chondromalacia VS PFJ problem

[angela929]

I would like to ask if there is any differences between them...and is there any special test or observation that I should do in the examination. Any exercise is recommended??!! Thanks X 10000!!!

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[alophysio]

?same same but different?

[matteopeo]

I would say that chondromalacia patellae is one of the PFJ poblems...

Not every PFPS involves a problem in the cartilage, as it may be the case in early maltracking symptoms, or damage to the alar ligaments...

Commonly, rehab strategies will focus on similar aspects though... VMO retraining, ITB-VL release, patella taping, lower limb biomechanical Ax and correction.

Cheers

[alophysio]

Indeed a good answer

[ginger]

The difference is really history , rather than anatomy or physiology. For most of the history of the spectrum of signs and symptoms now known as patellofemoral pain syndrome, (sometimes known as retro petella syndrome, also known as runners knee, jumpers knee, plica, fat pat syndrome and numerous others) this was thought to be a distinct pathology of the patella and associated ligs. As such it was assigned a name indicative of its perceived pathology.
Since the pioneering work of Australian researcher and physiotherapist Jenny MConnell, these signs and symptoms are generally now known to be a non pathological movement issue known as PFPS.
Those who approach the solution to this VMO recruitment problem from a spinal perspective , know this to be a referred event, where altered patterns of recruitment lead to patellar pressures and irritations and other improper biomechanics of the patella.
These are the result of irritations at the L3 facet joint and its' associated spinal nerve root, leading to these altered recruitment patterns , chiefly at VMO.
For the most part , the old tag of Chondromalachia Patella has been superceded by PFPS , though there remains an inclination in some to see this galaxy of eminently treatable problems as mysterious and therefore requiring somewhat more ponderous epithets.

[alophysio]

Indeed Ginger. However, the first step to solving a problem is to describe the signs, symptoms and physical findings.

I appreciate that some problems - certainly a lot more than are given credit for - are referred pain events.

Chondromalacia is simply cartilage pain (in this case retropatella is the most common reason).

But as you rightly point out elsewhere, it doesn't tell you WHY it happened.

But (as i have stated elsewhere), if life were as easy as restoring joint function in the L/S, thousands of intelligent therapists who have come before you will have solved many of life's problems.

Certainty is the enemy of learning...

[ginger]

Alophysio , there are very few real challenges in MSk treatments, I find so very few to be anything other than referred events from spinal joints and associated structures and their nerves. It could be that if this is not so for you, then it may be your method that fails you , As I have pointed out before. Have another look at the CM method , then perhaps , if you have relevant questions and wish to adapt , by all means give me a PM or a call , I'm only to glad to help.
As a busy working private practice owner , there are too few opportunities for me to put my research hat on and perform the hoops and hurdles I would love to be able to . There are , however , thanks to students , the internet and discussions groups I am part of , some means to reach out to guide and possibly inspire. I would feel I had failed my profession were I to keep secrets that are valuable . I'm open to both challenge and discussion .
Cheers

[alophysio]

Thanks Ginger. The following is simply my opinion...

I can appreciate your position. My question to doctors and researchers has always been: 85% of people low back pain at some stage of their lives, some ridiculously high level of them have what is termed "non-specific low back pain" - what is the common thread?

Now i believe that your response would be your referred events from spinal joints, their associated structures and nerves.

Mine would be similar in that it would be spinal dysfunction and loss of motion control.

However, the complicated part of MSK treatments is once we have missed the boat. e.g. (in your terms) an L3 referred event leading to quads dysfunction leading to PFPS undiagnosed by either you or me ( ) which leads to Grade III chondral damage/wear.

Now what? Changing the spinal joints may mitigate the pain temporarily but not necessarily restore normal function to the muscle because it is now inhibited by physical factors and the pain returning.

We can choose denerative events from all joints as examples.

That is where i find the challenge - it is not actually getting them early that is a diagnostic and treatment planning problem, it is getting them LATE where there are now associated physical issues that i can't change that are the problem.

As for contributing to your profession and your lack of time...we all hear you. We are all busy. Being a business owner is more like buying your own job plus that of an accountant and practice manager!

You have mentioned that you teach - this should produce opportunities to hire talented students you could train to replace you. The ideal business model would have you doing minimal work with your employees doing the bulk of it. Read "Rich Dad, Poor Dad" for inspiration...

If you find your patients ONLY want to see YOU, then you need to raise your prices for YOU alone. This makes your employees more attractive to see for simple follow-up.

Lastly, if everything were so simple and easy to treat, you should have a massive patient load, been on TV by now and be internationally touring with courses booked out in advance. You should be rolling in it. You should have lots of physios wanting to work for you. You should have enough turnover to justify a practice manager. This should all lead to more time to share your "secrets" properly in a peer-reviewed process via research. If not you, then you should have sufficiently inspired others with your fantastic results to WANT to do research FOR YOU.

If not, why not?

