Universidad de Sta.

Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

PRELIM REQUIREMENT
LEG AND ANKLE ORTHOPAEDIC CONDITIONS

Sinding-Larsen-Johansson Syndrome

I. Definition
 Sinding Larsen Johansson syndrome aka ‘Distal Patella Apophysitis’ is an inflammation of the
bone at the bottom of the patella/kneecap (patellar tendinopathy), at the proximal attachment of
the patellar tendon, particularly the growth plate/apophysis, where the tendon from the shin
bone (tibia) attaches. It is an overuse knee injury rather than a traumatic injury. It is a juvenile
osteochondrosis that disturbs the patella tendon attachment to the inferior pole of the patella.
 This condition was described independently by Sinding-Larsen in 1921 and Johansson in 1922.
Following a strain or partial rupture of the patellar ligament, the patient (usually a young athletic
individual) develops a traction ‘tendinitis’ characterised by pain and point tenderness at the
lower pole of the patella.
 Sometimes, if the condition does not settle, calcification appears in the ligament (Medlar and
Lyne, 1978).
 CT or ultrasonography may reveal the abnormal area in the ligament. A similar disorder has been
described at the proximal pole of the patella.
 The condition is comparable to Osgood-Schlatter’s disease and usually recovers spontaneously.
If rest fails to provide relief, the abnormal area is removed and the paratenon stripped (King et
al., 1990; Khan et al., 1998).

II. Related Anatomy

 The Sinding-Larsen Johansson Syndrome is a rupture or avulsion of the patellar ligament at the
distal point of the patella caused by traction.
 The patellar ligament/tendon - distal part of the tendon of the M. Rectus Femoris, part of
the quadriceps femoris which is a continuation of it.
 It goes over the patella and is attached to the tibial tuberosity. Its other attachment is the spina
iliaca anterior inferior.
 superficial fibers originate from the rectus femoris, the deepest layer from the vastus intermedius
and the intermediate layer from the vastus lateralis and vastus medialis.

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College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

 The syndrome may lead to tendinitis, which is an inflammation of the tendon, and calcification in
the ligament. This means that calcium deposits in the substance of the tendon. The presence of
such can cause an increase in rupture rate, slower recovery times and a higher frequency of
complications after surgery.

III. Pathophysiology
 Osteochondroses all involve a defect in ossification. The mechanism in Sinding-Larsen Johansson
disease is thought to be persistent repetitive traction by the patella tendon on the lower pole of
the patella. It is essentially a chronic stress injury with overuse of the patella-patellar tendon
junction. Similar symptoms have been reported to occur proximally, at the junction of the
quadriceps tendon and the patella. At the distal end of the patellar tendon, Osgood-Schlatter
disease may produce similar exercise-related pain.

IV. Etiology
 (1991 and 1992) Sinding-Larsen and Johansson respectively and independently described a
syndrome, in the adolescent consisting of tenderness at the inferior pole of the patella
accompanied by radiographic evidence of fragmentation of the pole. This is the Sinding-Larsen-
Johansson disease (SLJD), and has been used as an umbrella term for the syndrome that causes
pain of the inferior pole of the patella accompanied by fragmentation of the pole or a calcification
at the pole.
 mostly caused by repeated microtrauma
 affects children and adolescents between 10-15 y/o
 athletes
 can also affect active adults who run for moderate to long distances or are involved in sports that
require much jumping or squatting
 The diagnosis of SLJ can be difficult to make, it is used as a general term for all pain conditions at
the pole of the patella but its etiology is not clear.

RISK FACTORS:
 Repetitive running and jumping activities
 Increase in training (for example, in the beginning of the season, summer camp, increased
running mileage, overlapping sport seasons)
 Sport specialization - Doing the same sport year round without adequate breaks places stress on
the same areas of the body
 Fall on the front of the knee
 Improper training technique, including poor form for conditioning, running, and/ or jumping.
 Improper foot wear
 Muscle tightness in the leg
 Weak hip or core muscles

V. Clinical Manifestation
S/Sy:
 Localised pain, swelling or tenderness felt at the front of the knee - base of the patella
 Increasing pain during or after physical activity
 Pain is relieved with rest
 Tenderness to touch around the inferior portion of the knee cap

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 Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

 Limping
 Osseous fragmentation of the distal patellar pole

Medlar identified four radiographic stages of the disease process:

 STAGE 1, normal findings
 STAGE 2, irregular calcifications at the inferior pole of the patella
 STAGE 3, coalescence of the calcification
 STAGE 4A, incorporation of the calcification into the patella to yield a normal radiographic
configuration of the area
 STAGE 4B, a coalesced calcification mass separated from the patella.

VI. Diagnostic Studies

 Knee X-ray: may be normal but can show calcification in the patellar tendon at the lower pole of
the patella. This heals leaving an elongation of the patella that is often found in footballers.
 Ultrasound is the examination of choice when imaging is required. It can depict all manifestations
of the syndrome, including swelling of the cartilage, tendon thickening, fragmentation of the
lower pole of the patella and bursitis.
 MRI scan may show bone marrow oedema in the patella.
 To confirm SLJ, arthroscopic excision (an orthopedic surgeon uses anarthroscope, a fiber-
optic instrument, to see the inside of a joint) of the distal pole of the patella is an effective
procedure to check the tendon.
 The physiotherapist performs a physical examination of the knee and reviews the patient’s
symptoms.
 Tests for ant. knee pain (supine):
1) Patellar Grind Test: Tester places thumb web-space just above the patella, then asks to contract
their quad forcefully. The test is positive if there is pain or grinding
2) Compression Test: Hard downward pressure is applied with rotation, pain indicates meniscal
injury
3) Extension Resistance Test: patient performs an extension of the knee joint, while exercising
pressure in the opposite direction (flexion), positive when the affected knee shows less power to
hold the pressure hence, extensor mechanism of the knee is disturbed

VII. Treatment
 Rest from activities which increase pain.
 Activities which place stress on the patella such as squatting, jumping and hopping should be
avoided.
 Cold therapy is beneficial in reducing pain and inflammation.
 Light exercises to stretch the quad help in quad strengthening, but they should be pain-free.
 Sports massage can be done to quads to increase flexibility.
 Sports massage to tendon helps in blood flow. It also breaks down the adhesions.
 Patellar knee brace or taping also helps in pain relief and load reduction.
 Operative: debridement of damaged tissue/stimulation of healing response, in some cases
refractory to nonoperative treatment

VIII. Physical Therapy Management

Physiotherapy assessment and treatment is a proven benefit for Sinding-Larsen-Johansson
syndrome sufferers. Left untreated most patients will fully resolve their symptoms within 3 to 18

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Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

months (Duri et al 2002). With the good management, most athletes will be able to return to their
sport within 6 to 14 weeks (Iwamoto et al 2009).

