KNEE PAIN IN YOUNG ADULTS - CHONDROMALACIA PATELLA

CHONDROMALACIA PATELLA (ANTERIOR KNEE PAIN)

Introduction:

The most common location of knee pain in young adults is at the front of the knee joint. The problem usually arises from patella (Knee cap bone) and surrounding soft tissue.

Knee cap (Patella) is a small bone which lies in front of lower end of thigh bone (Femur). The back side of knee cap is lined by smooth tissue called cartilage. This covering helps the patella to glide in a groove on the lower end of thigh bone. The knee cap is held on the top by thigh muscles (Quadriceps) and lower part is connected to the shin bone by Patellar tendon. Function of knee cap is to aid knee movement and stabilize knee joint while walking.

Causes:

There are many theories suggesting softening and micro injuries to this lining resulting in pain. It could be due to repetitive micro trauma during falls, or vigorous unaccustomed exercises etc. Abnormal position of knee cap over the knee joint with or without weak ligaments may also damage the cartilage lining. As cartilage lining gets softened and roughened it may cause pain and crepitus (clicks and sounds) over the knee cap. Obesity makes the condition worse.

Complaints:

• Pain in front of knee.
• Pain on climbing up and down the steps or ramps.
• Sudden ‘catch’ over the knee cap while getting up from the ground.
• Dull aching pain after sitting for long time.
• Discomfort during squatting (Using Indian toilet) and sitting cross legged.
• Ocassional clicks and sounds over the knee cap.
• Swelling.

Diagnosis:

Orthopaedician can make diagnosis based on your symptoms and examining the knee. Grating sensation behind knee cap might give us some idea of the roughness of patella when you tighten the knee cap muscles.

Some times there may be a little swelling the joint.

Tests:

Blood tests are normal.

X-rays are not helpful as the problem is with cartilage lining which cannot be seen on X-rays.

MRI (Magnetic resonance Imaging) scans can detect changes in the cartilage, but is used as last resort in unresponsive cases.

 Arthroscopy: It is possible to look inside the knee joint and back of the knee cap with pencil shaped camera (Arthroscope) to confirm the diagnosis. But arthroscopy is not done just for diagnosis and is only done if there is any need for surgery.

Treatment:

This condition generally improves over a period with some changes in the life style. But in some patients, symptoms persist for several years.

Analgesics (Pain Killers): Simple pain killers like Paracetomol and tramadol may be sufficient in most of the cases. Sometimes anti inflammatory medications (NSAIDS) may be necessary for a short period.

Nutritional supplements to cartilage lining like Glucosamine, Chondroitin, MSM and collagen peptides can be taken for 2 to 3 months which may relieve the symptoms.

Injections:

In some unresponsive cases Intra articualr Hyaluronic injections can help. They act by providing lubrication between joint surfaces and help to nourish cartilage lining of knee cap.

Physiotherapy:

Strengthening the anterior thigh muscles (Quadriceps) and muscles around the knee cap (VMO) helps to keep knee cap in right position.    

Surgery:

Surgical management is last resort in severe or unresponsive patients. It can be performed with arthroscope (Key hole surgery). The principle is to smoothen the rough surface of the back of knee cap. In some cases where there are large defects in the cartilage, multiple drill holes into the bone may help regrow some cartilage. Now a days we are combining this procedure with stem cell treatment in selective cases.

Do's & Dont's:

Please avoid any movement or position of which makes you feel the pain. It is better to avoid kneeling, squatting or sitting cross legged. One may go up and down the steps occasionally but avoid repeated stair climbing. Pain may get worse with exercise bicycle and walking on a treadmill with upward gradient (slope).

Arthroscopy (keyhole surgery)

What is Arthroscopy?

Greek word for joints is “Arthros”, and Greek word for looking is “Scope”, so arthroscopy means looking in to the joints. Since this is done through a small cut it is commonly known as a minimally invasive surgery or a key hole surgery. It can be performed on many joints like shoulder, elbow, wrist, hip, knee and ankle joints, though shoulder and knee are the commonest.

Why Arthroscopy?

When investigating the conditions of the joints it is very helpful  to be able to look inside the joint in order to see exactly what is going on in addition to examining the joint from outside. It is done with special equipment. Operative procedures for any abnormalities can be done through a second small cut. It is routinely done as a planned procedure as a day case, but sometimes it is done as a matter of urgency, for example following injury to a joint like a twisted swollen knee joint.

What are the advantages?

a) Small incisions and small scares.

b) Less tissue damage and less chance of infection.

c) Less pain and disability after surgery and patient can return to sedentary work almost immediately and to more vigorous work within 1 to 2 weeks.

d) Better diagnosis of many joint problems.

e) Most procedures can be performed as outpatient basis. If hospitalization is required most procedures need 1-2 days of stay compared to several days of stay with open procedures.

f) Some procedures can be done better with arthroscopic surgery and perhaps for some that is the only way they can be done.

Preparation for surgery

After deciding to proceed with arthroscopy some basic blood tests are done and patient’s fitness is assessed. Like any other surgery patients would be asked not to eat or drink any for at least 6 hours prior to surgery. Patients can watch the surgery if it is done under regional anaesthesia.

 After surgery

Prescription would be given for pain killer tablets and other medicines as necessary. The joint needs to be rested a little for a couple of days but like in case of arthroscopy of the knee joint you can walk to and from the toilet with crutches but to avoid excessive use of the joint. One important aspect is physiotherapy to get full movement in the joint and to strengthen the muscles around the joints. Within the limits of pain these exercises can be started as soon as possible after surgery. The exercises can be carried out many times in a day.  Start with 4-6 repetitions of each exercise, increasing to as many as you feel able to do without getting any pain. When you had any other reconstructive surgery like ligament and meniscal surgery post operative care and advice will be different. Similarly arthroscopy of shoulder would be followed up by specific exercises depending upon the type surgery. You would be asked to visit the hospital after 2 days for a change of dressing.

 Common conditions needing Arthroscopy

Knee Arthroscopy:

A torn meniscus ( to repair or remove), a torn anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL), For removal or biopsy of inflamed or damaged lining of the joint(synovium), Misalignment of the kneecap (patella), Small pieces of broken cartilage and loose bodies in the knee joint, Removal of Baker's cyst(a swelling behind the knee that is filled with fluid), Some fractures of the bones of the knee. Washing the knee which is constantly sore due to arthritis can also be beneficial.

Shoulder Arthroscopy:

Arthroscopy of the shoulder may be recommended for infective arthritis(septic lesions), biceps tear, SLAP lesions, Rotator cuff lesions, impingement syndrome, recurrent dislocation of shoulder and other  instability problems with or without hyper laxity, Frozen shoulder, loose bodies etc. Problems associated with the other joints in shoulder joint complex i.e. subacromial joint, acromio-clavicular joint are also easily examined giving access to rotator cuff lesions, acromion pathology and  clavicular problems.