Overview Chondromalacia patellae is also known as chondromalacia patellae and patellofemoral strain. It is caused by repetitive friction between the patella and femur during long-term extension and flexion, resulting in wear and tear of the cartilage surface. It is a relatively common knee joint disorder. It belongs to the category of “injury to tendons” in Chinese medicine. The pain is aggravated when going up and down steps, bending the knee for a long time or squatting. The disease begins in youth, more in women than in men, and is more common in athletes, and is associated with the patella being repeatedly squeezed and rubbed over time. Some may develop into patellofemoral osteoarthropathy. Axial (tangential) X-rays and CT of the patella show changes such as narrowing of the joint surface, sclerosis, patellar tilt and subluxation. Arthroscopy is useful for early diagnosis and surgery. Non-surgical treatment is generally used to improve knee movement to reduce pressure and friction on the patellar cartilage, and physical therapy and medications can relieve symptoms. For severe chondromalacia patella, patellar osteotomy, patellar osteoplasty or patellar resection can be used if the lesion is extensive.
Chondromalacia patellae is a disease of adolescents or young adults and is more common in females, but there are no significant gender differences in athletes. The cartilage surface of the patella becomes roughened, softened, fragmented, detached, and fibrotic in patients. The cause is not completely clear, but is definitely related to overstrain and chronic strain on the knee joint.
The true meaning of chondromalacia patellae is: those with pathological changes of chondromalacia patellae, along with symptoms and signs such as patellofemoral pain, patellar friction sound and quadriceps atrophy, etc. The degree of chondromalacia patellae is not consistent with the degree of pain, therefore, the degree of chondromalacia patellae cannot be judged based on clinical symptoms alone, but must be combined with physical signs and necessary auxiliary examinations to make an accurate judgment.
Chondromalacia patellae is defined as an osteoarthrosis of the patellofemoral joint that occurs when the cartilage surface of the patella is swollen, cracked, broken, eroded, and dislodged due to chronic injury, and eventually the cartilage of the femoral condyle opposite to it also undergoes the same pathological changes.
Etiology
1, congenital patellofemoral developmental disorders, position abnormalities and femoral condyles large and small abnormalities; or acquired knee joint internal and external rotation, tibial external rotation deformity, etc., can make the patella unstable and become the basis of chronic injury.
2, long-term, rapid, forceful flexion and extension of the knee joint, increasing the wear and tear of the patellofemoral joint, is a common cause of this disease.
3, various causes of synovial fluid composition abnormalities, can make the patellar cartilage malnutrition, vulnerable to minor injuries and degenerative changes.
The pathogenesis of the lesion centers on the medial surface of the patella and the medial deviation (there is a small independent articular surface on the medial edge of the patella, separated from the medial surface by a linear ridge). The initial lesion begins in the deeper layers of the cartilage and the cartilage glia are contracted in bundles, but do not invade the cartilage surface, so the surface appearance is not abnormal, but touching the cartilage by hand reveals a feeling of hollowing out. If the lesion continues to progress and the cartilage surface is involved, fragmentation and detachment will occur.
Outerbrige divided the pathological changes of CP into four stages.
Stage I: cartilage swelling and softening, diameter less than 0.5 cm; Stage II: cartilage fragmentation in the form of fissures, diameter 0.5-1.0 cm; Stage III: cartilage surface breakdown, subchondral bone exposure, diameter less than or equal to 2.0 cm; Stage IV: subchondral bone densification of the broken cartilage, diameter greater than 2.0 cm.
Clinical manifestations are slow in onset. Initially, the knee is uncomfortable and the pain is poorly localized. Later, the pain behind the patella is obvious, and the pain increases during and after activities, especially when going up stairs. In severe cases, there was a sensation of friction in the knee joint. On examination, squeezing the patella can induce pain and a friction sound. A sharp pain behind the patella during the patellar squeeze test indicates patellofemoral joint cartilage injury and has diagnostic significance.
A, young athletes are common, the initial pain under the patella, slightly relieved by activity, and aggravated after prolonged exercise, gradually disappeared after rest. With the prolongation of the disease pain time more than the relief time, so that can not squat, up and down the ladder difficulties or sudden weakness and fall.
