I saw a physical therapy patient this week with a chronic knee injury. His knee was swollen and stiff, much more than normal. I know his knee well and it typically has only mild swelling with good muscle tone. His diagnosis is Grade 1 chondromalacia or irritation behind his kneecap. It’s an issue which most of us, myself included, over 30 years old commonly have behind our patella or kneecaps.
Puzzled with how his knee looked, I asked: “What have you done to make your knee so cranky?” “Nothing different Doc,” the 42 year old cross-trainer said frustratingly, “Same damn workouts I’ve done for the past 6-7 weeks.”
Here comes my big question: “What did you do after your workouts in regards to cooling down, rollers, stretching and ice?”
There it is….the look of a cow looking at a new fence post!
The answer was clear even before he embarrassingly replied: “I didn’t do anything…I didn’t have time.” It’s a lame excuse and a common practice for athletes of all ages. It’s my mission with MikeRyanSportsMedicine.com to change that mindset and behavior.
The Truth about Joint Swelling
There are many sources of joint swelling or effusion. The extra fluid inside a joint can come from the inner lining of the joint, the bone itself or from an infection.
It’s much easier and less painful to keep swelling out of a joint than it is to get the swelling out of a swollen joint.
The important part to note here is to minimize the reason for the swelling instead of trying to convince your body to reabsorb the fluids after they have filled the joint. I think of process as similar to a flooded bathroom: fixing the leaky pipe under the sink is a much easier solution than mopping up 20 gallons of water covering the floor and soaked under the cabinets.
Tips to Control Joint Effusion
Roll – using a roller on your muscles before and after a workout is a simple relax muscles and to allow your joints to move normally and to do their job.
Stretch – Five minutes of lengthening muscles and fascia before and after a workout improves blood flow and promotes the drainage of waste products from your hard-working muscles.
Ice – Ice is your best friend so start spending more time with it. If a joint or soft tissue is either overly warm, red in color or sore after a workout, ice it for 10-15 minutes. Ice quickly decreases the metabolism or joint activity while also decreasing pain. Both are important.
Posture – As most of us do after our workouts, sitting in a car or at a desk for prolonged periods of time is not good for our spine or joints. Sitting shortens some of our major muscle groups like our hip flexors and chest muscles. If you have to sit after a workout, make a point to do some of the following:
Use perfect spine posture
Consistently engage your core muscles
Kneel on one knee every 20-30 minutes
Sit on a large therapy ball instead of a chair
Get up every 20-30 minutes to stretch hamstrings, hip flexors and chest muscles
These are simple steps which don’t require much time or effort. Keeping our bodies healthy is important for many reasons. Controlling inflammation and swelling should be a top priority for athletes with the common bumps & bruises and wear & tear that comes along with aging and the sports we love.
Chondromalacia, known as “Runner’s Knee”, is one of the most common sources of knee pain for athletes over 20 years old. The patella injury involves the patellofemoral joint, where the patella (kneecap) and the femur (thigh bone) interact.
Chondromalacia is the pathology that takes place when the articular cartilage on the back of the kneecap becomes irregular and damaged. Because the back of the patella is now not the smooth and firm surface it usually is, it can damage the distal femur articular cartilage surface. Much like a damaged pulley, the stresses that are placed on the moving surfaces being loaded become a source of patella pain.
Healthy articulating surfaces in the human body, including the patellofemoral joint, have 3 times less resistance than a wet ice cube on ice! Think about that for a minute. This simple yet amazingly efficient system of transferring forces over joint surfaces allows 400 pound men to run and jump with minimal damage to the joint…..until that articular cartilage becomes damaged.
The back of the patella has a medial (inner) facet and the lateral (outer) facet that both come into contact with the medial and lateral condyles on the distal femur bone.
What Happens When You Have Chondromalacia
In between the two facets is the intrafacet ridge which glides in the trohclea groove located between the medial and lateral condyles of the femur or thigh bone. Patella injury can result in damage to any combination of these articular contacts or the patella tendon itself.
With activity, the patella may not glide or track in the proper manner with knee flexion and extension. With abnormal motion, damage to the surrounding tissues and/or the cartilage on the underside of the patella or distal thigh bone can take place.
