For daily pain level, ROM, daily stiffness, crepitus, and walking and exercise ability, sustained improvement of over 75% was reported by 85% of patients.

Keywords: Chondromalacia patella, Catilage, Knee, Pain, Prolotherapy

INTRODUCTION The medical condition of softening, thinning, who are engaged in active sports are mostly and degradation of cartilage underneath the affected by it. patella and the inflammation of it is termed as Chondromalacia patellae need to be Chondromalacia patella. It is characterized by distinguished from osteoarthritis of the patella patella femoral pain syndrome, affecting patients femoral joint. The former is usually a self- of all ages. In young patients the syndrome limiting condition of adolescence, with a observed are mainly due to some kind of predilection for girls, affecting the articular external injury which results in the damage of cartilage ofthe medial patellar ridge. Few ofthese intraarticular cartilage which in turn results in patients show later overt clinical and osteoarthritis[17].In older patients the syndrome radiological osteoarthritis.Patellar pain must be in also seen but the action leading upto the separated from other causes of internal syndrome or the causative reason for the derangement of the knee by a careful history and syndrome is different from that to the younger precise examination followed by appropriate patients. In older patients, Chondromalacia investigations. Once the cause of the pain is patella is commonly due to the age-related determined, malalignment or malposition of the osteoarthritis. The smooth nature of the cartilage patella must be sought. The Merchant view of is no longer seen and thus usual movement and the patellar femoral joint is recommended in this daily activities becomes painful. Young children regard to demonstrate patellar incongruence. The Copyright © April, 2016; IJPBR 5

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 malalignment syndrome may or may not show cartilage possesses no pain fibres the pain is the pathologic changes described as thought to arise in that area ofbone no longer "chondromalacia" and respond particularly well cushioned from stress by the damaged articular after proximal patellar realignment. In the cartilage overlying it. Conservative, first line remaining cases, pain may be caused by overuse, therapy for chondromalacia patella includes trauma, the odd-facet syndrome, an abnormal exercise, physical therapy, non-steroidal anti- femoral ridge, or degenerative arthritis. This inflammatory drugs (NSAIDs) and group of cases should be managed corticosteroid injections[6]. In most cases these conservatively if possible because the results of treatment is not helpful which leads to the surgical treatment are often disappointing. In degradation of the cartilage and finally the selected cases some improvement may occur patients has to undergo knee replacement after excision of abnormal cartilage, tibial operation. tubercle elevation, patellar replacement, or Since chondromalacia patellae is usually patellectomy. a self-limiting condition, palliative conservative Daily activity subjects the human patella treatment is appropriatenamely, analgesics, to forces often several times the individual's suitable physiotherapy, and a support for the body weight. Healthy cartilage can adjust to patella. Strict avoidance of all sports and games, these forces if they are not too excessive, a serious deprivation for an adolescent, should concentrated, or repetitive. Such abnormal not be necessary. Overtreatment is always stresses most frequently occur with the possible when pain tolerance cannot be clearly disturbance of normal patellar mechanical assessed; adolescents frequently accept chronic function. Chondromalacia patellae are the result or recurrent discomfort badly and with common to a wide variety of unusual traumata. impatience. Other option for treatment of this Treatment must be directed primarily not toward inflammation issurgery, butdoctors try and avoid the damaged patellar cartilage but toward a surgery and diagnose the patients with correction of the mechanical abnormality conservative methods as long as possible. Other causing it. Until proven otherwise, a young used methods of treatment are patella female complaining of knee joint pain, resurfacing procedure, patellectomy. particularly if bilateral, should be considered as Structure of Patella suffering from a subluxating patella, with or Patella is commonly called kneecap.The without chondromalacia patellae. triangular shaped structured part is a sesamoid The clinical diagnosis in patients bone with its top facing down. The top portion is complaining of pain around the patella needs, the lowest part of patella.It gives attachment to therefore, to take account of age, any history of the patellar ligament. The base of patella is trauma, and evidence of pain under attached to the tendon of quadriceps femoris circumstances where the patellofemoral joint is muscle and the vastusintermedius muscle. The subjected to stress. Examination may elicit pain outer lateral and medial borders are connected to under the medial articular surface of patella on the vastuslateralis and vastusmedialis. The upper pressure or on manipulating the patella against front of the patella is coarse,flattened and rough. the femoral condyles.8 Factors thought to Its function is helping in the connection of provoke changes in the articular cartilage typical tendon of the quadriceps. The third lower of chondromalacia are patella alta, patella cumilates in the apex which serves as the origin malalignment, and structural abnormalities in the of the patellar ligament[12]. As part of a more form of an extra patellar facet or a ridge at the intricate anatomy of tendons and vasculature, the proximal margin of the articular surface ofthe patella overlies the joint consisting of the medial femoral condyle. Some, but not all, of junction of the femur and the tibia. The space these features can be identified clinically or between these two bones is where cartilage and radiologically to support the diagnosis. As an extracellular matrix exist. Additionally, the

