Delayed knee pain - possible Chondromalacia Patellae

Greetings, I'm welcoming myself to this site :)

Let me go on with my condition:
I am currently 21 years old. I've pretty much been inactive as a kid, not much involved in sports, mainly sitting around all day. A year ago I decided to change that, so I started working out at the gym. First few months were fine. But then issues started arising: I'd do my leg workout pain-free, I'd go home, then 2-3 hours later I'd feel my knee warming up, inflammated if you want. That still applies till today - I never get direct pain while doing leg stuff, it's always delayed.

Same thing kept happening for the next months, without signs of diminishing.
So I decided to visit a doctor about it. Among other things, he tried this:
While I was lying on the bed, he pressed his body against my kneecap, and started drifting it up and down along the leg. It made a cracking sound like it was drifting on rocks (not the cracking sound you'll get once every hours from trapped air in the joints, the constant grinding whenever he moved the patella). By that, I was diagnosed with CP.

So I took up Physiotherapy (September 2009). started with straight leg Terminal Knee Extensions on a hip machine (with as much weight as I could), went on to 30degrees, then 60 degrees, progressing whenever I stopped feeling delayed pain on that specific angle. After 60 degrees, I started doing some leg press (about 2 months ago), and in the meantime I was using some menthol cream. Apparently the cream was hiding pain, because when I stopped using it the pain came back, so I now knew nothing about what the painless angle was. In addition, I started getting some sort of popping on my kneecaps if I bent the knee more than 90 degrees. These are constant poppings, meaning each time I'll bend my knee and flex it back, it'll pop.

I took some x-rays last week which didn't show much (I have it in digital form if it can be helpful), and I'm planning to get an MRI one of the following days.
The doctors, unlike my physiotherapist, are still telling me not to do any sort of quad exercise beyond 30 degrees, which sounds pretty restricting..

I'm not sure if any of the above is helpful, but I could really use some of your expertise to fix this issue. I'm not really concerned about the pain itself (the menthol cream covers most of it, i'm just not using it because I want to judge from pain), I'm more interested in what's causing the pain. It's really been dragging me down both physically and mentally. Thank you for reading.

Chondromalacia patella is an abnormal softening of the cartilage of the patella. However it fits within a larger group problems with the knee cap and is known as patello-femoral syndrome. Chondromalacia patella is an older term and was used in rather a blanket fashion. So even now it sometimes gets overused when you just have signs of patellofemoral syndrome. However you can have all the symptoms with patellofemoral syndrome and not have chondromalacia patella. The physio for either condition is much the same but it may take longer with chondormalacia patella due to the changes in cartilage.

Chondromalacia patella should be diagnosed from loss of cartilage seen on xrays or CT and you need to have a specific sort of xray called a "sunrise view" which it sounds like you have had. Not just based on cracking noises when you passive glide the patella against the femoral bone

in Patellofemoral syndrome, including chondromalacia patella, you may have changes in the way the patella works in the joint such as

• it failing to track correctly in the joint when you move your knee joint with your quadriceps muscle

• small or misshaped patellae

• Increased Q angle

• Weakness of the part of the quariceps on the inner side (vastis medialis obliqus)

• tightening of the tissue ant the front of the join on the outer side (lateral patellar retinaculum)

• Tight/overactive hamstrings muscles.

It sounds to me the physio gave you rational exercise but your physio should also have checked out the above points. The issue with the increase in knee flexion angle while working the quadriceps the greater the force is placed on the joint. The purpose of the exercise is to increase the strength of the quadriceps muscle including and also cause the joint cartilage to remodel in a useful way that will make the joint and cartilage more functional and more healthy.

The exercise has to be balanced and incrementally increased so that on one hand you don't flare up the inflammatory process (most likely reason why you feel the pain and swelling later is stirring up the inflammatory process with the disorder) but on the other hand challenging enough to increase the strength of the muscle and to stimulate remodelling of the cartilage

Gradual increase in the angle while strengthening sounds a good idea. Using the reduction in pain and inflammation later as a marker for increasing the challenge of the exercise sounds good. However there are a few things to consider:

• Ice packs or anti inflammatory gel can help if you apply them immediately after the exercise. Menthol cream may help the pain but isn’t really anti-inflammatory

• Have the knee cap assessed for poor tracking and having the knee taped may sometimes help reduce the abnormal force on the joint while exercising and thereby reduce the pain and inflammation so you can do more. As long as you don’t have any skin problems with sports taping this may be a good point to discuss with your physio

• Closed chain exercises may actually be more effective than open chain exercises. “Closed chain” means the weight is going through the foot as with squats whereas open chain is where the weight is not going through the foot as in leg extension machine. Probably a variety is good but if you are having problems the closed chain variety may be better.