Phase 1 - Knee Load Management

 Immediate restriction of high impact activities (e.g. jumping, running)
 Low impact activities eg. cycling, cross-trainer, water running or swimming are usually fine.
 Infrapatellar knee strap to dissipate forces away from the site of Sinding-Larsen-Johansson
syndrome (Duri et al 2002)
 Kinesiology taping: for pain relief and load reduction at the site of pain and injury.
 Crutches: for rare cases
Phase 2 - Anti-inflammatory Treatment
 Ice & Electrotherapy: for reduction of pain and improvement of healing rate. This usually hastens
the recovery rate of sufferers. Ice is useful at home or after exercise. (Michlovitz et al 2007)
Phase 3 - Functional Training
 Rest is also important in the management of Sinding-Larsen-Johansson syndrome and relief of
pain. Whether or not you should continue playing sport is dependent on symptoms. Patients with
mild symptoms may be able to continue to play some or all sport. Others may choose to modify
their program. In mild cases, it may enough to just limit your physical activity so that the post-
exercise pain is only mild and lasts for maximum of 24-hrs. When symptoms become worse it
may be necessary to take a short break from your aggravating sports.
Phase 4 - Therapeutic Exercises
 Stretching, Massage & Foam Rollers: One of the common reasons for developing Sinding-Larsen-
Johansson syndrome is excessively tight quadriceps muscles, ITB, hamstrings, hip flexors and calf
muscles. (Iwamoto et al 2009).
 Massage and foam rollers are beneficial especially in the early phase when stretches create pain
at the Sinding-Larsen-Johansson syndrome site.
 Strengthening: Your muscle control around the knee will usually need to be addressed to control
or maintain your symptoms during the active phase of Sinding-Larsen-Johansson syndrome. Your
physiotherapist will commonly prescribe or modify exercises for your quadriceps, hamstrings,
calves, foot arch and gluteal (buttock) muscles. (Franchesci et al 2007)
 Foot Arch Control & Orthotics: Your foot biomechanics or arch control may be inadequate for
your intensity of sport. Your physiotherapist can assist both the assessment and corrective
exercises for your dynamic foot control. Active Foot Correction Exercises can be beneficial as
both a preventative and corrective strategy: Occasionally, your foot biomechanics may be
predisposing you to torsional stresses that can cause abnormal knee forces, which can cause knee
injury. In these instances, foot orthotics may need to be prescribed. There are mixed views on
how effective these are, since the foot structure is rapidly changing at this age.

IX. Differential Diagnosis

 Patella sleeve fractures - represent chondral or osteochondral avulsion injury at the inferior pole
of the patella.
 Patella stress fracture - break in the patella, or kneecap due to trauma
 Bipartite patella - congenital condition (present at birth) that occurs when the patella (kneecap)
is made of two bones instead of a single bone.
 Osgood-Schlatter disease – inferior attachment of the patellar tendon into the tibial tuberosity
 Jumper’s knee – same location and similar pathology, but seen in adults.

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Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

 Infrapatellar bursitis - inflammation of one or both of the infrapatellar bursa, which are located
just below the kneecap characterized by pain and swelling

X. Related Terms
 Apophysitis - inflammation of an apophysis, secondary to trauma-induced bone microfractures
characteristically of immature bone (i.e. bone whose epiphyses have not undergone ossification),
where muscle contraction force at the point of tendon insertion causes detachment of the centre
of ossification from the parent bone
 Calcification - the deposit of calcium salts in a tissue
 Ossification - the process of creating bone, that is of transforming cartilage (or fibrous tissue) into
bone
 Osseous fragmentation – breakage of bone into small pieces
 Paratenon - the areolar tissue filling the space between a tendon and its sheath
 Patellofemoral Pain Syndrome - condition characterized by knee pain ranging from severe to mild
discomfort seemingly originating from the contact of the posterior surface of the patella with the
femur

XI. References
Apley’s System of Orthopaedics and Fractures, 9th Edition, “PATELLAR ‘TENDINOPATHY’ (SINDING–
LARSEN JOHANSSON SYNDROME)”, (p. 576)
https://www.physio-pedia.com/Sinding_Larsen_Johansson_Syndrome
http://boneandspine.com/sinding-larsen-johansson-disease/
https://www.epainassist.com/sports-injuries/knee-injuries/sinding-larsen-johansson-slj-
syndrome
https://www.physioadvisor.com.au/injuries/knee/sindinglarsenjohansson-disease/
https://www.luriechildrens.org/en-us/care-services/specialties-services/institute-for-sports-
medicine/conditions/Documents/slj-syndrome.pdf
https://www.orthobullets.com/sports/3030/sinding-larsen-johansson-syndrome
https://patient.info/doctor/sinding-larsen-johansson-disease#nav-0
http://physioworks.com.au/injuries-conditions-1/sinding-larsen-johansson-disease
https://www.sportsmedtoday.com/sindinglarsen-johansson-disease-slj-va-124.htm

XII. Notes

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Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

Osteochondritis Dissecans

I. Definition
 Osteochondritis dissecans is an idiopathic disease which affects the subchondral bone and its
overlying articular cartilage due to loss of blood flow.
 This may result in separation and instability of a segment of cartilage and free movement of these
osteochondral fragments within the joint space. That process can lead to pain, loose body
formation and joint effusion.
 It is applied to a group of conditions in which there is demarcation, and sometimes separation
and necrosis, of a small segment of articular cartilage and bone.
 The affected area shows many of the features of ischaemic necrosis, including death of bone cells
in the osteoarticular fragment and reactive vascularity and osteogenesis in the surrounding bone.

II. Related Anatomy

 The knee is a synovial joint where 3 bones articulate with each other: femur, tibia and patella.
 It consists of 2 articulations:
1) Located between the femur and tibia (art. femorotibialis). The femoral condyles (lateral
and medial) which are the distal rounded ends of the femur, articulate with the proximal
side of the tibia (tibia plateau).
2) The one between the femur and the patella.

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College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

 The articular bones are covered by white, shiny and elastic cartilage. The smooth articular surface
of the femur rolls and slides on the tibia plateau.
 Synovial fluid nourishes and lubricates the cartilage.
 In patients with osteochondritis dissecans, the subchondral bone with his articular cartilage
doesn’t get any blood supply anymore and degenerates.
 The most common location of OCD is in the knee at the end of the femur.