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 surface under the patella is covered with associated with chondromalacia patella is articular cartilage that is smooth and slippery. osteoarthritis. Although the pathogenesis of When the knee flexes and extends, this smooth osteoarthritis involves both the degradation and surface allows the patella to slide easily into the synthesis of articular cartilage, cytokines cause groove of the femur. This cartilage becomes greater breakdown than repair [9]. rough and wears away in chondromalacia Chondromalacia patella is differentiated from patella. the diagnoses of anterior cruciate ligament tear During normal function the patella is and tendon injuries, although these conditions subjected to heavy mechanical loading as it contribute to the development of patellofemoral increases the moment-arm of the extensors ofthe pain syndrome. In chondromalacia patella, the knee. The act ofclimbing stairs applies a force occurrence of degeneration of cartilage is hidden across the patellofemoral joint of more than behind the hard bony, floating structure of the three times the body weight4 -around 170 patella. kg .One cause of early damage to the articular Signs and Symptoms cartilage may be a shear stress imposed by Symptoms of chondromalacia patella include differing stiffness zones in the underlying bone- acute or chronic pain, popping and cracking relative osteopenia in one area permitting the sounds, climbing stairs, running, kneeling, bone to collapse a little relative to an adjoining squatting, or other physical activity involving region. The patella may also be damaged in falls the knee can worsen these symptoms. With the or by contact with the facia in motor accidents: negligence from patient’s part and with time the forces short ofthose required to fracture the bone symptoms of chondromalacia patella worsen. may damage the articular cartilage , though this Crepitation or dysfunction of the patella may be is likely only when the contact area between also being noted.Crepitation will result in patella and femur at the time of impact is quite palpation of the patellofemoral articulation small (as occurs when the knee is at right- during active and passive range of motion of the angles). knee of the patella within the femoral trochlea. Causes of Chondromalacia Patella Compression of the patella against the femur at In adolescents and active adults, varying degrees of knee flexion may elicit chondromalacia patella can be due to sports articular pain. An alternative method involves injury with participation in athletics, such as manually resisting the upward movement of the running, soccer, cycling, skiing, and gymnastics, patella as the patient actively contracts the which are high-impact sports, involve abrupt quadriceps. Manipulating the patella with stopping, and apply repetitive torsion, stress, and simultaneous compression of the patellofemoral force to the joint. Overuse or injury can lead to joint may elicit pain, but, more importantly, may the degradation of intraarticular cartilage under identify areas of significant cartilage wear on the the knee cap. This osteoarthritis can result from joint surfaces. The examination is completed by ligament injury, excess laxity, joint thorough evaluation of the knee ligaments. This hypermobility, and clinical instability with includes examination of the medial and lateral osteoarthritis appearing in the synovial joint[4]. collateral ligaments as well as examination of Other sources that can lead to patella femoral the anterior and posterior cruciate ligaments. pain syndrome in teens and young adults include Joint line tenderness and crepitation of the joint injury due to car accidents (dislocation and may identify medial and lateral meniscus tears fracture) and congenital flat feet. When the with provocative maneuvers such as McMurray patella does not fit properly into the femoral testing. groove upon movement or is dislocated to one Treatment side due to anomaly of the ligaments or Rest and vitamin D are the primary treatment for musculature, chondromalacia patella can result. chondromalacia patella, but these therapies have In older adults, the hallmark condition a disadvantage. They do not regenerate