Second, pressure pain at the edge of the patella, squeezing or pushing the patella in the extended knee position can have a rubbing sensation, accompanied by pain. When the patellar cartilage is damaged alone, there is no joint effusion, but when osteoarthrosis of the patellofemoral joint is formed later, synovitis may occur and joint effusion may appear. If the disease is of long duration, quadriceps atrophy may occur.
Occult pain behind the patella and medial knee is the most common symptom, which is aggravated after exertion or after walking up or down stairs. Sometimes there is fluid accumulation in the knee joint. If the patella is pushed against the cartilage surface of the patella, there may be pressure pain, and there is also a distinct pressure pain point in front of the medial femoral condyle. When extending and flexing the knee joint, the examiner’s hand can feel an abrasive sound below the patella. X-rays are often unremarkable.
Signs: Patellar, peripatellar, patellar rim, and posterior patellar tenderness are evident, along with patellar sliding pain and patellar crepitus, but the degree of patellar crepitus is not consistent with the severity of patellar cartilage lesion. A small number of patients have joint effusion. In severe cases, knee extension and flexion activities are limited and the patient cannot stand on one leg. The apprehensive test is often positive, meaning that the patella is pushed to one side and knee flexion is stopped due to fear of knee pain during knee flexion activities. The squat test is positive, meaning that the patient has significant pain in the patella when squatting. If the patella moves more than 1/4 of the transverse patellar diameter when the knee is flexed at 20° to 30°, it is indicative of patellar subluxation.
Physical examination
1, patellar compression and grinding test: the patella and its relative femoral intercondylar articular surface squeeze and grind each other or slide up and down, there is a rough grinding sensation, grinding sound and painful discomfort; or the examiner forcefully push the patella to one side with one hand, and press the thumb of the other hand behind the edge of the patella can cause pain.
2.When there is joint cavity effusion, the floating patella test may be positive.
3, single-leg squat test: the patient holds weight on one leg and gradually squats to 90° to 135° with pain, tenderness, and cannot stand up on one leg after squatting.
The main basis for the diagnosis of chondromalacia patella is the post-patellar pain, which is caused by the patellar compression and grinding test and the single-leg squat test. Care should be taken to check for any combined meniscal injury and traumatic arthritis.
Merchant divided chondromalacia into two types: normal patellar alignment and malalignment, and proposed that the type of chondromalacia can be determined by taking an axial X-ray of the patella at 45° of knee flexion and 30° of the angle between the ball and the horizontal line.
In the early stage of X-ray examination, no abnormal findings can be seen. As the disease progresses, narrowing of the patellofemoral joint space, sclerosis of the subchondral bone and osteophytes at the patellar rim can be seen.
X-ray examination: frontal, lateral and tangential x-ray of the knee joint, no abnormalities can be seen in the early stage, but in the late stage, the gap between the patella and the femoral condyle can be narrowed due to extensive cartilage wear, and there can be osteophytes at the edges of the patella and the femoral condyle.
Radionuclide bone imaging shows limited radioconcentration of the patella in the lateral position, which has early diagnostic significance.
Diagnostic points: (1) The onset of the disease is slow, with initial vague knee pain and weakness, followed by post-patellar pain, aggravated by exertion, difficulty in walking up and down stairs, and severe cases affecting walking. There is no obvious swelling in the knee, and there is pressure pain in the posterior part of the patella on both sides. The patella test was positive. The lateral and tangential radiographs of the lateral and tangential views showed osteophytes at the edge of the patella, roughness and unevenness of the patellofemoral joint surface, sclerosis of the subchondral bone, and narrowing of the patellofemoral joint space.
Routinely ask for medical history, injury history, pain location and nature, and make a preliminary diagnosis of the knee injury. Diagnostic criteria: (1) history of patellofemoral collision or patellar dislocation or subluxation; (2) history of repeated squatting strain on the knee with a clear location of post-patellar pain or special soreness, especially in squatting or going up or down stairs (slope); (3) positive patellofemoral grinding pain, positive single leg semi-squatting pain, positive post-patellar acupressure pain, all three must be present; (4) non-synovial post-patellar grinding sound and (4) non-synovial post-patellar grinding sound and obvious atrophy of the medial head of the quadriceps muscle, where (1) (2) (3) meet the preliminary diagnosis of CP, and (4) especially post-patellar grinding sound can be diagnosed as CP; then use local seal, X-ray and other means for differential diagnosis of suspicious cases.
