Patellar chondromalacia is a degeneration of the articular cartilage that covers the patella, in the inner area where the femur is articulated. It represents between 10% and 25% of consultations for problems in the knee to specialists in Traumatology and Physiotherapy, and affects young adults, something more to women.
When hyaline cartilage, whose function is to facilitate the sliding of the bones at their joint ends and the absorption of impacts, is damaged, the patella and the femur do not glide smoothly with each other, which increases wear and friction between them.
Although we can impose limitations, chondromalacia patella is not the end of an athlete, not a runner, not even a marathon.
There are four degrees of injury:
- Grade 1: edema and softened cartilage.
- Grade 2: cracking or alteration of cartilage surface.
- Grade 3: alteration of the deeper layers of the cartilage.
- Grade 4: involvement of the subchondral bone.
Causes of Patellar Chondromalacia
Although the causes of many chondromalacia are unknown (idiopathic), it is thought that most are caused by repeated low-intensity trauma. On the other hand, there are many predisposing factors that favor the onset of this pathology, such as alterations in knee alignment, repetitive trauma of medium or high intensity, joint dysplasias that cause poor congruence between the patella and the femur, trauma direct or high-intensity rheumatic or autoimmune diseases such as rheumatoid arthritis, obesity and metabolic diseases, infections or the aftermath of accidents.
Diagnosis of patellar chondromalacia
The diagnosis of chondromalacia patella is made through clinical history and imaging tests.
Usually, patients present pain in the anterior aspect of the knee, sometimes irradiated to the popliteal void, crepitation when bending and extending the knee, burning, feeling of pressure or swelling or, less commonly, episodes of failure or insecurity, especially to the down and up stairs or after sitting for a long time with shrunken legs, when walking ("sign of the seat" or "movie sign").
To confirm the diagnosis, or to rule out other causes of pain, nuclear magnetic resonance. Simple X-rays and CT scan or dynamic scan reflect poor alignment of the patella with the femur, poor position or poor congruence (these are more or less severe forms of dysplasia). All this contributes to the support between the two bones is not optimal, facilitating early wear (it is like a car with the wrong parallel made, the wheels wear more).
Treatment of patellar chondromalacia
There is no definitive treatment that reverses cartilage degeneration. Depending on the degree and limitation of the patient, it can be used from physiotherapy or exercise, to the use of cartilage protective drugs, orthokine infiltrations, growth factors or hyaluronic acid.
With postural care you want to avoid having your knee flexed for a long time. Fold and stretch frequently and avoid kneeling or squatting.. Also, better not to go up and down stairs if it is not necessary or if we have chondromalacia, we are not trained on the knee and wear out the cartilage.
In the case of chondromalacia patella, physiotherapy is aimed at relieving pain and enhancing the quadriceps. Undoubtedly, the runner may have to change his stride and give up some exercises, but better this than not running. Adapting exercise or modulating it or combining it with other less traumatic disciplines for joints can be key.
Chondroprotective medications have the highest scientific evidence for long-term cartilage preservation. Other products like collagen, magnesium, hyaluronic ... may be good, but do not have the evidence required by the scientific method.
Infiltrations of hyaluronic acid and plasma rich in growth factors improve the sensation of stiffness, crepitation, pain and mobility of patients. However, in the treatment of degenerative joint damage, the plasma rich in growth factors has been shown to be more inconsistent, with poor durations.
Ortokine (autologous serum-conditioned) is a biological therapy through which the blood obtained from the patient is incubated for 7-8 hours at body temperature (37 ° C) in special syringes containing crystal beads. In this way we generate Growth Factors as well as large amounts of the IL-1ra protein, which is the main natural anti-inflammatory of our organism. This combination is especially indicated in chondromalacia, painful arthrosis and with inflammation, both in joints and in the back, and tendinopathies. Many research highlights its benefits in reducing pain, improving mobility and, above all, its results are more durable than with other therapies, with improvements that can last for more than two years.
True stem cells, for their part, have little scientific evidence, in small series. The results are similar to other infiltrations but their price can be between 3-10 times higher than the therapies cited, depending on whether they are cultivated or not, so they can not currently be considered a common treatment option.
Arthroscopies do not have to be performed to establish the diagnosis of chondromalacia. "Cleaning arthroscopies" usually offer a transient improvement, probably because fringes of very unstable cartilage are regularized and mediators of inflammation are cleaned, but after a time, at weeks or months, the patient is the same. These improvements can often be achieved with infiltrations, without the need to operate.
In focal cartilage defects they can be used to make blasts or bleeding, as well as microperforations in the subchondral bone that stimulate the slow repair of the damaged cartilage, although hardly it becomes of optimal quality.
Chondrocyte culture, along with growth factors or other substances, is used for focal cartilage defects. This occurs when there is a "crater" in it. They are applied in defects of 2-8 cm square, but chondromalacia is, in general, a diffuse defect of the entire cartilage, not a focal osteochondral lesion (that affects cartilage and subchondral bone), so this treatment does not would be indicated. These cell culture techniques involve two operations (one to take cartilage and another to implant). Its price is very high and, after 25 years in use, despite good clinical results, it has its very restricted indications and limitations.
Living with chondromalacia patella
Chondromalacia hurts seasons, sometimes more, sometimes less, depending on many factors. It is possible that the athlete may have to modify his training, combine other sports perhaps, but it does not mean that he has to give up his favorite sport.
There is no scientific evidence to quantify what weighs more in the development of osteoarthritis: if running, even less, take chondroprotectors, occasionally infiltrate the knees or live, without weighing, day by day 10-15 kilos more and assume the effects of metabolism of adipose tissue, which generates many inflammatory radicals that damage the connective tissue, in addition to the mechanical factor.
As a traumatologist I always explain all these aspects to patients, the modulating role of exercise at the threshold of pain or the protection of the musculature on the joint. Doing sport, running, so fashionable, demands a sacrifice but allows us to live our life at another speed. If we were once, as some anthropologists explain, hunters due to exhaustion of our prey, and in view of the fever for the sport that surrounds us, there is no doubt that we have been "born to run."