This is Darla's Chondromalacia report, written entirely in Darla-speak. A printer-friendly version is available.
I. Disclaimer!
I'm not a doctor. (I don't even play one on T.V.) I'm a 37-year-old woman
suffering from chondromalacia patella, an obstinate desire to keep playing
competitive volleyball, and possibly even a mid-life crisis. Consult your
doctor or sports medicine specialist if you are suffering from knee pain. (Update 18-Feb-2002: I find it terribly ironic that I've been sidelined from volleyball since late 1999 for torn wrist ligaments that could only be partially repaired by surgery. Creaking around on bad knees is one thing; doing without the use of one hand is another! Until technology gives me a fully-repaired wrist, I'll be watching my daughter, the Wild Child, a chip off the amazon block, slam volleyballs down short chicks' throats, instead of playing myself. She even stuffs those silly hitters who try to dink over her--just like Mama! :-D That's my baby! PS: I'm now almost 40! Egads!)
II. Definitions
- articular cartilage
- Articular cartilage is the flexible connecting tissue in a joint. Articular
patellar cartilage is located on the underside of the patella.
- chondromalacia patella (KON-droh-ma-LAY-she-ah pah-TEL-ah)
- Chondromalacia patella is a degenerative disorder of the articular cartilage
lining the undersurface of the patella, in which the cartilage softens and
wears away.
- osteoarthritis
- Osteoarthritis, generally considered to be the most common form of arthritis,
is a disease in which articular cartilage degenerates. The term osteoarthritis is typically used to describe chondromalacia patella in those over 30 years of age.
- patella
- Patella is just a fancy name for kneecap.
- vastus medialis
- The vastus medialis muscle is located on the inner side of the thigh,
almost above the patella.
III. Diagnosing Chondromalacia
Chondromalacia generally starts out as a vague pain during or after exercising.
In my case, it began that way, then became worse so that I experienced pain
during warm-up. Finally, it progressed to the point where I now can't sit
for long periods of time with my knee bent due to pain and discomfort.
The pain, in my case, is located directly under the patella. I can reproduce
the pain at will. The easiest way to produce quite a bit of pain is to stand
up and pause while my knees are flexed, forming a 135 degree angle at the
back of the knee. Standing up without pausing produces discomfort, but it
usually doesn't produce severe pain.
IV. Causes of Chondromalacia
Chondromalacia patella is generally caused by overuse of a knee with improper
patellar alignment (as in my case). The patella is not tracking along its
intended groove and rubs against the end of the femur (thigh bone). I believe
this is called patellar subluxation, or partial dislocation of the patella.
After rubbing against the thigh bone for a period of time (I have no idea
how long--probably years), the articular patellar cartiliage begins to wear
away. If you're unlucky to progress as far as I, the cartilage will actually
be entirely worn away in places, leaving subchondral bone exposed.
One of the most common causes of patellar subluxation is inadequate vastus
medialis strength.
Other less likely causes of chondromalacia are gena valgum (being "knock-kneed"),
foot pronation (corrected by orthotics), and trauma to the patella.
V. Treatment of Chondromalacia
If you have worn away cartilage, there is no cure, but there are many things you can do to live with chondromalacia and minimize the pain. My plan is to do my best to live with chondromalacia, and stall the inevitable knee replacement(s) for another 10 years. By then, I hope some promising technological advances will make it possible for my missing knee cartilage to be replaced, instead of requiring full knee replacement.
A. Avoid Hard Surfaces
One of the easiest things to do to minimize pain is to avoid exercising
on hard surfaces. I had been playing outdoor volleyball on asphalt, until I finally
figured out the pain was much worse there than playing inside on a wood
floor. Playing volleyball on one of the those indoor rubber floors is great!
B. Strengthen Vastus Medialis
A very important part in reducing pain and discomfort is to strengthen the
vastus medialis muscle.
1) Isometric Exercises
Doctors normally recommend isometric exercises for the quadriceps--tighten
then release the quadriceps muscles while holding the leg straight. These
may work well for people who were not muscularly strong to begin with, but
they did not work well for me. I've found that leg extensions and leg presses,
using a limited range of motion, work best for me.
2) Leg Extensions and Presses with Limited Range of Motion
I pull the leg extension attachment up with my arms, then lower the weight
onto one fully extended leg. I slowly lower the leg to just before the point
of pain, then slowly raise it again. I do this until muscle exhaustion,
then I switch legs. I normally lift about 35 pounds (free weights) with
one leg for 15 to 20 reps three times. Your mileage may vary.
I use the leg press machine in a similar fashion. Push the chair up close,
tuck your knees up to your chest, and push the weight until just before
the point of pain. Then adjust the setting on the chair so your legs are
just 30 - 45 degrees short of straight. Push the weights from just after
the point of pain to almost straight. (I use heavy weights and work one
leg at a time for this part. I try to do two sets of 15 - 20.)
C. Treating with Pain Medication
If your doctor is like mine, he won't give you any good pain medication.