Prevention
For the exercise therapy of this disease, some scholars believe that the original vertical sports therapy is not in line with the biomechanical point of view, and propose a horizontal paragravity sports therapy; the patient lies on his back, both lower limbs flex the hip and knee, the left and right knee joints upward for extension and flexion activities, taking turns to exchange, just like pedaling a bicycle, also a bit like acrobatic stirrups stirrups, flexion when the heel as close as possible to the hip, straighten when the knee as hard as possible to straighten. The point is that the flexed foot should not be placed on the bed, the right foot should be suspended against the hip when the left knee is extended. Straighten the foot up, thigh force, not forward stirrups (the movement should be slower, it is best to hook the ankle joint upward a little, in the straightening of the lower limbs feel the back side of the pull tighter, there is a sense of soreness and swelling, which is the so-called “sense of getting gas” in Chinese medicine). Each treatment is not based on time but on the number of knee extensions and flexions. The general principle is to go from less to more to ensure quality. At the same time, the number of knee extensions and flexions must be increased day by day during each treatment, and the results will be seen within 1-3 months.
This method has the following advantages: (1) supine bed, no weight-bearing knee joint, pressure is relatively reduced, the muscles and ligaments related to the knee joint in the state of non-weight-bearing for a large range of powerful and safe movement. (2) When the knee is flexed, the lower leg falls in accordance with gravity, the angle of movement is large, and the joint cartilage is relatively evenly stressed. (3) When the knee is straightened, the knee is lifted against gravity, which enhances the muscle strength of the quadriceps, and the strengthening of this muscle has an extremely important role in the knee joint, so elderly patients may wish to try it.
Avoid acute and chronic soft tissue injuries at the knee joint, especially when lifting heavy objects with care and caution. People who work in a semi-squatting position or often bend over and stand up with weight should take care not to work for too long and take a short break after working for a period of time, which can effectively achieve the purpose of preventing patellofemoral cartilage injury. Strengthen the quadriceps strength training, such as static squat (half squat), weighted up, squat; shoulder barbell continuous squat and stand. Pay attention to the correct and reasonable way to exercise. Prevent too much single training and exercise for the knee joint, reduce the time spent in a fixed position for too long, and avoid long runs or long walks in thin-soled shoes on hard surfaces.
Treatment
Early treatment is emphasized. Treatment at an early stage of cartilage injury has the potential to control the progression of the disease and achieve good results. Once the articular cartilage is destroyed and the joint surface is not smooth, the disease will develop rapidly, making it difficult to treat and achieve good results.
In the early stage of articular cartilage degeneration, when the joint surface is still intact and smooth, regular treatment can often achieve satisfactory results. Conservative treatment is suitable for patients with early joint discomfort or pain and no significant changes in the joint space. The most important point at this time is to limit the movement of the knee joint to reduce the pressure on the patellofemoral joint surface, thus blocking the role of mechanical factors that cause cartilage damage, which is conducive to the healing of injured tissue. The specific method is: minimize squatting action, avoid long squatting work. The patella is under the most pressure when squatting. The pressure on the patella when going up the stairs and riding a bicycle is also very large and should be noted. At the same time, pay attention to the combination of movement and static. The quadriceps atrophy will occur when the joint is completely rested, which is not conducive to the nutrition of the articular cartilage. A reasonable method is to actively and slowly extend and flex the knee joint in bed, which can maintain the lubrication and nutrition of the joint surface, enhance the quadriceps muscle strength, and also reduce the pressure on the patellofemoral joint surface.
Treatment for chondromalacia patellae focuses on improving blood flow to the knee and restoring or increasing the stability of the knee joint. The approach can be divided into two areas: one is conservative treatment; the other is surgical treatment. There is evidence that some chondromalacia patellae may heal on their own, so conservative treatment should be the first choice.