Also, i have posted questions about spinal innervation elsewhere before

- how do you consider hitting one level will hit the problem level when spinal innervation has been shown to be up to 4 levels superiorly and 4 levels inferiorly (That is, L1/2 can affect up to T9/10 and down to L5/S1)?
- How do you explain that mobilisations at one level cause movements many segments above and below the level "mobilised"?

Personally I have been using spinal treatment for many problems for some time - i don't necessarily do CM - i mobilise (if i choose mobilisation) for as long a joint needs it (which is what i think you do too).

There are plenty of chiropractors and osteopaths who would agree with your reasons as to why events occur (and i agree too to a certain extent) but use manipulation to achieve their results.

But anyway, time is short - if you are truly open to challenge and discussion, please respond to the above points

[ginger]

Thanks for your opinions Alophysio, I've taken a few of your comments to respond to this morning while I have a minute to sit still.

"non-specific low back pain" - what is the common thread?

Protective responses leading to hypomobility of facet joints. This leads to further inflammatory irritations and the cascades towards increased tone and the involvement of more and more of the spine in this response.

"However, the complicated part of MSK treatments is once we have missed the boat. e.g. (in your terms) an L3 referred event leading to quads dysfunction leading to PFPS undiagnosed by either you or me ( ) which leads to Grade III chondral damage/wear. "

Not complicated at all , for the most part the "damage " you refer to is irrelevant . In much the same way as the kinds of degenerative changes seen on x-ray etc in and around spinal joints and adjacenet structures is largely irrelevant. Once normal patterns of recruitment and referred pain and the galaxy of other altered ( referred ) neural events have been turned off , these identified features of the likely interaction of inflammatory chemistry on soft tissues remain , but are rarely the cause of pain. What you are noting are the consequences of dysfunction , rather than cause. A mistake often made by those whose notions of diagnosis are still rooted in the pathology model of MSK diagnosis ( doctors of medicine ).

"Now what? Changing the spinal joints may mitigate the pain temporarily but not necessarily restore normal function to the muscle because it is now inhibited by physical factors and the pain returning."

The purpose and result in dealing with spinal joints is to do what must always be first on the list, restore normal neurology. By doing so it becomes clear , what was local and what was not. In most cases this is all that is required as most MSK conditions not related to trauma ( along with many that are ) are simply referred events . By eliminating these events a lasting restoration to pain free normal function can be achieved in the majority of cases.

"Lastly, if everything were so simple and easy to treat, you should have a massive patient load"

I used to , but I had a year off and now keep a lower profile. There are more things in a balanced life than treating patients . Unfortunately , now that I have returned to private practice , I find the numbers are increasing rapidly again and I have trouble saying no. I don't advertise or accept referrals from doctors, don't see workcover or other compensables. Just cash paying people from all walks of life who manage to hear about me. Many from interstate , some from overseas. My interests vary widely and I do my best to balance them out. There is a lot of joy however , as you would know , in being the person who can fix what others could not.
Cheers

[alophysio]

Thanks for your reply Ginger.

Some replies to your comments above...

Not complicated at all , for the most part the "damage " you refer to is irrelevant . In much the same way as the kinds of degenerative changes seen on x-ray etc in and around spinal joints and adjacenet structures is largely irrelevant. Once normal patterns of recruitment and referred pain and the galaxy of other altered ( referred ) neural events have been turned off , these identified features of the likely interaction of inflammatory chemistry on soft tissues remain , but are rarely the cause of pain. What you are noting are the consequences of dysfunction , rather than cause. A mistake often made by those whose notions of diagnosis are still rooted in the pathology model of MSK diagnosis ( doctors of medicine ).

I would have to disagree with you here. Yes i am noting the consequences of dysfunction however there are signficant changes that can occur which DO alter biomechanics physically as well as being possibly pain producing.

For example, you mention that a lot of degenerative findings on XRay are irrelevant and i agree with you to a certain extent. However if someone has a large bumper osteophyte on their facet joint as a result of poor local control, then that degenerative finding - though not necessarily painful - WILL be significant because it will physically stop the motion at that joint (essentially self fusing). The goes for a degenerated facet joint that is bone on bone. If we had gotten there earlier, then maybe something could have been done but now it is bone on bone what can you do?

The same for cartilage problems in the knee. Grade III problems can have flaps and tears and all sorts of pathology that can mechanically alter function and induce pain.

I used to be more single-minded in my approach similar to you - restore normal spinal joint motion and nerve function and things will settle but i have seen far too many physical problems - we need to get them earlier...

The purpose and result in dealing with spinal joints is to do what must always be first on the list, restore normal neurology. By doing so it becomes clear , what was local and what was not. In most cases this is all that is required as most MSK conditions not related to trauma ( along with many that are ) are simply referred events . By eliminating these events a lasting restoration to pain free normal function can be achieved in the majority of cases.

I agree with you here to a certain extent. I am not sure i am as bold as saying the majority of cases but maybe it is a caseload thing?