I don’t think there is any golden rule for restricting the joint range for exercising – you should base it on how you go. However you can hit a ceiling where you just can’t increase the range without aggravating the joint and you have tried this gradual increase including trying taping, closed chain exs etc. then you may just have to accept that you can’t do much more. However the remodelling doesn’t happen within a few weeks. You do have to persist for a long time.

Increase in popping on bending may or may not be significant. If it is painful then that is concerning. You may be “overtraining” If not it may be due to changes in the force across the joint and it may settle down more in time. If the cartilage hs really worn away then the cracking can be due to bone rubbing against bone but that sounds unlikely since your xray was good. I would be more guided by getting stronger, able to do more such as squats without causing pain and inflammation than by cracking noises.

Good morning gcoe, your reply was most welcome.
I attached my x-ray for you, which should answer a few questions, but unfortunately I wasn't given the angle you hoped for (found out too late myself), and I was planning on having another x-ray just for it. Also I've shown the x-rays images to other people too and apparently they aren't the best of quality in their digital form, but should be better than nothing.

I consulted another doctor yesterday, he said he could see on the right leg, the bone under the kneecap was visually more worn out than the left leg's.

Now on to other quesions:
Misshapen patella: Can you judge that by the x-ray?
Q-angle: if I just look at my legs, it visually seems as if they do indeed have a Q-angle, but I'm not experienced enough to tell if its just some mass imbalance between my inner-outter thigh. X-ray should be enough to figure that.
Yes, my VMO was weak, at least visually. Now it has somewhat more mass.
Yes, if I go as heavy as I can on leg extensions, my knee actually hurts on the spot. that's why I turned to the closed-chain Terminal knee extention, and I intend to keep it that way :)
Lateral tightness, well, I'm not sure if I did have it, but I purchased a foam roller a week ago and have been rolling my quads/hams/glutes 2-3 times a week. First few time I rolled I would get pain in knees similar to the one I get from actually training. I guess I did hit some trigger points.

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Have the knee cap assessed for poor tracking

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Is there a way to find that out without the skyline(/sunrise) x-ray? Some sort of test? Combined with my visually confusing Q-angle, it almost appears that the patella is tracking outwards, but I can't say I got an experienced eye for this.

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Tight/Overactive Hamstrings

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Hmm, could you explain how that would affect the knee? I do stretch and foam oll the hamstring though, so it should be ok.

Now on to the popping/cracking stuff:
The popping won't hurt me right when it's happening, but if I try and pop 5-6 times consecutively and I stop, I get this numbness in my knee, as if you were pouring menthol in it actually. So its not exactly a direct-pain thing, just about same irritance as the other things I do to my knee.
Now, I wouldn't panic so much about the popping, if it wasn't for the fact that I didn't get it in the past.

Another type of cracking I didn't mention:
Suppose I sit down, straighten my leg to full extension, and keep trying to extend it so my knee is completely locked, and my quad flexed. Now I relax my leg, and as soon as the knee unlocks, there's a cracking sound while the patellae releases. This doesnt happen all the time, but its quite often.
A note: this test doesnt work if I try the same, but closed chained, with my feet on the ground. No cracking whatsoever like that (negative, seems like it does happen with closed chain movement too). It does happen if I walk though, while the foot rolls over and my leg bents to make the next step, i'll feel the cracking. No pain again, and this one doesn't actually give delayed pain either. It's probably a not-much-information case, but I thought I'd explain it in case it helps somewhere.

I'm getting my MRI today (only on the right knee but should be ok, since right one seems slightly more worn out than the left), hoping it completes my knee image and we can sort it out.

One last thing I forgot to write about on my initial post: after exercising the quads I do get this crunching feeling like my patella is rubbing against something.

And a final question. What would you recommend as anti-inflammatory, and what is wrong with inflammation exactly (appart from the painful part)? I guess swelling would be a bad thing, but I don't see it happening in my knee, at least not to a great extent (I do feel sometimes like my knee is thicker or something)

Hi - Glad you found it helpful

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I attached my x-ray for you, which should answer a few questions, but unfortunately I wasn't given the angle you hoped for (found out too late myself), and I was planning on having another x-ray just for it

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Yes the side view gives you some idea but the skyline/sunrise view is much more informative. I am really not an expert on reading xrays but this seems to indicate that you have a reasonable joint space at the PF joints - ie plenty of cartilage there. Of course an xray can't tell you about the quality of the cartilage as the cartilage is invisible on the xray - but you can see whether it is getting thin or not. The skyline view gives an idea of alignment of the patella against the femur. They really should have take this as this is a standard view for patello femoral joint syndrome. The MRI might tell you more.