Conservative treatment
Psychological treatment: At the beginning of treatment, it should be pointed out that the disease is not serious so that the patient can build up confidence that the disease can improve by reducing the activities that cause pain.
2. Reduce or avoid certain exercises that aggravate the pain: such as repeated kneeling, extreme knee flexion, half-squatting and squatting, and slow knee flexion and extension movements.
For those with milder non-surgical symptoms, avoid direct impact on the patella and reduce patellofemoral friction activities, such as walking up and down hills, stairs, bicycles, etc. Symptoms can be expected to be reduced.
3, quadriceps contraction exercise: very important, because the knee joint damage, often appear affected side of the quadriceps atrophy, which reduces the stability of the knee joint, can aggravate the progress of the disease. For the patella, the medial femoral muscle is even more important, as patellar instability is one of the factors of patellar cartilage softening, so exercise of the quadriceps is an indispensable part of conservative treatment. Patients can take quadriceps isometric contraction exercises at least 15 min/ 4 times a day to improve the control of the quadriceps and its tone. Straight leg raises and kicks to the medial side can also be done to strengthen the medial femoral muscles.
Braking the knee joint for 1 to 2 weeks after the onset of symptoms, along with resistance exercises for the quadriceps, to increase knee stability.
4. Intermittently use an elastic bandage to protect the patella to prevent it from shifting.
5.Take anti-inflammatory and analgesic drugs: such as ibuprofen extended-release capsule 300mg, 3 times/d; or diclofenac sodium 50mg, 3 times/d; anti-inflammatory pain, etc. It is believed that aspirin has a strong anti-inflammatory effect, and after animal experiments, aspirin can accelerate the healing of the incision on the cartilage, therefore, it is advocated to use aspirin for the treatment of chondromalacia patella, on the one hand, it can reduce the synovitis caused by the destruction of articular cartilage when the patellar cartilage is chondromalacia, on the other hand, it is used to reduce the destruction of cartilage, take aspirin 600mg/d for at least 6 weeks.
The anti-inflammatory drug aminoglycoside is applied moderately to both relieve pain and facilitate cartilage repair.
6.Physiotherapy (physical factor treatment): cold compress should be applied when the swelling and pain suddenly increase, and change to wet heat compress and physiotherapy after 48 hours. Low to medium high frequency electrotherapy, magnetic therapy, herbal fumigation of the knee and other methods. Physiotherapy can relieve pain, of which, ion introduction is more effective.
7. Closure or joint cavity injection: If the pain is predominant or limited, local closure, local injection of Chinese herbs, or joint cavity injection treatment can be done. Sodium hyaluronate intra-articular injection is also available, which has the effect of repairing joint cartilage. If the pain is severe, procaine plus prednisolone can be used to close the painful points.
Intra-articular injection of sodium vitreous acid can increase the viscosity and lubrication of joint fluid, which can relieve pain and increase joint mobility.
Although joint cavity closure can relieve symptoms, it is detrimental to cartilage repair and should be used with caution. Intra-articular hormone injection is not recommended because hormones themselves can damage joint cartilage.
Massage and manual therapy.
3.1 Acupressure points: Fu Hare, Calvaria, and Foot San Li.
3.2 The patient lies on his back, the operator presses the lower and middle thighs with both hands and relaxes the quadriceps with the lifting method, and relaxes the lateral calf muscle group with the same method. The operator presses along the periosteum with the small fissure to relax the periosteum tissue, and another heavier technique is used to press the lateral femur. This method has a great effect on reducing knee pain. 3.3 The operator pushes the patella along the edge of the skeleton with the thumb and index finger using scraping method to make its edge buckle; pushing the upper edge of the patella will make its lower edge buckle; pushing the tip of the patella upward with the knee flexed at 15° will make the upper edge of the patella buckle; pushing the outer edge of the skeleton will make the inner edge buckle. In this way, each edge of the patella can be buckled, and in the buckled edge, scraping is used, and in the painful area, aggravated techniques are used, from light to heavy, with strong stimulation techniques, to the extent that the patient can tolerate them. Then the operator used the five fingers to do pinching around the patella. The fingers are inserted as far as possible under the skeleton, and the patella is lifted upward and moved up, down, left and right. This method is the main technique for treating this disease.
