Chondromalacia patella is a condition routinely seen in the chiropractic office. While it is more common in females, it can affect either gender, especially younger adults. The patient will complain of knee stiffness and pain, especially with prolonged sitting or excessive use. Symptomatic history, along with simply moving the patella around to check for grinding and roughening underneath the patella, helps confirm the diagnosis. X-rays typically are not helpful. MRI will detail this area much better, and the radiologist will grade the chondromalacia patella on a scale of I-IV depending on the extent of the degenerative changes. Often the degenerative changes will be asymmetrical secondary to the poor tracking pattern of the patella, with the medial patella much more affected. True retropatellar osteoarthritis is usually seen with OA of the rest of the knee.1
With any knee complaints, I routinely like to check the sacroiliac joints, as that is a common pain referral pattern, especially for anterior knee pain. Adjustments to the sacroiliac joints, along with the iliofemoral joints, often are helpful. Since the knee is a transition area between the hip and the foot, the entire lower-extremity locomotor chain needs to be checked. Often there will be a muscle imbalance with overactivity of the lateral muscles, including the piriformis, tensor fascia latae and vastus lateralis, with relative hypotonicity of the medial quadriceps, especially the vastus medialis obliques component. The hamstrings often are shortened in chondromalacia patella patients, but not always. Stretching of these lateral muscles will help improve the tracking; this will be enhanced further by activating the medial quadriceps muscles.
I like to use postisometric relaxation stretches for the shortened muscles. For the medial component and quadriceps strengthening in general, I prefer to emphasize motor control rather than bulk strengthening. To replicate gait, with the patient seated and his or her leg upon the table, I have the patient place a rolled up towel underneath the posterior knee and activate the hamstring first by driving the heel into the table, then activating the quadriceps with leg straightening while maintaining a hamstring contraction.2 Once patients develop motor control, they can be moved up to short-arc quad exercises and standing one-leg quarter squats. They can progress to lunges and balance work, including wobble boards and foam balance pads, to help with neurologic facilitation in these cases.
Many clinicians utilize soft-tissue work such as Graston technique or active release technique to remove muscular adhesions that prevent normal gliding of the patella and surrounding musculature. Whatever your chosen technique, this soft-tissue component is important to remove the muscular adhesions and allow for more normal movement.
My nutritional intervention is based on reducing inflammation in the area, so glucosamine with chondroitin and EPA/DHA essential fatty acids are used, along with anti-inflammatory herbs such as ginger and turmeric, and a proprietary plant extract derived from Phellodendron amurense. Chondromalacia patella is biomechanical in origin; however, there are neurologic and biochemical components that need to be addressed. Although it is a very broad topic, foot pronation and possible need for orthotics should be evaluated on these patients, as the pronated foot also will lead to poor tracking at the knee.
If you can treat chondromalacia patella cases successfully, you can expand your patient base, leading to an increase in your practice and your reputation as an expert in conservative care. This is another example of a condition that chiropractors should be treating routinely.
- Yochum and Rowe. Essentials of Skeletal Radiology, 3rd ed. Lippincott Williams & Wilkins, 2005, p. 983-984.
- Johnston J. Personal communication, February 2005.
Dr. Mark King graduated from Life Chiropractic College in 1986. He is a clinician at Mt. Lookout Chiropractic Sports & Injury Center in Cincinnati; president and lead instructor of the Motion Palpation Institute; and a coach and co-founder of Cutting Edge Chiropractic Consultants.