Chronic Knee Problems

The majority of people do not suffer from one inglorious moment, but rather develop problems over time and then wonder why their knee is so angry. This type of injury is called chronic—it takes a long time to develop, and once it’s around, it’s hard to get it to leave.

Here’s a collection of conditions, a summary of symptoms and treatment, and a look at the general prognosis.

CHONDROMALACIA PATELLA (“Runner's Knee”)

The most common knee complaint is kneecap pain and the most common cause is deterioration of the cartilage on the undersurface of the kneecap. The deterioration is called chondromalacia, the kneecap is the patella, hence the mouthful chondromalacia patella. According to the latest figures (1980), this condition is diagnosed twice as often in women as it is in men; however, in athletes in general, it appears to affect men and women equally. ‘

It is often associated with running and aerobics. Individuals whose feet pronate, or tend to roll toward the inside, are more susceptible to this condition. Dancers and weight lifters are at greater risk due to the number of deep knee bends they perform. Occasionally this condition is caused by some other problem, such as rheumatoid arthritis, recurrent bleeding into the knee, or infection. It may also be associated with long-forgotten knee injury. For example, a severe blow to the kneecap—or several over the course of time—may years later creep up on you as chondromalacia. And if you have ever sustained a knee injury requiring repeated cortisone injections or prolonged immobilization, this, too, may predispose you to this degenerative process.

The onset of chondromalacia patella is insidious, progressing slowly and often involving both knees. The exception, of course, is when it’s associated with injury to just one knee, such as in an automobile accident with the front of the knee striking the dashboard. If you find yourself victim to this disease, it is not to be ignored. Chondromalacia can lead to degenerative arthritis.

Symptoms

Typically this condition affects an otherwise healthy young person between the ages of twelve and thirty-five who complains of a poorly localized, dull aching pain on the front of the knee. The first pain is likely to result from activity such as running or hiking or after prolonged sitting, such as a long car or plane trip. The symptoms can be aggravated by climbing, walking inclines, or running hills. A crackling sound or grating feeling also often accompanies this problem, but itsshould be noted that to at least some degree this particular symptom is common in people over the age of twenty.

When your knee is straightened the kneecap is quite mobile, almost “floating.” However, when your leg is bent (flexed), the patella sits tightly in its groove. If the kneecap starts to soften around the edges, there are nerve endings that can’t take the pressure like they used to and eventually they let you know they are not pleased. So after sitting in one position for a while the classic “theater sign” occurs: Your legs take on a mind of their own and say, “Hey, dummy! Either stand up and stretch or at least grab an aisle seat.” Either way, you’ll take the pressure off your patella and it will feel better.

Treatment

If your complaints are mild, rest and avoidance of those activities that cause pain are best. This means no kneeling, extensive stair climbing, or prolonged sitting. When you do sit, stretch your legs or put your feet up and relax. Aspirin, or some other non-steroidal anti-inflammatory medication, three to four times a day for a couple of weeks may bring some relief. Warm soaks are also recommended.

Braces can be helpful when symptoms are related to specific activities. The best braces for chondromalacia consist of an elastic sleeve with a central opening for the kneecap and a pad that helps hold the patella in place. There are braces that have pads that totally surround the kneecap. These, however, should be avoided since they can actually hold the kneecap down in the flexed position even during activity. If symptoms are severe, crutches can be used until the pain subsides.

Isometric exercises for the quadriceps may also be started, but if they irritate the knee, back off. Don’t quit, just back off. Exercising improves quads strength, which will improve patellar tracking and reduce pain. Although you may worry about exercising while in pain, as long as your leg is straight during exercise, pain should be limited. However, exercises that have the knee going through its full range of motion (isotonic exercises) should be avoided, as should squatting. (You’ll find appropriate progressive resistance exercises
to help you overcome chondromalacia patella in Appendix A.)

If you have chondromalacia, the worst exercises are full deep squats, leg presses, “hack squats,” and lunges. Jumping activities, such as basketball and volleyball, are also not advised. Runners who suffer from chondromalacia need to take it easy during their recovery, but jogging (on flat land) is not considered as stressful as deep squatting or jumping.

If medical management has failed, you may have to consider surgical treatment. There are certain realignment measures that can be done arthroscopically; these will take pressure off of sensitive areas. Arthroscopic shaving is another alternative. In this procedure loose fibers of cartilage are removed, which decreases some of the breakdown products that may cause inflammation. Operative results in general, however, have really been too inconsistent to recommend surgery as an early approach.

So conservative management is preferred. If you can achieve your ideal weight range, avoid activities that involve repetitive squatting or kneeling, and rebuild thigh muscles to normal strength, probably 85 percent of symptoms can be brought under control. That does not mean complete freedom of symptoms, but it does mean results that are as good or even better than currently attainable by surgery.

	CHONDROMALACIA PATELLA	-
Common Name	Who Gets It	Where It Hurts
Runner’s Knee	Runners Aerobic dancers The overweight (may be secondary to subluating patella) May follow traumatic injury ("dasboard knee")	The kneecap
Other Symptoms	What to Do	Often Confused With
All bent-knee activities cause discomfort	Avoid bent-knee activities	Tear of the medial meniscus
Grinding, occasional swelling, sensation   of locking	Strengthening leg muscles is critical
Weakness Knee fatigues quickly	Orthotics may be beneficial. Use cold packs and anti-inflammatory medication.