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 cartilage,so there is no end to chondromalacia whereas in the presence of recurrent subluxation, patella.Non-steroidal anti-inflammatory drugs the release does not correct the basic (NSAIDs) may also be prescribed, but studies biomechanical disturbance[3]. show further degradation of cartilage with this One of the best methods for the therapy in both animals and humans [7].In elimination of pain of the inflammation and to reverse the process of cartilage degeneration, addition to molecular changes in the cartilage by prolotherapy . The term prolotherapy was coined NSAIDs, the cartilage break down also may be by Hacket [5] in the 1940s and 1950s to imply due to increased joint use and load upon the proliferation of normal tissue at ligamentous and knee following pain amelioration[1,11,16]. tendinousentheses; the procedure has been Muscle strengthening exercises may described by other terms, such as sclerotherapy, improve the relative location of the patella upon regenerative injection therapy, and stimulated movement, but do not improve the tendons, ligament repair. More recently, Reeves defined ligaments, or cartilage. As chondromalacia prolotherapy as injection of growth factors or patella worsens, corticosteroid injections may be growth factor production stimulants to grow provided in an attempt to relieve pain symptoms. normalcells or tissue[14]. However, a comprehensive review of the Prolotherapy is an alternative medicine literature documents significant necrosis of [13] treatment of tissue with the injection of an cartilage from even just one injection[8].The irritant solution into a joint space , known effects of intraarticular corticosteroids on weakened ligament , or tendon insertion to articular cartilage have been documented in a relieve pain. Prolotherapy involves the injection study by Hauser. As it worsens, arthroscopy may of an irritant solution into a joint space, be recommended to remove the degraded weakened ligament, or tendon insertion to cartilage. Finally, due to the resultant relieve pain. Most commonly, osteoarthritis, knee replacement may ultimately hyperosmolar dextrose (a sugar) is the solution be recommended. used; glycerine [10], lidocaine (a commonly Another treatment process is lateral used local anesthetic ), phenol [10], and sodium retinacular release/prolotherapy of the patella. morrhuate (a derivative of cod liver oil extract) A lateral release is a surgical procedure to are other commonly used agents. The injection is release tight capsular structures (lateral administered at joints or at tendons where they retinuculum) on the outer aspect (lateral aspect) connect to bone. of the kneecap (patella) . This is usually Prolotherapy treatment sessions are performed because of knee pain related to the generally given every two to six weeks for kneecap being pulled over to the outer (lateral) several months in a series ranging from 3 to 6 or side and not being able to run properly in the more treatments[10]. Many patients receive centre of the groove of the femur bone as the treatment at less frequent intervals until knee bends and straightens. The procedure is treatments are rarely required, if at all. also known as a 'lateral retinacular release'. A A case study was made to find out the series of 59 knees in 58 patients were surgically success of prolotherapy. Of the 117 patients treated from 1977 to 1982 for chondromalacia recruited for this study, 61 patients with 69 patellae, and were followed for an average of 1.2 knees (8 patients with bilateral knee to 4.6 years after the operation. The operative prolotherapy) were included in this study. Of the procedure was open lateral retinacular release in 69 knees, 36 (52%) were from female patients all knees. In knees with recurrent patellar and 33 (48%) were from male patients. The subluxation, the number of poor results average age of patients was 47.2 years with a increased from 24% to 70% and in knees with range of 18–82 years[15]. no subluxation from 21% to 24%. The difference Patients were administered a survey of after 4.6 years was statistically significant. No 32 questions via phone to evaluate the effects of correlation between the severity or location of prolotherapy. A self-assessment of pain at rest the cartilage changes and the operative effect was ranked on a 10-point scale, which aligns was found. Open lateral retinacular release is an with the Visual Analog Pain Scale.32 No pain to acceptable treatment of chondromalacia minimal pain was calculated as scores 0 through patellae without subluxation of the patella, Copyright © April, 2016; IJPBR 8

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 3. Moderate pain was considered as 4−6 points from 7−10. The following data was reported by on the questionnaire, and severe pain was scores patients before prolotherapy [15]:

Walking ability was completely affected with an patient was a non-responder on ability before inability to ambulate in 6 knees (8.8%) in 68 prolotherapy. After prolotherapy 56 knees responders. Before prolotherapy, walking ability (82.3%) had no distance restrictions and were was severely compromised with an inability to able to walk over three blocks. Eleven knees walk one block in 8 knees (11.8%). Four knees (16.2%) were mildly compromised[15] and (5.9%) were moderately affected with an ability could walk over three blocks, but not as far as to walk only one to two blocks. Twenty-six desired. Only 1 patient (1.5%) stated moderate knees (38.2%) were mildly affected, with an compromise with an ability to walk one to two ability to walk more than three blocks, but not as blocksto strengthenthe success of prolotherapy far as desired. Before receiving prolotherapy 24 in treating Chondromalacia patella. knees (35.3%) were not compromised. One

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 A case study was done by Bradley D. Fullerton, with no significant medical historypresented MD where High-Resolution Ultrasound and with intermittent, progressively worsening Magnetic Resonance Imaging to Document medial and anterior knee pain over the past 3 Tissue Repair After Prolotherapy [2]. A case years. He had undergoing prolotherapy. was studied. In the first case a 34-year-old man

Fig. 1: Proton density,fat saturation MRI of the knee(pre- and postprolotherapy). Top row,october 2004; bottom row, October 2005. (A and C) Sagittal views of left knee.the thin arrow(originally added by the interpreting radiologist) inidicates a high signal in the deep,midportion of the patellar tendon consistent with partial tear. Note the reactive edema in the inferior pole of the patella (A) in 2004. Post-prolotherapy, the edema is resolved and a subperiosteal cyst is noted (C). Images on the right (B,D) are axial views of the left knee through the patellar tendon; the large arrow in B points to the region of the thickened abnormal tendon with high signal intensity just distal to the patellar enthesis, indicating a partial patellar tendon tear. The postprolotherapy (D) shows new tendon growth and partial repair of the tear .

Patients were surveyed regarding the total medication and 5 knees (7.2%) needed 2 pain number of pain medications as well as number medications. After prolotherapy, 66 knees of pills of each that they needed prior to (95.6%) of patients in the study required no pain prolotherapy. No pain medication was needed in medication and only 3 patients (4.3%) required 1 40 study knees (58.0%) before prolotherapy, but medication for pain relief [15]. 24 knees (34.8%) needed at least 1 pain

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726

DISCUSSION Improvements in pain range of motion, stiffness, In the United States, approximately one third of and crepitus were sustained in over 92% of adults between the ages of 25 and 74 years have patients. Pain medication usage also was radiological evidence of osteoarthritis in a major decreased following prolotherapy. joint. The knee is the most commonly affected Range of motion, walking ability, and exercise joint in those greater than 45 years old. ability all were improved with prolotherapy. Of Chondromalacia patella, the result of 8 knees (11.6%) with a severely limited range of osteoarthritis in the knee, can be age-related or motion and 8 knees (11.6%) with moderate due to trauma. Chondromalacia patella should be limitation, 14 knees showed improvement treated with conservative methods such as following prolotherapy. Before prolotherapy, 5 excersing, pheotherapy etc. many doctors does patients with 6 knees (8.8%) were completely not approve surgery the ultimate treatment to unable to walk. Of these patients, 4 achieved the chondromalacia patella as after surgery many ability to walk with no distance restrictions and compications are seen which ultimately results 1 patient could walk farther than 3 blocks, but in knee replacement surgery.over the years focus not as far as desired. In the remainder of patients has to give to the improvement of the treatment whose walking ability was mildly to severely methods and as of now the best method of affected, 82.3% (56 knees) had no distance treatment is prolotherapy. restrictions during walking after prolotherapy. Prolotherapy improved the pain and associated Of 17 knees (25.8%) that could not tolerate symptoms of chondromalacia patella in nearly exercise before prolotherapy, only 1 knee all knees in this study despite the fact that continued to be completely compromised. patients waited an average of nearly 2 years Although 18 knees (27.3%) could not tolerate (21.6 months) before prolotherapy. exercise beyond 30 min, only 1 knee was Copyright © April, 2016; IJPBR 11