I used to , but I had a year off and now keep a lower profile. There are more things in a balanced life than treating patients . Unfortunately , now that I have returned to private practice , I find the numbers are increasing rapidly again and I have trouble saying no. I don't advertise or accept referrals from doctors, don't see workcover or other compensables. Just cash paying people from all walks of life who manage to hear about me. Many from interstate , some from overseas. My interests vary widely and I do my best to balance them out. There is a lot of joy however , as you would know , in being the person who can fix what others could not.

Any good physio worth their salt will have the same patterns. I have no doubt that you are a good physio. In fact, I have been told that there aren't many good manual therapists in the mould of you and i in Melbourne (apparently - Melbourne physios seem to have a good rep for sports but not musculoskeletal / manip physio) so perhaps your patients are just getting good manual therapy!!

Having said that, i have not heard of you before nor have i heard of CM until you posted on this forum. Whereabouts are you (don't mind if you PM me on that ). I have had a lot of trouble finding good physios in melbourne - i only have a couple of names. How are people finding out about you?

Lastly, I would appreciate some comments from you about the some of my other comments earlier posted...
1. Why no research - if it is as fantastic as you claim, then there should be plenty of confidence in the findings and it wouldn't be hard to do - so many existing models we could use. You have plenty of patients to draw on and apparently students who no doubt would be willing to help.
2. Mobilisation - is it hitting the level you want?
3. Spinal innervation - are the levels you believe are the problem REALLY the levels.

Thanks Ginger, always a pleasure to hear your comments

BTW - comments from others welcome too!

[ginger]

"However if someone has a large bumper osteophyte on their facet joint as a result of poor local control, then that degenerative finding - though not necessarily painful - WILL be significant because it will physically stop the motion at that joint (essentially self fusing). "

Interested in why you would believe that osteophytes are the result of poor local control. When they occur they may inhibit the best and speediest effects of mobilisation, by virtue of their interposition where delicate and inflamed tissues occur , in the midst of protective responses, though these responses , are unlikely to be caused by ostephytes. These occasions require more care and sometimes the abandonment of mobs as the means to short circuiting protective events and pain.
I don't agree that osteophtes are likely to physically stop movements , nor are their presence the likely precurser to fusing, rather they are one of the consequences of long periods of inflammatory activity and chemistry at or near facet joints. Their presence, often seen in company with other degenerative events , lipping , fibrous and other exostoses etc are an artifact rather than cause of pain.

"Having said that, i have not heard of you before nor have i heard of CM until you posted on this forum"

I have been writing about CM and publishing on other furums for a few years now. My first introduction of the CM method was during public lectures during the nineties. I still do these lectures and will be speaking and demonstating again at a forum/conference at the end of the year.
Apart from having a string of students and mentees , lecturing at a local uni here in melbourne last year and what other dissemination I can.

Patients hear about me by word of mouth , which suits me, I have a very large network now after twenty two years in practice. My office and practice is kept deliberately small , in south melbourne.

1. Why no research ?
no time , no money, no support.
2. Mobilisation - is it hitting the level you want?
Confused as to the thread of your question here, do you mean am I specific with the location of my thumb and the intention with each joint?, yes. as far as is possible without turning on my x-ray vision.
3. Spinal innervation - are the levels you believe are the problem REALLY the levels.
Sometimes yes sometimes no, I am thorough in my attention to a group of joints , the intention being to not just bring about a speedy resolution to say C5 type shoulder pain , but to also observe the protective behaviour and restore normal pain free movements to as many as three or four adjacent joints/nerves. By doing so I am removing the impetus for a return to protective behaviour within the region of the cervical spine. best results follow a thorough a wide reaching resolution of spinal hypomobility in general , in addition to those known or thought to be involved in the complained of referred event.

[nasde]

Interesting discussion alophysio and ginger!

Just wanted to ask Ginger - I'm quite interested to hear more about this CM type stuff too. What lectures do you do and where did you speak at? Are any of these talks coming up? What university do you lecture at? Is it at physiotherapy conferences that you talk at? Do you teach at a university, lecturing to physiotherapy students?

If you would prefer not to say on the forums as a matter of privacy or whatever, send me a PM.

Thanks

[Dr Damien]

i have nothing to contribute because everything is well said. I particularly like matteopeo's answer. Its all a matter of terminology and anatomy.

[ginger]

nasde and others, I'm not currently taking students from melbourne uni , taking a break from that for the present. I do have an assortment of mentees who spend the odd day and others weeks in my practice rooms with me . The occasions when I have accepted mentees however are fewer these days. My other interests take over somewhat and I now prefer to do lectures and workshops whenever they are arranged , either for me , or by me . Nothing on the horizon at present as I am spending much more time preparing for an exhibition of my other love, painting.
Were you to be in Melbourne at some time ,I'm happy to meet with and discuss Cm .
Just gve me a PM and I will be happy to make a connection.
Cheers