If chondromalacia patella is the MRI diagnosis then look for any patello femoral overload, alignment and congruence. As such conservative treatment will help with physio. Strengthening exercises of quadriceps helps. Cortisol will give symptomatic improvement for few months may be 6-8 months later recurrence is common..

Cortisone injections helps but only few months; physiotherapy helps improve patelar pains, specially strengthening Vastus medialis oblique and hip rotators. Hope this helps you

Dear Priya, can you describe the demographic feature of the patient so that I can have better understanding.

Chondromalacia patella is one of troubling condition encountered by Physiotherapist and Orthopedic Surgeon which is seen in young age group specially in female for many reasons. The etiology of the condition is multi-factoral and its prevention will play a major role in minimizing recurrence . As per my experience, in chondromalacia patella, treatment protocol concentrate only to structure around the knee does not resolve the symptoms in all patients. Many time imbalance in lower limb kinetic chain give raise to the pathology. Correcting lower limb kinetic chain will benefit the patient for long term and can aid in prevention of recurrence of the condition. Following method of treatment may be of benefit to your patient:

In Hip:

• Releasing of hip flexor, IT band, TFL using MET, MFR or traditional stretching.
• strengthening of hip extensor & external rotator

In Knee:

• Releasing of lateral retinaculum, and VL using patellar medial glide, MET & Stretching
• Strengthening of VMO

In Ankle:

• Releasing of calf muscles using MET or traditional stretching

In foot:

• Check for high arch or flat foot and correct it using taping, bracing or wedges

Regards

Thank you all for the answers. The patient has swelling in ankles and feet especially in the late hours of the day. What could be the reason for this in the absence of any other rheumatological diseases?

Dear Priya,

I would suggest you to assess the stability of ankle joint, ROM,  Tension of medial and lateral ligaments of ankle. And also examine for arches, superior & inferior tibiofibular joint. More importantly, monitor the patients daily activities to establish any possible correlation with amount & types of physical activity and swelling in ankle joint.   

Regards

Chondromalacia patella is not responsible; and repeat it is not responsible for swelling of the ankles and feet. There are some details for the patient that are not mentioned. Weight, sex, age and co-morbidities that the patient may have. we do not know also the habits and the occupation of the patient.

For example: 

An older overweight and with cardiac disease patient can present swelling down to the ankles due to systemic condition and not due to local problems.

Overweight patients can have patellar symptoms, due to overloading of patello-femoral joint (approximately 5 times the body weight in every step by walking on plain ground and that can go up to 10 times according to the used speed when the person is using stairs). In the same time they may have venous insufficiency that can result to swelling of feet and ankles.

Repetitive climbing of stairs can create knee pain and may irritate the ankle joint.

Siting in front of a computer for all the working life with unsuitable chair use may create swelling of the lower limb joints and pains

Steroid will help for a while but without knowing the underlying problem it will not be the treatment of choice. Finding the problem and treat it correctly is the treatment of choice.

I believe that as doctors and in extension as health workers, we must stop treating symptoms only if we cannot understand the cause, but we must understand before the treatment what the problem is. And if we are unable to find the cause, better to refer than to treat.

Pulmonary hyertension, Venous insufficiency, and women between menarche and menopause are some of the possible etiologies for non-traumatic swelling of the feet and ankles. Have you looked into this? I hope this helps.

There is no role of intra-articular steroid injections in 'chondromalacia patellae'. In fact, it can worsen the state of the affected cartilage. Quadriceps strengthening exercises, avoiding deep flexion activities and prolonged sitting and realignment of the patellae (if required) are the mainstay in the treatment of this curious condition affecting mostly younger ladies. 

The actual location of the chondromalacia (medial, lateral or odd facet), femoral groove, femoral-tibial alignment, dynamic control and analysis and knowledge of biomechanical stresses with rehabilitation ex's as well as differences in ranges of motion, flexibility, each individual factors, etc., etc. are needed in order to develop an individualized therapeutic ex program. In some instances use of kinesiotape or leukotape has appeared to decrease pt's complaints as well.

The described pathology is not chondromalacia but swelling of he ankles and feet. Chondromalacia is a red herring. Discussion on the subject is irrelevant. Also systemic steroids as Priya mentioned may help to reduce the generalised inflammation. Intra-articular injections will not help at all.

I thank you all for the responses and expertise. I would like to further provide with more details regarding the patient. The patient is 33 year old female weighing around 45kgs.The patient has bilateral knee pain since 18 months. It started as a dull aching pain but now the pain is under the medial patella on right knee and both medial and lateral on the left. Tests for Anti nuclear antibodies were negative, RA factor was also negative, all other tests urea, creatinine, uric acid were all normal. MRI was done six months back, which showed thinning of cartilage in both knees and cartilage was within the margins and other soft tissues around were normal.

The patient is unable to climb down the stairs though climbing up is not quite difficult. There is pain when standing or walking for more than 10 minutes, sitting with knee bent for more than 15 - 20 minutes. The patient had avoided squatting, cross leg sitting , kneeling since the pain started and these activities are also not possible now. The pain had aggravated more as the patient had continued to use stairs once in a day regularly. The mild swelling in the ankles and feet sstarted only since the knee pain had started.

Also the patient complains of pain worsening after doing static quadriceps and VMO  strengthening in supine lying. Knee  bending is painful beyond 100 degrees of knee flexion. The nature of her job is physically demanding and has quit the job now.

Further to the new information, and I thank you for this, your patient seems that she has a mal-aligned patella-femoral tracking. If physiotherapy is not helping, then a full assessment needs to be done on her gait and this may help you to understand the symptoms of the other joints. For example a tibial rotation can explain the mal-tracking and also the ankle malposition which may lead to swellings. Her feet have to be checked for pes planus or cavus and the femoral anteversion to be recorded. Foot and hip "deformities" may lead to ankle and knee mal-positions. Following all this she may be a candidate for patello-femoral re-alignment with surgical means.

Hoping you will find this helpful.

Massive Topic-depends on the aetiology,location etc.

Please see my papers on the topic.