III. Pathophysiology
 Pathoanatomic cascade
 softening of the overlying articular cartilage with intact articular surface
 early articular cartilage separation
 partial detachment of lesion
 osteochondral separation with loose bodies
 The lower, lateral surface of the medial femoral condyle is usually affected, rarely the lateral
condyle, and still more rarely the patella.
 An area of subchondral bone becomes avascular and within this area an ovoid osteocartilaginous
segment is demarcated from the surrounding bone. At first the overlying cartilage is intact and
the fragment is stable; over a period of months the fragment separates but remains in position;
finally the fragment breaks free to become a loose body in the joint. The small crater is slowly
filled with fibrocartilage, leaving a depression on the articular surface.

IV. Etiology
 2 forms:
1) JUVENILE (JOCD): occurring with an open epiphyseal plate
2) ADULT FORM: after the physis has closed
 There are two main places in the knee joint where osteochondritis dissecans can appear.
1) ±80%: femoral condyles (especially the medial condyle on the lateral joint surface.) This
area carries the least weight.
2) 10%: on the patella
 more common in males
 ±25%: bilateral representation is rare

RISK FACTORS:
 Repeated physical trauma (about half of cases)
 Overuse due to sporting activity
 Children and adolescents between the ages of 10 and 20 who are highly active in sports
 Male sex (although incidence is increasing in women and girls)
 Ligamentous weakness
 Genu valgum/varum
 Meniscal lesions in the knee
 Certain case reports also suggest genetic predisposition

V. Clinical Manifestation
S/Sy:
 Pain: This most common symptom of osteochondritis dissecans might be triggered by
physical activity — walking up stairs, climbing a hill or playing sports.

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College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

 Joint weakness: You might feel as though your joint is "giving way" or weakening.
 Gradual onset of stiffness, and intermittent swelling during or after activity occurs
 For presence of early or small OCD lesions: will present with nonspecific, poorly localized
knee pain with activity
 For presence of advanced or larger lesions: may experience catching or locking of joint,
especially if a loose foreign body is present
 Decreased range of motion. You might be unable to straighten the affected limb completely.

Clanton Classification of Osteochondritis (Clanton and DeLee):

 Type I: Depressed osteochondral fracture
 Type II: Fragment attached by osseous bridge
 Type III: Detached non-displaced fragment
 Type IV: Displaced fragment

VI. Diagnostic Studies

Physical Examination
 (-) swelling or (+) swelling
 Full ROM is typically found
 Palpation of both femoral condyles for tenderness with the knee in flexion.
 OCD is suggested by tenderness to palpation with the knee flexed and pressure directed over
the medial femoral condyle, just medial to the inferior pole of the patella
 Crepitus may also be noted. Patients with chronic symptoms may display an antalgic gait or
alteration of gait with the foot of the affected side rotated laterally to reduce the pain of
weight-bearing.

Wilson sign: is a provocative test that can identify OCD lesions present at the lateral aspect of the
medial femoral condyle.
 The patient is asked to sit with the knee flexed over the examining table. The knee is then
extended actively with the tibia rotated medially.
 With increasing extension, at approximately 30 degrees of flexion, the pain in the knee should
increase.
 At this point, the patient is asked to stop, rotate the tibia laterally, and the pain disappears.
Although helpful in establishing the diagnosis of OCD when present, the Wilson sign is
negative in approximately 75 percent of patients with juvenile OCD found on imaging.

Plain radiographs — Patients with suspected OCD should initially undergo plain radiographs of the
affected joint. However, radiographs can be normal, especially in patients with small, compressed
fragments
MRI - Preferred choice to detect the location of the lesion and the size, when not visible on plain
radiographs. With MRI the status of the subchondral bone, the articular cartilage, and the stability of
the OCD lesion can be assessed.
Computed tomography and single photon emission computed tomography – In some patients with
loose intra-articular bony foreign bodies, especially involving the talus, CT may aide in characterizing
the location and appearance of the bony fragment for surgical planning and management.
Ultrasound – Ultrasound in the hands of experienced operators can identify OCD lesions of the knee
and elbow and provide information on stability. However, US is not routinely used or available for
this purpose and provides information that is inferior to MRI.

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Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

Radionuclide bone scan – Radionuclide bone scans have largely been replaced by MRI for the
diagnosis of OCD in symptomatic patients with normal plain radiographs because of radiation
exposure and limited information provided by the images.

VII. Treatment
Nonoperative:
 restricted weight bearing and bracing
o stable lesions in children with open physes
 asymptomatic lesions in adults
Operative:
 diagnostic arthroscopy
o impending physeal closure
o clinical signs of instability
o expanding lesions on plain films
o failed non-operative management
 subchondral drilling with K-wire or drill (leads to formation of fibrocartilaginous tissue &
improved outcomes in skeletally immature patients)
o stable lesion seen on arthroscopy
 fixation of unstable lesion
o unstable lesion seen on arthroscopy or MRI >2cm in size
 chondral resurfacing
o large lesions, >2cm x 2cm
 knee arthroplasty for patients > 60 years
Surgical:
 Microfracture: tap awl to a depth of 1-1.5cm below articular surface
 Internal fixation
 cannulated screws
 Herbert screws
 bone pegs
 Kirschner wires
***Cons: may require hardware removal
 Osteochondral grafting
o arthrotomy (vs. arthroscopy) indicated in lesions > 3cm
 open vs. arthroscopic
 arthroscopy generally used for lesions <3cm
 arthrotomy used for lesions > 3cm
 allograft plugs
 autograft OATS
 Periosteal patches

VIII. Physical Therapy Management

In stages one and two the condition is localized in the subchondral bone, the cartilage is still intact
and gets its nourishment from synovial fluid. In these two stages, conservative therapy can be
applied. The goals of conservative therapy are: pain reduction, promote the repair of the cartilage
and prevent degeneration of the surface of the knee joint. There is no standard treatment.

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Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

Stretching: improve range of motion

Strengthening exercises for the muscles
Closed chain exercises, low impact activities like cycle and swim. Using exercises as straight leg raises
and ankle band exercises, strength can be maintained.
Coactivation or setting of the quadriceps and hamstring can be performed while in an immobilizer or
cast.
Using NMES to the quadriceps and hamstrings for coactivation contractions can further augment the
strength maintenance program.
 Following immobilization, range of motion exercises, as well as progressive quadriceps and
hamstring strengthening should be performed.
 Weight-bearing progression throughout rehabilitation should be to patient tolerance.
 In facilitating the return to full-weight-bearing status is aquatic therapy very beneficial.
 To address any gait deviations that developed during the immobilization and decreased weight-
bearing phases of rehabilitation gait training techniques may be used, such as manual facilitation
and visual feedback to the patient via a full length mirror.
 Additional exercises to restore ankle joint and normal knee proprioception, such as
biomechanical ankle platform systems (BAPS board) exercises or unilateral stance, are also
beneficial to the athlete planning to return to competition.
 Next criteria should be managed: the patient is pain free, has a full joint mobility, no swelling, no
pressure sensitivity and there’s radiological prove of recovery.
 POST OP: An operative treatment is indicated if, after a treatment of three to six months and no
recovery has occurred, or when the loose fragment is too big. The surgery goals would be to
remove loose fragments or to reattach fragments.
 Immobilization is not necessary before surgery. Immediately after the intervention the knee get
continuous passive motion for 48 hours. After this therapy is recommend, including 8 weeks of
rehabilitation exercises for limb function and recruitment. Between week 6 and 8 weight-bearing
is gradually introduced to full weight bearing.