3.4 Use the rubbing method around the knee and patella to make the skin red, and pay attention to heat preservation in the knee after surgery to prevent moisture and cold.
The above techniques are used once a day for 15 days as a course of treatment.
Chinese medicine treatment: Yanghe Tang is used as the basic formula with added flavor.
Needle and jar method
Acupuncture points]: Inner and outer knee eyes, crane top, ayurvedic point, calf nose
[Method] After routine disinfection of the local skin on the affected side, use a No. 28 milli-needle, enter the needle and use a flat complementary and flat diarrheal technique, retain the needle for 15~20 minutes, after starting the needle, use the flash fire method to cupping on the small caliber fire can for 15 minutes, after taking the can, routine disinfection and decontamination can be done. Treatment every 1 to 2 days, 15 times for a course of treatment.
Indications】Chondrodysplasia of patella. With this method, 82 cases were observed and treated, 26 cases (32%) were cured, 32 cases (39%) were apparently effective, 21 cases (26%) were improved, and 3 cases (3%) were ineffective.
Source】Chinese Acupuncture 1988;8(6):37 Attachment 1: Knee joint hyperplastic arthritis acupuncture (blood stabbing) cupping method [Acupuncture point] Ah Yes acupuncture point [Operation method] is mostly used at the knee joint rouge fossa, after routine local skin disinfection, percussion around the affected joint, so that the skin is red and slightly bleeding, and then cupping, if a small amount of blood stasis can be extracted, the treatment is more effective.
Indications】Proliferative arthritis of the knee joint (a general term for a series of symptoms caused by proliferation and damage to the cartilage surface of the knee joint due to various causes).
Note】Patients should pay attention to keep warm and avoid excessive weight bearing on the knee joint to avoid aggravating the disease. If the hyperplasia is serious and causes significant knee dysfunction, such as difficulty in flexing the knee, the patient can be treated with acupressure therapy at the same time to improve the efficacy.
Source】Acupuncture and Moxibustion in Chinese Medicine
Attachment 2: Knee synovial bursitis fluid accumulation acupuncture jar method
Acupuncture points】① Blood Sea, Liang Qiu, Fu Hare, Calvaria, Inner Knee Eye, Foot San Li, Yang Ling Quan, San Yin Jiao. ②Lateral upper edge of the patella and lateral femoral recess.
After routine sterilization, use a 28-gauge milli-needle to perform a flat tonic and flat diarrheal technique. Then at the ② group of points, local routine sterilization, the first 28 milli-needle stumbled into the effusion sac, there is a sense of emptiness under the needle, most patients feel a slight tingling, that is, out of the needle cupping on the fire can, 20 minutes after taking the can routine sterilization decontamination treatment can. There is yellow exudate and a little bloody secretion at the needle hole and see the skin purple, are normal phenomenon.
If the symptoms are mild, only the ① group of acupuncture points can be used. If the swelling is severe, the patient can be made to straighten the leg, and at the ② group of points, after disinfection with iodine and deiodination with alcohol, a puncture needle or a No. 7 injection needle is used to pierce the bursa, and the fluid immediately flows outward from the needle, and 100-500 ml of fluid can be pumped. Note that only 2/3 of the fluid can be withdrawn and released, and the remaining part can be absorbed by itself after treatment by this method. The remaining part can be absorbed on its own after treatment.
Indications】Knee synovial bursitis effusion (is in various pathological conditions such as trauma, inflammation, rheumatism, etc. a formation of synovitis of the knee joint. The disease that produces bursal effusion). In 34 cases treated with this method of observation, 27 cases (79.41%) were cured, 4 cases (11.76%) were improved, and 3 cases (8.83%) were ineffective.a The total effective rate reached 91.17%.
The surgical treatment is strictly applicable to those who are ineffective in non-surgical treatment or have congenital malformation.
Surgical objectives.
1.Increase the stability of the patella in the process of joint movement.