Khan and Paul Int. J. Phar. & Biomedi. Rese. 2016, 3 (2): 5-12 ISSN: 2394 – 3726 affected to this extent after prolotherapy. 6. Hauser, R.A. and Cukla, J.J., Standard Seventeen knees before prolotherapy with 5 clinical x-ray studies document cartilage patients stating moderate compromise after regeneration in five degenerated knees after prolotherapy, meaning patients could not prolotherapy. Journal of Prolotherapy , exercise the knee beyond 60 min. Initially, only 2009 , 1:22–8. 9 knees (13.6%) reported mild compromise and 7. Hauser, R.A., The acceleration of articular 6 knees (9.1%) were not affected by exercise. cartilage degeneration in osteoarthritis by After prolotherapy, the condition of 23 patients nonsteroidal anti-inflammatory drugs. (33.8%) had improved to mildly compromised, Journal of Prolotherapy , 2010 ,2(1):305–22. and 38 knees (55.9%) experienced no degree of 8. Hauser, R.A., The deterioration of articular compromise during exercise. Fifty-eight of 64 cartilage in osteoarthritis by corticosteroid knees (90.6%) had sustained this improvement injections . Journal of Prolotherapy , at rates $ 75% of the effect achieved at their last 2009 ,2:107–23. prolotherapysession [15]. Ultrasound imaging 9. Hauser, R.A., The regeneration of articular can show tissue growth and repair. Prolotherapy cartilage with prolotherapy. Journal of doesstimulate tissue growth in tendon (patellar), Prolotherapy, 2009 ,1(1):39–44. and that this is an organized growth with a return 10. Judson, Christopher,H. Wolf, and Jennifer, toward a normal appearance on ultrasound. M.,Lateral Epicondylitis. Orthopedic Clinics Further clinical studies with of North America , 2013 , 44 (4): 615–623. ultrasoundconfirmation are recommended. The 11. Lane, N.E. and Wallace, D.J., All About development of quantitative methods to analyze Osteoarthritis: The Definitive Resource for ultrasound images will be valuable in blinded Arthritis Patients and Their Families. Oxford efficacy studies of prolotherapy and other University Press, Oxford, England . pp.19- rehabilitative interventions. 29, 2002 12. Platzer and werner.,Color atlas of human REFERENCES anatomy .Locomotor system ,2004, 2(5):194. 1. Andriacchi, T.P. and Lang, P.L. Alexander, 13. Rabago, D. Slattengren, A. and Zgierska, E.J. and Hurwitz, D.E., Methods for A.,Prolotherapy in primary care practise evaluating the progression of osteoarthritis. Primary Care: Clinics in Office Practice , J Rehab Res ., 2000 ,37(2):163–70. 2010 ,37(1): 65–80. 2. Bradley, D. and Fullerton, M.D., High 14. Reeves, K.D.,Prolotherapy: regenerative resolution ultrasound and magnetic injection therapy. Pain management. resonance imaging to document tissue repair Philadelphia: WB Saunders , 2007 ,2: 1106- after prolotherapy. Arch Phys Med 1127. Rehabil ., 2008 , 89:377-385. 15. Ross, A. Hauser,M.D. and Ingrid, S.S., 3. Christensen, F. Soballe, K. and Snerum, L., Outcomes of prolotherapy in chonromalacia Treatment of chondromalacia patellae by patella patients:improvement in pain level lateral retinacular release of the patella . and funvtion,clinical medicine ClinOrthopRelat Res ., 1988 ,234:145-147. insights .Arthritis and musculoskeleton 4. Ferences, L. Wheaton, M.T. and Jensen N., disorders, 2014 , 13-20 The ligament injury connection to 16. Schnitzer, T. Popovich, J.M. Andersson, osteoarthritis. Journal of Prolotherapy . G.B. andAndriacchi, T.P., Effect of 2010 ,2(1):294–304. piroxicam on gait in patients with 5. Hackett, G.S.Hemwall, G.A.and osteoarthritis of the knee. Arthritis Rheum . Montgomery, G.A., Ligament and Tendon 1990 ,36(9):1207–13. Relaxation Treated by Prolotherapy. 5th 17. Wheaton, M.T.and Jensen, N., The ligament edition. Oak Park (IL): Gustav A. Hemwall; injury connection to osteoarthritis. Journal 1993 . of Prolotherapy , 2010, 2(1):294–304.