IX. Differential Diagnosis

 Meniscus and collateral ligament injuries - physical examination can rule this out.

If there is no certain radiological determination of osteochondritis dissecans, there can also be

alternative causes of the same symptoms that should be sought for e.g.:
 Inflammatory arthritides: a group of conditions which affect your own immune system
 Osteoarthritis: degradation of joints
 Bone cysts: type of cyst in joints
 Septic arthritis: purulent invasion of the knee which produces arthritis
 Idiopathic osteonecrosis: bone death cause by lack of blood supply
 Chondral separations: result of articular cartilage damage within the knee
 Osteochondral fractures

X. Related Terms
 Arthroscopy - surgical technique in which a tube-like instrument is inserted into a joint to
inspect, diagnose, and repair tissues
 Arthrotomy - creation of an opening in a joint that may be used in drainage
 Demarcation - separation

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College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

 Osteogenesis – development and formation of bone

 Osteonecrosis – bone desth cause by lack of blood supply
 Subchondral – situated beneath cartilage

XI. References
Apley’s System of Orthopaedics and Fractures 9th Edition, “Pathology of Osteochondritis Dissecans”,
(p. 566)
(https://www.physio-pedia.com/Osteochondritis_Dissecans_of_the_Knee)
(http://www.uptodate.com/contents/osteochondritis-dissecans-ocd-clinical-manifestations-and-
diagnosis?source=search_result&search=Clinical+manifestations+and+diagnosis+of+osteochondrit
is+dissecans+%28OCD%29&selectedTitle=1~125#H2510199)
(https://www.mayoclinic.org/diseases-conditions/osteochondritis-dissecans/symptoms-
causes/syc-20375887)
https://emedicine.medscape.com/article/89718-overview#showall
https://www.orthobullets.com/sports/3028/osteochondritis-dissecans
https://patient.info/doctor/osteochondritis-dissecans
https://www.mayoclinic.org/diseases-conditions/osteochondritis-dissecans/symptoms-
causes/syc-20375887
http://www.medindia.net/patients/patientinfo/osteochondritis-dissecans.htm

XII. Notes

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Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

Osgood-Schlatter’s Disease

I. Definition
 Osgood-Schlatter’s Disease aka ‘Tibial Tubercle Apophysitis’ is an inflammation of the area
just below the knee where the tendon from the kneecap (patellar tendon) attaches to the
shinbone (tibia) due to repetitive strain on the secondary ossification center (tibial tubercle)
of the tibial tuberosity. The repetitive strain is from the strong pull of the quadriceps muscle
produced during sporting activities.
 The Osgood-Schlatter disease is localized at the tibial tubercle at the anterior side of the knee,
but only in an adoslecent knee.
 At this tibial tubercle the pain can be felt by the patient (unilateral/bilateral). The patellar
tendon attaches to the tibial tuberosity inferior to the patella. Stress at this musculo-
tendonous junction can cause pain and swelling.
 Although often called osteochondritis or apophysitis, it is nothing more than a traction injury
of the apophysis into which part of the patellar tendon is inserted (the remainder is inserted
on each side of the apophysis and prevents complete separation). Spontaneous recovery is
usual but takes time, and it is wise to restrict such activities as cycling, jumping and soccer.
Occasionally, symptoms persist and, if patience or wearing a back-splint during the day are
unavailing, a separate ossicle in the tendon is usually responsible; its removal is then
worthwhile.

II. Related Anatomy

Quadriceps ms: is located in the thigh on both the right and left sides of the lower extremity composed
of:
1. the rectus femoris - originates on the ASIS. When it concentrically contracts (shortens) it
causes flexion at the hip along with extension at the knee
2. vastus lateralis
3. vastus medialis originate on the femur and extends the knee
4. vastus intermedius
The four quadriceps muscles come together to form the common quadriceps tendon (also referred
to as the patellar tendon) that inserts into the superior (upper) aspect of the patella.

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College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

The patella is a sesamoid bone. A sesamoid bone is bone that is embedded in a tendon that creates a
mechanical advantage for the action of the muscle that attaches to that tendon. At the inferior (lower)
aspect of the patella, the patellar ligament (also
referred to as the patellar tendon) begins and
inserts into the tibial tuberosity of the tibia (also

referred to as the shin bone).

The insertion of the patellar ligament into the tibial

tuberosity is the location of the injury associated
with Osgood Schlatter's Disease.

Ehrenborg described four stages of development of the tibial tubercle:

1. The cartilaginous stage - is from birth to 8 to 10 years of age and consists of a cartilaginous
tongue-like mass.
2. The apophyseal stage - begins when one or more centers of ossification are identified in the tibial
tuberosity.
3. The epiphyseal stage - quickly follows and is heralded when the ossification center from the
proximal tibia and tibial tuberosity coalesce.
4. The bony stage - is seen when the closure of the physis of the tuberosity is complete.

III. Pathophysiology
 Osgood-Schlatter disease is common in active adolescents, possibly caused by multiple small
avulsion fractures from contractions of the quadriceps muscles at their insertion into the
proximal tibial apophysis (ossification centre).
 This condition usually occurs during the adolescent growth spurt before the tibial tuberosity
has finished ossification. The strength of quadriceps, in children regularly practicing sports that
involve running and jumping, may exceed the ability of the tibial tuberosity to resist that force.
As the avulsed fragments heal and grow, the tibial tubercle may enlarge. The extent will depend
on the severity and frequency of injury.

IV. Etiology
 Unknown

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A/Y 2017-18

 However, theories suggest that this condition is a result of repeated knee extensor mechanism
contraction that causes partial microavulsions of the chondrofibro-osseous tibial tubercle.
 During running, jumping, gymnastics, and other sports requiring repeated contractions of the
quadriceps, an extra-articular osteochondral stress fracture or microavulsion occurs. The
proximal area of the patellar tendon insertion separates, resulting in elevation of the tibial
tubercle.
 During the reparative phase of this stress fracture, new bone is laid down in the avulsion space,
which may result in a deviated and prominent tibial tubercle.
 When an individual with an injured tibial tubercle continues to participate in sports, more and
more microavulsions develop, and the reparative process may result in a markedly pronounced
prominence of the tubercle, with longer-term cosmetic and functional implications. A separated
fragment may develop at the patellar tendon insertion and may lead to chronic, nonunion-type
pain.
 Histologic studies support a traumatic etiology.