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Misshapen patella: Can you judge that by the x-ray?

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The patella look ok to me - just based on the xrays. A clinical exam can also gives you info about this but doesn't seem anything grossly wrong

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Q-angle: if I just look at my legs, it visually seems as if they do indeed have a Q-angle, but I'm not experienced enough to tell if its just some mass imbalance between my inner-outter thigh. X-ray should be enough to figure that.

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Q angle is a bit technical but have a look at Figure 2 in this article.
http://www.aafp.org/afp/2003/0901/p907.html

Women generally have a larger normal Q angle than men due to having a wider pelvis. An abnormal Q angle is excessive this is associated with patellofemoral pain. It would be best to get your physio to measure this. I couldn't really work it out from your xray as I would need to see the hip bone.

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Yes, my VMO was weak, at least visually. Now it has somewhat more mass.

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That is good! Well done! the muscle is prone to weakness and seems to get switched off with the pain and inflammation so you should keep the exercises up.

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Lateral tightness, well, I'm not sure if I did have it, but I purchased a foam roller a week ago and have been rolling my quads/hams/glutes 2-3 times a week. First few time I rolled I would get pain in knees similar to the one I get from actually training. I guess I did hit some trigger points.

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. Not sure if this would do the trick. However your physio should have assessed it and can show you how to mobilise the knee cap if need be to stretch the tissue

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I wouldn't panic so much about the popping, if it wasn't for the fact that I didn't get it in the past.

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Yes I can understand you being worried if it wasn't there before and you are getting it now. However as long as the exercise you have done was introduced gradually as it sounds like it was it won't be causing you harm. Audible noises from joints when you have joint problems are quite common. It may be that the patellae are tracking slightly differently since you have been exercising and this is causing them to "rub" differently. If the cartilage isn't as smooth as it should be this could be why and in which case it should get better. As I said, it may just settle down but if you are worried you could always talk to your physio

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after exercising the quads I do get this crunching feeling like my patella is rubbing against something.

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As above. You may find this is just something you have to live with and the more you can improve the strength of the muscles and the quality of the cartilage the better things will get. I would take it as a sign that you are exercising fine but not to do too much more. Give the joints time to adapt to the exercise load.

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Hmm, could you explain how that would affect the knee? I do stretch and foam oll the hamstring though, so it should be ok.

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Not everyone with PF syndrome has this.

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What would you recommend as anti-inflammatory, and what is wrong with inflammation exactly (apart from the painful part)?

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No sorry I am not able to recommend something - it is beyond my legal scope of practice. However your pharmacist or Dr can recommend something. There are a number of gels and creams that in our country we can by over the counter - basically you can buy one with Non-steroidal anti inflammatory drug as the active ingredient. As far as I know they all are about as equally effective. The issue with inflammation is that in the acute situation inflammation is an essential part of the healing process. However chronic inflammation as in the case of joint disease, causes the pain, and in the long run can be harmful to the joint structures. The accompanying swelling is not good for the joint and cause laxity of the joint. It will also keep "switching off" the muscles you are working so hard to build up. So one of key aims of your rehabilitation is to keep the inflammation under control. You want to break the vicious cycle of stressing the knees and getting inflammation which results in decreased function.

Will have a talk with the physio about tissue stretching.
So far though I was only stretching (foam rolling) the muscle sort of (like the IT Band), and stopped 4-5cm's away from the knee. should I get stretching directly around the knee too?

Also, I wanted to ask:
I understand the inflammation can mean a lot of things, but what about that test that they try on my knee

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While I was lying on the bed, he pressed his body against my kneecap, and started drifting it up and down along the leg. It made a cracking sound like it was drifting on rocks (not the cracking sound you'll get once every hours from trapped air in the joints, the constant grinding whenever he moved the patella). By that, I was diagnosed with CP.

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Does this cracking actually mean anything? I don't think this test specifically indicates trackins issues since, well, the quad is inactive and the patella is being driven by the doctor. So does it really indicate something specific? Unfortunately all members of my family have been "diagnosed" with CP, so I haven't had the chance to test it on someone else's knee :p

I am not saying you don't have CP. The cracking noise on passive gliding could inidicate CP but is should be confirmed on imaging. The cracking sound may be softening and abnormalities in the smooth surface of the cartilage of the patellar cartilage but not necessarily. The IT band is continuous with the lateral patellar retinaculum and of course the IT band is continuous with two muscles at it's upper end - the tensor fascia latae and the gluteus maximus. So these muscles, the ITB band itself and the lateral retinaculum are all continuous and one or all structures could be shortened which can contribute to pullling the knee cap to the lateral side and causing tracking problems

I am not really familiar with the foam rolling technique you are talking about. Did your physio give you this to do? I couldn't comment on its effectiveness or where you should be applying it to get the best effect. However if you have any problems with this overall complex of muscles, tendon and fascia it is best if your physio sorts it out for you and gives you specific exercise.