2. To scrape away the smaller erosion lesions on the patellofemoral articular cartilage to promote repair.
3, patellofemoral articular cartilage has been completely destroyed with patellar resection method to reduce the development of patellofemoral joint osteoarthropathy, but the postoperative knee joint is obviously weak, difficult to engage in heavy physical labor.
Surgical excision of the diseased cartilage down to the subchondral bone and drilling to improve the blood supply is the commonly used method, but some people also advocate cutting the protruding medial femoral condyle, inward displacement of the patellar tendon stop, release of the lateral quadriceps extension and cutting the protruding patellofemoral articular surface.
If the symptoms do not improve with conservative treatment or if the symptoms are more severe, surgical treatment is feasible, and there are two main types of surgical methods: one is to change the knee extension device and the ordering abnormality of the patellofemoral joint; the other is to treat the diseased cartilage. Etiological treatment is the key to successful surgical treatment. The clinical decision on the surgical procedure should be based on the pathogenic factors and the lesion of the patella.
Surgical treatment should be performed promptly for more severe symptoms, and appropriate treatment should be made according to the lesion of the patella.
1, patellar cartilage cutting includes superficial cartilage cutting, cutting cartilage up to the bone and bone drilling.
(1) Superficial cartilage cutting uses a sharp knife to cut the degenerated cartilage up to the normal part of the cartilage. Although the cartilage repair ability is very weak after superficial cutting, the surface becomes smooth and covered with several layers of flattened cells after several months of shaping by cutting away the eroded cartilage, so that the operation can achieve more satisfactory results.
(2) Cartilage cutting to bone If the cartilage damage has reached the bone, the whole cartilage can be cut and the edges of the wound can be trimmed to make a beveled surface, and the exposed bone is not treated. The full-layer cartilage defect that does not reach the medullary cavity can be slowly regenerated endogenously, and the regenerated cartilage is transparent cartilage.
(3) Cartilage cutting to the bone and drilling to remove the full cartilage layer of the lesion, the exposed bone is drilled with several holes with a Kristen needle to cause bleeding in the bone bed, and the full defect of articular cartilage deep to the medullary cavity can be repaired exogenously by mesenchymal tissue from the medullary cavity.
The above procedure can be done arthroscopically, with planer cutting, or under direct vision with arthrotomy.
2, patellar osteoplasty after cutting away the diseased cartilage, the bone exposed larger (2-3 cm), available adjacent synovial membrane or cutting a layer of fat pad flip suture to cover the exposed bone surface.
In patients with extensive cartilage destruction, the diseased cartilage can be removed and covered with autologous periosteum or fascia, which is expected to regenerate to form a new cartilage surface. This procedure is currently used clinically.
3, patellar resection can be considered if the patient is older, has heavy symptoms, has a large area of exposed bone (more than 3 cm), and the relative femoral ankle cartilage is worn out, so that patellar osteotomy cannot be performed.
If the patella and femoral articular surface are severely damaged, artificial patella replacement or patella resection is feasible.
If the patella is displaced, the lateral joint capsule is contracted or the patella is elevated, the lateral support band can be released, the patellar ligament stop can be internally displaced, and the patellar ligament can be overlappingly sutured. Patellofemoral joint surface cleanup and tibial tuberosity anterior displacement patellofemoral joint decompression can significantly relieve symptoms, but long-term results are uncertain, and the latter has more complications.
Patellar osteotomy is often used as a remedy for the failure of other surgical procedures and for severe chondromalacia of the patella with extensive lesions, but many patients have painful symptoms that do not completely resolve after surgery and have residual dysfunction of the knee extension device.
Artificial patella and patellofemoral surface replacement is suitable for patients with severe damage to the chondral surface of the patella, and has good clinical results in the near and medium term.
Arthroscopic treatment of chondromalacia patellae is a new technique. The arthroscopic procedure, with less injury, better results and faster recovery, allows walking on the 2nd postoperative day, whereas the old arthroscopic procedure requires absolute bed rest for 4 weeks, and postoperative knee adhesions and flexion and extension functions are affected. The arthroscopic treatment of chondromalacia patella consists of 4 steps: irrigation, chipping or planing of the diseased cartilage, lateral release to relieve the lateral pressure overload syndrome, and microscopic drilling.