RISK FACTORS:
 Age. Osgood-Schlatter disease occurs during puberty's growth spurts. Age ranges differ by sex
because girls enter puberty earlier than do boys. Osgood-Schlatter disease typically occurs in
boys ages 12 to 14 and girls ages 10 to 13.
 Sex. Osgood-Schlatter disease is more common in boys, but the gender gap is narrowing as
more girls become involved with sports.
 Sports. The condition happens most often with sports that involve running, jumping and swift
changes in direction.
 Flexibility. Tightness in the quadriceps muscles can increase the pull of the kneecap's tendon
on the growth plate at the top of the shinbone.

V. Clinical Manifestation
S/Sy:
 Gradual onset of pain with no specific mechanism of injury
 Pain is provoked by knee extension against resistance or by hyperflexing the knee with the
person lying prone.
 Tightness in the quadriceps muscle, hamstring & gastrocnemius ms
 Swelling and inflammation of the knee
 Point tenderness over the area of the tibial tuberosity
 In some cases, increased bony protuberance at the tibial tuberosity.

Hirano and colleagues evaluated the progression of Osgood-Schlatter Disease with magnetic
resonance imaging (MRI). They described five stages in the progression and resolution of this
condition:
1. NORMAL STAGE: with no MRI changes, was seen in the earliest of symptoms of Osgood-
Schlatter, mild pain and minimal swelling.
2. EARLY STAGE: showed low signal intensity at the secondary ossification center, which did
not translate to changes on plain radiographs.
3. PROGRESSIVE STAGE: Cartilaginous damage of the tibial tuberosity and tearing of the
secondary ossification center with an open shell separation were seen on MRI. The knee in
this stage also showed swelling at the insertion of the patellar tendon.

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4. TERMINAL STAGE: showed signs of healing and resolution of swelling. It was in this stage
that ossicles were identified and pulled superiorly.
5. FINAL STAGE: healing, showed almost normal radiographic findings with prominence of the
tibial tubercle.

VI. Diagnostic Studies

 A diagnosis can be made through a thorough history and examination. Tenderness to
palpation over the tibial tuberosity that worsens with weight bearing squat or jumping is
fairly indicative of this disease.
 Physical examination reveals pain during palpation of the tibial tubercle.
 Resisted extension of the knee from 90° flexed position will usually reproduce pain, but
resisted straight leg raised test is usually painless.
 Ely's test, which proves excessive tightness of the quadriceps femoris muscle, is positive in
all cases.
 X-Rays may be utilized to better visualize the musculotendinous junction in severe cases or
if avulsion is suspected.
 Radiographic examinations of both knees should always be performed, in both the anterior-
posterior and lateral projections, to rule out the possibility of tumors, fractures, ruptures or
infections. The lateral radiograph generally shows the characteristic picture of prominent
tibial tubercle with irregularly ossific nucleus, or free bony fragment proximal to the tubercle.
 Imaging is also useful to exclude tuberosity epiphysiolysis or tumors.
 Sonographic examination can also be used. The ultrasound can be directed to demonstrate
the appearance of the cartilage and bony surface, the patellar tendon, soft-tissue swelling
anterior to the tibial tuberosity, and fragmentation of the tibial tuberosity.

VII. Treatment
Nonoperative:
 NSAIDS
 RICE Therapy
 Activity modification
 Strapping/sleeves to decrease tension on the apophysitis
 Quadriceps stretching
 Cast immobilization x 6 weeks for severe symptoms not responding to simple conservative
management above
Operative:
 ossicle excision for refractory cases and in skeletally mature patients with persistent
symptoms
Surgical:
 Skin incision
 Shaving of the tibial tuberosity
 Removal of any bone spurs, and bone plugs to reposition the tibial tuberosity
 Drillimg of the tibial tubercle
 Excision of the tibial tubercle & the disunited ossicle and free pieces of cartilage, insertion of
bone pegs to reattach the tibial tubersity, or a combination of all of these procedures.

VIII. Physical Therapy Management

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1) Exercise Therapy
 Flexibility exercises
 Strengthening exercises
 Stretching should initially be
performed statically at a low intensity to
prevent pain before progressing to dynamic or
PNF stretching. A duration of at least thirty
seconds with three repetitions is
recommended at least once a day to increase
the range of motion.
 Low-intensity quadriceps-
strengthening exercises, such as isometric
multiple-angle quadriceps exercises, are
therefore instituted earlier in the conditioning
program.
 High-intensity quadriceps exercises
and hamstring stretching are introduced
gradually and have been proven effective with
high evidence rating.
2) Shockwave
 Extracorporeal Shockwave therapy is
a treatment which has been discussed in the
use of Osgood-Schlatter’s but due to the low
value evidence recommendations cannot be
made for this treatment.
3) Activity Limitation
 Non-operative treatment of this disease is based on the same principles that apply all overuse
injuries.
 Today, there is no need for total immobilization, or for totally refraining from athletic
activities. Of vital importance is that the physician informs the parents, the coach, and the
child athlete of the natural course of this disease. The child should continue his normal
physical activities, to the limit that the pain allows it, so lower intensity of frequency of
exercising (activity modification).
 Also swimming, as a secondary athletic activity, is very good during this disease (no
discomfort). Also knee-braces, tapes, slip-on knee support with an infrapatellar strap or pad
are recommended and may help during physical activities and can reduce pain.

4) Taping via patellar tendon unloading technique

 Keeping the knee in a slight bend (approximately 30 degrees), tape around the knee just below
the knee cap, at the level of the patella tendon.
 Apply the tape firmly to the front of the knee for support and gently at the back of the knee to
prevent circulatory problems. 1 – 3 pieces of tape may be used depending on the level of support
required.

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 Occasionally this taping technique may be

made more effective by rolling up a small section of
tape into a small cylinder and placing it horizontally
across the patella tendon and underneath the tape.
The size and shape of this cylinder may need to be
tailored to the individual to ensure maximal comfort
and minimal pain.