In my case, he feels I should give up volleyball because otherwise I'll
be enjoying middle age from a wheelchair. With cancer, heart disease, and
stroke running rampant in my family, I'm not planning on living to be too
terribly old. Anyway, I could get hit by a bus tomorrow, for all I know.
I live for today, enjoying myself while I can. When it gets too bad, I've
got my eye on one of those designer black wheelchairs. (I'll spend my days
cruisin' the net!)
For single volleyball matches, I normally take two to three 200mg ibuprofen
caplets after the match. For an all-day tourney, I start three hours before
the first match by gobbling down three caplets. I take two more each hour
until I've taken ten to twelve. (Warning! The bottle says to take no more
than six during a 24-hour period! Check with your doctor before trying my
dosage!) This will usually get me through the day without getting weak or
nauseous from pain, although it in no way eliminates the pain.
NOTE: I've read somewhere that acetominophen (Tylenol) is just as effective as ibuprofen for chondromalacia sufferers, but it does not work for me. Your mileage may vary.
D. Surgical Treatment
1) Lateral Retinacular Release
In severe cases, your doctor may recommend a lateral retinacular release.
This involves cutting partially through a tendon on the outer side of the
patella, to improve patellar tracking. Arthroscopy is used.
I've had this surgery (March '92, I think), but I can't say that it's
done me much good. I did get some really good pictures of my worn away cartilage,
in living color.
I was on crutches for three days. Recovery took several months, and I ended
up missing most of the spring USVBA season. (The doctor told me recovery
was four to six weeks.)
2) Cartilage Grafts
Once your cartilage is gone, most experts agree that it won't regenerate.
Some experimentation is going on with cartilage grafting. However, these grafts seem to be better suited to missing cartilage on the tibia or fibula, not the patella.
E. Treating with Chondroitin Sulfate/Glucosamine
THE ARTHRITIS CURE (a book by Jason Theodosakis) tells of a new medical miracle for arthritis suffers: chondroitin sulfate and glucosamine. Normally used to treat arthritis in dogs and horses, this over-the-counter drug combo is gaining popularity as an arthritis treament for humans.
I tried taking three tablets (Osteo-Bioflex brand) twice per day for about four months, and had no change in my condition (other than my wallet being lightened a bit). As always, your mileage may vary.
F. Treating with Cho-Pat Braces
Originally made for "runner's knee," I've found that these simple braces provide more relief for me than a truckload of painkillers. It's a simple strap, secured with velcro, that you wear right below the kneecap.
I was just getting ready to hang up my kneepads, when I decided to give this a try. I was amazed at how much pain relief they provided. I guess what that tells me is that my kneecaps work a lot better when they're forced to track properly.
I did have trouble keeping the straps on both knees in place. (They would fall down my sweaty legs after every jump or two.) So, I just secured them in place with athletic tape, winding another strip around every time the last strip I put in place worked loose. (Here's a picture of a Cho-Pat strap.)
Here is a page of numerous knee braces, including some that may stay up better than the Cho-Pats. (Thanks, Kurt!)
Update 18-Feb-2002: A few months ago, I got a call from the President and inventor of the Cho-Pat brace, George Gauvry. He told me the problem I have keeping the strap up could be because I don't have my knee bent when putting the strap on. I still didn't have much success keeping it in place, and the McDavid strap seems to work best for me, BUT a friend from church pointed out something very obvious that I had overlooked--if you're a man with hairy legs, you really don't want a rubber-backed McDavid strap ripping your hair off. He said prefers the Cho-Pats since there is no rubber.
G. Complete HEALING with Salubria????
(Thanks to loyal reader, Ron, for pointing out this article!)
A research scientist at Georgia Tech has recently developed a cartilage replacement called "Salubria." Initial lab testing is complete, and approval from FDA is being sought (which may take five to seven years). See this article for more info.
I sent Dr. Ku an email asking if Salubria would work as an articular patellar cartilage replacement, and he said, "Yes!!" (He also said he uses a Macintosh! Cool!) He has begun a company to test and market Salubria, SaluMedica (formerly called "Restore Therapeutics"). Visit the SaluMedica website for some articles about Salubria.
VI. Summary
There's nothing fun about chondromalacia patella. It's normally caused by
improper tracking of the patella along its groove, which in turn is usually
caused by a weak vastus medialis muscle.
Once chondromalacia is diagnosed, your doctor will likely prescribe isometric
exersices for your quadriceps as a means of strengthening the vastus medialis.
I prefer leg extensions and presses with a limited range of motion.
Acetominophen, ibuprofen, or aspirin may help alleviate swelling and pain. Check with your doctor. I find the best pain relief comes from using Cho-Pat braces. Your mileage may vary.
A lateral retinacular release may be indicated for severe cases, but the
effectiveness is questionable. Experiments in cartilage grafting are going
on now, as well as some research on a substance called Salubria, a cartilage replacement biomaterial.
VII. Bibliography
Cailliet, Rene, M.D., Knee Pain and Disability, Edition 3, F.A.
Davis and Company (Philadelphia), 1992.
Garrick, James G., M.D., "Anterior Knee Pain (Chondromalacia Patellae),"
The Physician and Sports Medicine, Vol. 17, .No. 1, January 1989.