The vastus medialis muscle, the most distal and medial of the quad muscles, will usually become weak with any patella injury. With this inner quad weakness and resulting tightening of the outer knee structures, the patella tends to shift too far laterally or to the outside.
Younger Athletes and Osgood Schlatters
With younger athletes who have not physically matured enough to close their growth plates, they are susceptible to Osgood Schlatter disease. Osgood Schlatters is a condition where the insertion of the distal patella tendon is elevated. It significantly changes the tracking and movements of the kneecap. Because of the alterations with the wear patterns of the backside of the patella, excessive articular cartilage damage occurs and patella tendon quickly becomes symptomatic.
Signs and Symptoms of Patellofemoral Pain Syndrome
A visible (atrophy) and functional quadriceps weakness when compared bilateral.
May have discomfort/pain in the anywhere around the patella with prolonged sitting and activities involving resistive knee extension such as running and jumping.
May have a history of Osgood Schlatters disease or patella injury.
Swelling sometimes occurs after activity.
A palpable grinding/clicking sensation from behind the kneecap with leg extension that may or may not be accompanied by pain.
A Q-angle greater than 20 degrees.
Professional Treatment for Chondromalacia & Osgood Schlatters
A product like the Trigger Point Quadballer is a great therapy option to relax the quad and increase the knee range of motion
Biomechanical analysis to assess the lower extremities bilaterally to determine if there are specific mechanical issues that are contributing to the Chondromalacia. Common factors are:
Leg length discrepancy
Excessive pronation or supination
Weak abdominal musculature
Consistent use of rollers and massage to the entire thigh area including the lateral thigh, groin and hamstring muscles.
Implementing aggressive quad strengthening exercises that are pain-free with minimal patella crackling or noise present. To accomplish this, the types of exercises, the specific range of motion and the amount of resistance must be closely monitored to safely improve strength without increasing the symptoms.
Full flexibility of the lower extremity and low back. The hip flexors, the IT band, the calves and, believe it or not, the big toe are the most overlooked areas for athletes who are not successful in overcoming this patella injury.
Warming up the knees are often overlooked but it is priceless with this injury.
Aggressive manual therapy and modalities to decrease the pain while increasing the mobility of the soft tissue associated with the patella.
Ice, ice, ice….immediately after any activity.
Questions a Pro Athlete Would Ask about Chondromalacia
To ensure you are treated like a smart professional athlete with a patella injury or Chondromalacia who wants to safely return to his/her sport, you’ll want to ask your sports medicine specialist the following questions:
Are you certain of the diagnosis?
Do I need any other tests to determine the extent of this injury?
How badly damaged is the cartilage on the back of my kneecap and are there any activities that I need to avoid as I rehab this injury?
What are my options with treating this injury?
What factors do you consider to be the main reasons for my injury and, more importantly, need to be addressed with my rehab?
Who do you consider to be the expert patella rehab specialist in this area?
Do you have a detailed rehabilitation protocol to direct my rehab for both my therapist and me?
Tips To Help You Heal And Reduce Knee Pain
Be Farsighted – Chondromalacia is often the result of a biomechanical problem that needs to be corrected. Look above, below, behind and in front of the kneecap to find the source(s) for the pain..
Change Now & Stay the Course – Most factors for patella injuries don’t just go away. Plan on finding the problem, making the necessary changes and then maintain those changes for the long haul.
Be Honest With Yourself – Look closely at your workouts for the past 3 months and ask: “Did I change too much too soon?” Increasing the workload too fast is a common problem with athletes suffering from acute patella injuries.
Ice is Your Friend – Here we go again…….Ice hurts but it’s exactly what you need for this injury. The Pro’s will tell you that ice is their best teammate. You’ve heard me say this many times throughout MRF, however I can’t stress the importance enough. You need ICE and lots of it. Also, if you have a child with Osgood Schlatters, make sure he/she is icing properly.
Father Time Has a Bum Knee – As we age our flexibility naturally decreases unless we work at it. Consistently maintaining out flexibility is the key while joining a yoga or Pilates class is the ideal solution. Start stretching NOW and take a lot of stress off your knees, patellas and low back so you can make this patella pain a thing of the past.