IX. Differential Diagnosis

 Jumper’s knee (patellar tendinitis) or Sinding- Larsen-Johansson syndrome – inflammation
of the bone at the bottom of the patella (kneecap), where the tendon from the shin bone
(tibia) attaches
 Hoffa’s syndrome - aka Infrapatellar Fat Pad Syndrome (IPFPS), occurs when the fatty tissue
under the knee-cap is pinched between the femur (thigh bone) and tibia (shin bone)
 Synovial Plica Injury - occurs when a plica (an extension of the protective synovial capsule of
the knee) becomes irritated, enlarged, or inflamed.
 Tibial Tubercule Fracture - infrequent fractures affecting physically active adolescents.
Activities involving powerful contraction of the knee extensors, such as springing and
jumping movements, can result in avulsion fractures of the tibial tuberosity apophysis.
 Patellofemoral Stress Syndrome - term used to describe pain in the front part of the knee
(medically termed as anterior knee pain) that occurs due to abnormal motion or pressure
between the kneecap (patella) and thighbone (femur).
 Pes Anserinus Bursitis: inflammatory condition of bursa of the conjoined insertion of the
sartorius, gracilis and semitendinosus
 Infection

X. Related Terms
 Apophysitis - inflammation of an apophysis, secondary to trauma-induced bone
microfractures characteristically of immature bone (i.e. bone whose epiphyses have not
undergone ossification), where muscle contraction force at the point of tendon insertion
causes detachment of the centre of ossification from the parent bone
 Microavulsions – gradual detachment of a body from its point of insertion due to microtrauma
 Epiphysiolysis - abnormal separation of an epiphysis from the bone shaft.
 Ossicle excision – separation of ossicles from the surrounding soft tissue with a motorized
shave
 Patellofemoral Pain Syndrome - condition characterized by knee pain ranging from severe to
mild discomfort seemingly originating from the contact of the posterior surface of the patella
with the femur

XI. References
Apley’s System of Orthopaedics and Fractures, 9th Edition, “OSGOOD–SCHLATTER DISEASE
(‘APOPHYSITIS’ OF THE TIBIAL TUBERCLE)” (p. 576)

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https://www.physioadvisor.com.au/health/taping-techniques-lower-body/patella-tendon/
https://www.physio-pedia.com/Osgood-Schlatter%27s_Disease
https://emedicine.medscape.com/article/1993268-overview#showall
https://www.orthobullets.com/sports/3029/osgood-schlatters-disease-tibial-tubercle-apophysitis
https://www.mayoclinic.org/diseases-conditions/osgood-schlatter-disease/diagnosis-
treatment/drc-20354869
http://morphopedics.wikidot.com/osgood-schlatter-s-disease
https://patient.info/doctor/osgood-schlatter-disease-pro#nav-0
https://www.physiotherapy-treatment.com/osgood-schlatter-disease.html

XII. Notes

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Chondromalacia Patella

I. Definition
 Chondromalacia Patellae (CMP) aka Patellofemoral Overload Syndrome, Anterior Knee
Syndrome, Runner’s Knee is referred to as anterior knee pain due to the physical and
biomechanical changes. The articular cartilage of the posterior surface of the patella is going
though degenerative changes which manifests as a softening, swelling, fraying, and erosion
of the hyaline cartilage underlying the patella and sclerosis of underlying bone.
 The word chondromalacia is derived from the Greek words chrondros, meaning cartilage and
malakia, meaning softening. Hence chondromalacia patellae is a softening of the articular
cartilage on the posterior surface of the patella which may eventually lead to fibrillation,
fissuring and erosion.
 CMP is one of the main conditions under the blanket term, Patellofemoral Pain Syndrome
(PFPS)
 Chondromalacia patellae is one of the most frequently encountered causes of anterior knee
pain among young people.

II. Related Anatomy

The knee comprises of 4 major bones:
1) Femur
2) Tibia
3) Fibula
4) Patella

The patella articulates with the femur at the trochlear

groove. Articular cartilage on the underside of the patella allows
the patella to glide over the femoral groove, necessary for
efficient motion at the knee joint.
Excess and persistent turning forces on the lateral side
of the knee can have a negative effect on the nutrition of the
articular cartilage and more specifically in the medial and
central area of the patella, where degenerative change will occur
more readily.
The quadriceps insert into the patella via the quadriceps
tendon and are divided into four separate muscles: rectus
femoris (RF), vastus lateralis (VL), vastus intermedius (VI) and

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vastus medialis (VM). The VM has oblique fibres which are referred to the vastus medialis obliques
(VMO)

These muscles are active stabilisers during knee extension, especially the VL (on the lateral
side) and the VMO (on the medial side). The VMO is active during knee extension, but does not extend
the knee. Its function is to keep the patella centred in the trochlea. This muscle is the only active
stabiliser on the medial aspect, so it's functional timing and amount of activity is critical to
patellofemoral movement, the smallest change having significant effects on the position of the patella.

Other significant anatomical structures:

Femoral anteversion or medial torsion of the
femur is a condition which changes the alignment of the
bones at the knee. This may lead to overuse injuries of
the knee due to malalignment of the femur in relation to
the patella and tibia.
The Q-angle: or quadriceps angle is the
geometric relationship between the pelvis, the tibia, the
patella and the femur and is defined as the angle
between the first line from the anterior superior iliac
spine to the centre of the patella and the second line
from the centre of the patella to the tibial tuberosity.
If there is an increased adduction and/or
internal rotation of the hip, the Q-angle will increase,
which increases the relative valgus of the lower
extremity as well. This higher Q-angle and valgus will
increase the contact pressure on the lateral side of the patellofemoral joint (which is also increased
by external rotation of the tibia)

III. Pathophysiology
 Pain over the anterior aspect of the knee occurs as one of the symptoms in a number of well-
recognized disorders, the commonest of which are bursitis,
 Osgood–Schlatter disease, a neuroma, plica syndromes, patello-femoral arthritis and tendinitis
affecting either the insertion of the quadriceps tendon or the patellar ligament – Sinding-
Larsen’s disease.
 When these are excluded and no other cause can be found, one is left with a clinically
recognizable syndrome that has earned the unsatisfactory label of ‘anterior knee pain’ or
‘patello-femoral pain syndrome’.
 The basic disorder is probably mechanical overload of the patello-femoral joint. Rarely, a single
injury (sudden impact on the front of the knee) may damage the articular surfaces. Much more
common is repetitive overload due to either:
(1) malcongruence of the patello-femoral surfaces because of some abnormal shape of the patella or
intercondylar groove,
(2) malalignment of the lower extremity and/or the patella,
(3) muscular imbalance of the lower extremity with decreased strength due to atrophy or inhibition,
or relative weakness of the vastus medialis, which causes the patella to tilt, or subluxate, or bear more
heavily on one facet than the other during flexion and extension
(4) overactivity.