In terms of importance - generally I am of the opinion that the strengthening and training of the VMO muscle and the overall quadriceps muscle is more important Than stretching of tight structures, but that is just an opinion

I just got my MRI results (are the images any use for you?)
The diagnosis was clear. Said there was no signs of patella conditions and the cartillage looked normal.

Now, does that mean I don't have CP or what?

You definitely have the clinical signs of patello-femoral syndrome. Given the good quality of the cartilage you may not meet the diagnostic criteria for CM. Remember with these sorts of things often different sources of info give different impressions

I think this is a good thing, Excili. You may of course have some minor changes that aren't detectable on the MRI but basically it suggests the patellae are in a reasonably robust condition.

Does it affect the treatment? Not really. I would just keep persevering. As I said in an earlier response the only thing to be sure of is if the tracking of the patellae needs addressing. Otherwise carry on the strengthening exs and be patient.

I guess that skyline x-ray could help with the tracking question after all.
I will try get that angle if it helps.

Now, about my eagerness to find out if I got CP or not - well, I just want to rub it in the face of all the doctors that told me I had to stick to straight leg strengthening for the rest of my life. :)

Also, I've been taking a glucosamine/chondroitin/MSM supplement for a month, and I was told it might be causing part of the pain, so I'll stop it since there's no point taking it if I don't have actual knee tissue issues

I think that the popping sound on flexion suggessts that your ITB and Rectus femoris muscles are still very tight. Try doing your lateral releases all the way down the side of your upper leg to the patella and then push your patella in towards the middle. This will only work if you have your leg relaxed out straight whilst sitting.

For the rectus femoris stretching lie prone and bend right knee up as far as you can and use your left leg to gently push the right knee further back into flexion. This may well give you a popping, grinding or pain so if it does try twisting your right foot in or out until you find the most comfortable postion. If you can't do this comfortably then you should be very gentle and perhaps use ice or your cream immediately after.

I wouldnt worry too much about the actual technical diagnosis because physios create the treatment plan based on the signs and symptoms that we find. The only benefit of more investigations would be to to better advise how long the symptoms may take to improve.

It seems as though its already taking a long time so your exercises may not be quite right and need review again by your physio.

I would bias your strengthening for the quads in standing with the 30 deg limit and doing small slow/step ups and downs to improve control rather than just strength. in my experience straight leg raises in sitting or lying are a waste of time.

Good luck and let everyone know how you progress.

I got my MRI results a few days ago.
Diagnosis was pretty clear, nothing wrong found in it.

I had a look at the pics and found some angle that should work similar to skyline x-ray view, so I'll attach them in case they are of any use.

So, on to the clean diagnosis, does it mean CP isn't there, or could it mean it's just not a severe form of it (considering i'm only 21 years old) so it can't be seen in the MRI?

As a side note, I'm still getting minor annoyance on the outter part of the knee after I foam roll my IT band, even if I didn't do any quad movement previously :(
When I checked with my pt about it, he told me I should give it 2 weeks and see if the pain persists, and that the first few times I foam roll a tight muscle it might give pain signals to the knee or something like that. I will be visiting my PT this week hopefully, and ask him about the tissue stretching etc.

Anyways, here's 5 pics from the MRI, tell me if it helps addressing the patella position question.(also tell me if you have any use for the rest pics of the mri)

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So, on to the clean diagnosis, does it mean CP isn't there, or could it mean it's just not a severe form of it (considering i'm only 21 years old) so it can't be seen in the MRI

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So I am not an expert image reader. I would go by the radiologist's report. However superficially it looks like the patello-femoral cartilage surfaces are well preserved and the alignment looks ok.

From the report you got this would suggest you don't have CP. Yes it is possible there could be some minor changes not detectable on the MRI. But even if this is so it is nothing to worry about.

In most musculoskeletal conditions, there is more often than not not a hazy association between the severity of radiological evidence and severity of symptoms. You may just have had a lot of symptoms without much underlying radiological evidence. I wouldn't worry about it - as long as you are getting at least some marked improvement by now, even if there is a way to go with the PT.