Etiology
Several paths can lead to the development of chondromalacia patellae; however, the pain generator is not clearly identified and is usually multifactorial. Multiple factors have been involved, including:
Lower Limb Malalignment and Patellar Maltracking
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The Q angle is the measurement of the pull of the quadriceps muscle relative to the pull of the patella tendon on the patella. A normal angle is 14 degrees in men and 17 degrees in women. This variance is created because anatomically, there is normally a wider pelvis in females than in males. The Q angle is measured by drawing a line from the center of the anterior iliac spine to the center of the patella (quadriceps pull) and a second line from the mid-portion of the patella to the tibial tubercle (patella tendon pull). An abnormally high Q angle > 20 to 25 degrees, indicates lateral pull of the patella in the trochlear groove of the femur and a mechanism of articular cartilage wear and tear. The tibial tubercle trochlear groove distance (TT-TG) is a linear equivalent of the Q angle and a more accurate measure of assessing patellar maltracking.
Patellar maltracking results in narrow contact pressure areas with increased stresses and a further increase in pain. Additionally, the alignment of the patella in the vertical plane can also be abnormal. Patella Alta (high riding), and patella Baja (low riding), are both conditions that have also been implicated as a cause of chondromalacia.
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Foot and ankle anatomic variances (pes planus) that cause an increased valgus orientation of the knee cause increased lateral wear of the patellofemoral joint. For example, high-heel shoes, which create increased stress on the patellofemoral joint, can also contribute to chondromalacia.
Chondromalacia patellae can be associated with miserable malalignment syndrome, a combination of specific anatomic criteria that results in increased Q angle and patellofemoral dysplasia. These criteria include femoral anteversion, genu valgum, and external tibial torsion or pronated feet.
Muscular Weakness
Weakness of vastus medialis obliques and general core muscles weakness.
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Patellar Lesions
Chondromalacia is also seen as a complication of injuries direct to the patella, immobilization (casting rehabilitative periods), and surgical procedures that lead to quadriceps atrophy. The cause is the micro-trauma created by the decreased pull of the quadriceps muscle on the patella.
Most often, chondromalacia is associated with abnormal (microtrauma) wear and tear of the patellofemoral joint’s hyaline cartilage. Lateral positioning of the patella in the patella-femoral joint is a frequent cause of chondromalacia. Although a tight lateral retinaculum or a lateral synovial plica may be implicated as the cause of this positioning, an abnormal Q angle is often the cause.
Contrary to congenital increased cartilage vulnerability, which is not modifiable, iatrogenic injection of chondrotoxic medication into a joint is one that patients can avoid. Intra-articular injections of bupivacaine and high doses or frequent intra-articular injections of corticosteroid lead to softening and/or articular cartilage dysfunction.
Among the causes, patella subluxation is the most common as it is more frequently missed as there is no frank dislocation.[8]
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