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IV. Etiology
The etiology of CMP is poorly understood, although it is believed that the causes of
chondromalacia are:
1. Injury
2. generalised constitutional disturbance and patellofemoral contact
3. as a result of trauma to the chondrocytes in the articular cartilage (leading to proteolytic
enzymatic digestion of the superficial matrix)
4. by instability or maltracking of the patella which softens the articular cartilage
5. usually described as an overload injury, caused by malalignment of the femur to the patella
and the tibia.
6. Patellar malalignment d/t abnormality of the Q-angle (N: 14° for men and 17° for women)
7. Ms tightness of Rectus femoris, TFL, hamstrings and gastrocnemius
8. Excessive pronation: prolonged pronation of the subtalar joint is caused by internal rotation
of the leg. This internal rotation will result in malalignment of the patella.
9. Patella alta: this is a condition where the patella is positioned in an abnormally superior
position. It is present when the length of the patellar tendon is 20% greater than the height
of the patella.
10. Vastus medialis insufficiency: the function of the vastus medialis is to realign the patella
during knee extension. If the strength of VM is insufficient this will cause a lateral drift of the
patella.

Degenerative changes of the articular cartilage can be caused by:

1) Trauma: instability caused by a previous trauma or overuse during recovery
2) Repetitive micro trauma and inflammatory conditions
3) Postural distortion: causes malposition or dislocation of the patella in the trochlear groove

RISK FACTORS:
1) Age: Adolescents and young adults are at high risk for this condition. During growth spurts, the
muscles and bones develop rapidly, which may contribute to short-term muscle imbalances.
2) Sex: Females are more likely than males to develop runner’s knee, as they typically possess less
muscle mass than males. This can cause abnormal knee positioning, as well as more lateral
(side) pressure on the kneecap.
3) Flat feet: Flat feet may place more stress on your knee joints than in people who have higher
arches in their feet.
4) Previous injury: A prior injury to the kneecap, such as a dislocation, can increase your risk of
developing runner’s knee.
5) High activity level: If you have a high activity level or engage in frequent exercises that place
pressure on your knee joints, this can increase the risk for knee problems.
6) Arthritis: Runner’s knee can also be a symptom of arthritis, a condition causing inflammation
to the joint and tissue. Inflammation can prevent the kneecap from functioning properly.

V. Clinical Manifestation
S/Sy:
 diffuse pain in the peripatellar or retropatellar area of the knee (major symptom)
 insidious onset and typically vague in nature
 aggravated by activity (running, jumping, climbing or descending stairs)

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 prolonged sitting with knees in a moderately bent position (the so called "theater sign" of
pain upon arising from a desk or theater seat)
 vague sense of "tightness" or "fullness" in the knee area
 loss of thigh muscle strength and reduction in quadriceps muscle mass due to disregard of
chronic symptoms
 mild swelling of the knee area may occur
 palpable crepitus

Chondromalacia can be divided into 4 grades by MRI, typically using fat saturated proton density
sequences. This grading system is the modified Outerbridge grading system, which was devised for
arthroscopy initially for assessment of chondromalacia patella, but then modified and extended for
all chondral surfaces.
 Grade I
o focal areas of hyperintensity with normal contour
o arthroscopically: softening or swelling of cartilage
 Grade II
o Blister-like swelling/fraying of articular cartilage extending to surface
o Arthroscopically: fragmentation and fissuring within soft areas of articular cartilage
 Grade III
o partial thickness cartilage loss with focal ulceration
o arthroscopically: partial thickness cartilage loss with fibrillation (crab-meat
appearance)
 Grade IV
o full thickness cartilage loss with underlying bone reactive changes
o arthroscopically: cartilage destruction with exposed subchondral bone

VI. Diagnostic Studies

Examination of the knee is 4 fold: observation, mobility, feel, X-ray.
Observation: joint appearance is usually normal, but there may be a slight effusion.
Mobility: passive movements are usually full and painless, but repeated extension of the knee from
flexion will produce pain and a grating feeling underneath the patella, especially if the articular
surfaces are compressed together.
Feel: Pain and crepitus will be felt if the patella is compressed against the femur, either vertically or
horizontally, with the knee in full extension. By displacing the patella medially or laterally, the
patellar margins and their articular surfaces may be felt. Tenderness of one or other margin may be
elicited and more frequently the felt medially. Resisting a static quadriceps contraction, will generally
produce a sharp pain under the patella. This may be apparent in both knees, but more severe on the
affected side.
X-ray: an AP view of the patellofemoral joint is needed to detect any radiological change. In all but
the most advanced cases, there is no convincing radiological change. In the latter stages,
patellofemoral joint space narrows and osteoarthritic changes begin to appear.

Tests
The patient's posture can be an initial clue as well as any observed asymmetries, such as; limb
alignment in standing, internal femoral rotation, anterior or posterior pelvic tilt, hyperextended or
‘locked back’ knees, genu varum or valgum and abnormal pronation of the foot. Gait pattern may also
be affected.

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Mobility and range of motion (ROM) of the joint are tested, which can be limited. if bursitis is present,
passive flexion or active extension will be painful. Loss of power in the affected leg may also be
present on isometric testing. There are specific tests for anterior knee pain syndrome:

 Patellar grind test or Clarke’s sign: This test detects the presence of patellofemoral joint disorder.
A positive sign on this test is pain in the patellofemoral joint.
 Compression test
 Extension-resistance test: This test is used to perform a maximal provocation on the muscle-
tendon mechanism of the extensor muscles and is positive when the affected knee demonstrates
less power to when trying to maintain the pressure.
 The critical test: This is done with the patient in high sitting and performing isometric quadriceps
contractions at 5 different angles (0°, 30°, 60°, 90° and 120°) while the femur is externally
rotated, sustaining the contractions for 10 seconds. If pain is produced, then the leg is positioned
in full extension. In this position the patella and femur have no more contact. The lower leg of the
patient is supported by the therapist so the quadriceps can be fully relaxed. When the quadriceps
is relaxed, the therapist is able to glide the patella medially. This glide is maintained while the
isometric contractions are again performed. If this reduces the pain and the pain is patellofemoral
in origin, there is a high chance of a favorable outcome.
It is possible to diagnose incorrectly and these tests may aid in determining chondromalacia, but
other possible conditions also need to be excluded.

VII. Treatment

Education - helps the patient to understand the condition and how they should deal with it for
optimal recovery.
Exercise - stretching and strengthening of the hamstrings, quadriceps and gastrocnemius as well as
length and strength of the gluteal muscles.
Fire needling and acupuncture - may also relieve clinical symptoms of chondromalacia patellae and
recovers the biodynamical structure of patellae.

If conservative measures fail, there are a number of possible surgical procedures.

1) Chondrectomy: also known as shaving. This treatment includes shaving down the damaged
cartilage to the non-damaged cartilage underneath. The success of this treatment depends on
the severity of the cartilage damage.
2) Drilling is also a method that is frequently used to heal damaged cartilage. However, this
procedure has not so far been proven to be effective. More localized degeneration might
respond better to drilling small holes through the damaged cartilage. This facilitates the
growth of the healthy tissue through the holes from the layers underneath.
3) Full patellectomy: This is the most severe surgical treatment. This method is only used when
no other procedures were helpful, but a significant consequence is that the quadriceps will
become weak.

Two other treatments that may be successful:

1. Replacement of the damaged cartilage: The damaged cartilage is replaced by a polyethylene
cap prosthesis. Early results have been good, but eventual wearing of the opposing articular
surface is inevitable.

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2. Autologous chondrocyte transplantation under a tibial periosteal patch.

Simply removing the cartilage is not a cure for chondromalacia patellae. The biomechanical deficits
need addressing and there are various procedures to aid in managing this.

1. Tightening of the medial capsule (MC): If the MC is lax, it can be tightened by pulling the
patella back into its correct alignment.
2. Lateral release: A very tight lateral capsule will pull the patella laterally. Release of the lateral
patellar retinaculum allows the patella to track correctly into the femoral groove.
3. Medial shift of the tibial tubercle: Moving the insertion of the quadriceps tendon medially at
the tibial tubercle, allows the quadriceps to pull the patella more directly. It also decreases
the amount of wear on the underside of the patellar.
4. Partial removal of the patella

Although there is no overall agreement for the treatment of chondromalacia, the general consensus
is that the best treatment is a non-surgical one

VIII. Physical Therapy Management

Exercise Program

Conservative treatment of chondromalacia patellae is both physical and highly advised.

Short-wave diathermy can help to relieve pain and to increase the blood supply to the area,
improving nutrition supply to the articular cartilage. Care must be taken when planning an exercise
programme. Conservative therapeutic interventions include the following:

1) Isometric quadriceps strengthening and stretching exercises - Restoration of adequate

quadriceps strength and function is an essential factor in achieving good recovery. The most
effective exercises are isometric and isotonic in the inner range. Isotonic exercises through a
full range of motion will only lead to increased pain and even joint effusion.
2) Stretching of the vastus lateralis and strengthening of the vastus medialis is often
recommended, but they are difficult to isolate due to shared innervation and insertion.
3) Hamstring stretching exercises
4) Temporary modification of activity
5) Patellar taping
6) Foot orthoses
7) NSAIDS
8) Hip strength and stability training, as hip positioning and strength has a significant influence
on anterior knee pain.
9) Hip abductor strengthening as an increased hip adduction angle is associated with weakened
hip abductors.

Not only is strengthening important, but stretching should also be part of the programme. It
has been shown that patients with patellofemoral pain syndrome have shorter and less flexible
hamstrings than asymptomatic individuals. Although stretching can improve flexibility and knee
function, it doesn’t necessarily directly improve pain.

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1) Ice medication - may be useful for reducing pain in an acute flare up, but not as a long term
treatment protocol.
2) NSAIDS may also be of benefit in the short term to relieve pain so that knee function and
mobility is normalised and an exercise programme can begin.
3) Taping and braces – taping the patella to influence its movement may provide some short
term relief, but the evidence is varied. A commonly used technique is ‘McConnell taping or
kinesio taping.

Supporting the patella and knee joint by bracing is a further way to reduce pain and
symptoms, but it will also alter patella tracking and reduce active function of the quadriceps. Bracing
may be useful in the short term to offer patients some support and pain relief to help them avoid
antalgic movements and normalise gait as much as possible. Bracing can also be used for patients
pre- and postoperatively, but a brace should allow variation in medial pull on the patellar and
pressure.

4) Foot Orthoses - are another option for pain relief, but only in cases where a lower limb
mechanics is deemed to be contributing to the knee pain, which may be due to: poor
pronation control, excessive lower limb internal rotation during weight bearing and an
increased Q-angle.
5) Foam roller - Using a foam roller cab be useful for relieving tight musculature and reducing
pressure over the patella.

IX. Differential Diagnosis

 Patellar subluxation - patellar subluxation feels like the kneecap is shifting or jamming out of
place. Usually, a subluxated patella returns to its normal position by itself. But repeated incidents
can damage the cartilage on the back of the patella or stretch the connective ligaments.
 Osteoarthritis - degenerative joint disease or “wear and tear” arthritis
 Rheumatoid arthritis - autoimmune disease that causes chronic inflammation of the joints
 Anterior knee pain - Anterior knee pain is pain that occurs in the anterior and central aspect of
the knee. Its cause can be due to a number of conditions such as Patellofemoral pain syndrome,
Chondromalacia Patellae, Osgood-Schlatter’s disease, Sinding Larsen Johansson syndrome and
other knee-related diseases
 Patellofemoral pain syndrome - condition characterized by knee pain ranging from severe to mild
discomfort seemingly originating from the contact of the posterior surface of the patella with the
femur

X. Related Terms
 Runner’s Knee - the term doctors use for a number of specific conditions affecting the knee, such
as patellofemoral pain syndrome and chondromalacia of the patella, to name just two.
 Sclerosis of bone - abnormal increase in density and hardening of bone
 Bursitis - a painful condition that affects the small, fluid-filled sacs — called bursae — that
cushion the bones, tendons and muscles near your joints
 Plica Syndrome - a condition which occurs when a plica becomes irritated, enlarged, or inflamed
 Patella Alta - or high-riding patella refers to an abnormally high patella in relation to the femur

XI. References

| OLEA, ALYSSA KATHRYN A. | USI-PT Batch 2019 | 25 | P a g e

Universidad de Sta. Isabel
College of Physical Therapy
Consultation, Screening, Referral, Delegation
A/Y 2017-18

Apley’s System of Orthopaedics and Fractures, 9th Edition, “PATELLO-FEMORAL PAIN SYNDROME
(CHONDROMALACIA OF THE PATELLA; PATELLOFEMORAL OVERLOAD SYNDROME)”, (p. 564)
https://www.healthline.com/health/chondromalacia-patella#causes
https://www.medicinenet.com/patellofemoral_syndrome/article.htm
http://www.sportsinjuryclinic.net/sport-injuries/knee-pain/chondromalacia-patella
https://www.physio-pedia.com/Chondromalacia_Patellae
http://physioworks.com.au/injuries-conditions-1/chondromalacia-patella
https://patient.info/health/chondromalacia-patellae-leaflet
https://www.emedicinehealth.com/chondromalacia_patella/page2_em.htm
https://my.clevelandclinic.org/health/articles/knee-pain-chondromalacia-patella
https://www.orthobullets.com/sports/3022/idiopathic-chondromalacia-patellae

XII. Notes

| OLEA, ALYSSA KATHRYN A. | USI-PT Batch 2019 | 26 | P a g e