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Developing chondromalacia

Ok, guys. I have been asking here about my cracking and a bit weird knee, and finally went to a doctor + x-rays followed by a physiotherapist. The bad news is that they said I have early stages of chondromalacia (softening of cartilage under kneecap). And the physiotherapist said that it is very likely to develop into real arthritis in my thirties, no matter what I do, only that it is quicker if I don’t do anything. One reason for this was too tight quads + IT band, but it also can be somewhat genetic, I guess. (I thought I was stretching them enough, but I was not hitting them from all angles.) My kneecap is now located too high, and too much to the outside of the joint itself due to pull of quads and Vastus lateralis.

Any damage is not visible in x-rays as it is cartilage, but physio said that he can already feel something coarse in there. Naturally, I was given specific streching/VMO strengthening instructions, and recommedation to avoid deep squats for the moment. He okayed everything else as long it doesn’t hurt. Physio seemed quite knowledgeable as he has the same thing in both knees. Now, the knee area is not painful at all anymore after intense two weeks stretching, but naturally I am scared shitless and waiting for the moment that arthritis hits me (I am only 27).

Do you agree with this diagnosis that it is only going to get worse, even if I actively stretch my quads back to proper length? I am very motivated to do PNF stretches+VMO exercises even daily, but is there anything else I can do to help repair or prevent further damage? Is it even possible? And would glucosamine help in cartilage repair (I know that it lubricates the joint, but have heard conflicting info about actual regeneration)? The physio seemed to suggest that once cartilage is lost, you cannot regenerate it. But it seems intuitive that better joint lubrication = less wear&tear. He was hesitant to recommend any OTC glucosamine/chondroitine pills, though.

Could you please outline the VMO exercises and stretches that you have been doing? Did he recomend taping your knee?

I can not see any harm in taking glucosamine, chondriotin or msm. Maybe the reason the physio was hesitant about telling you whether of not to get these supplements is because cartiliage is an avascular tissue. With no blood supply the chances of regeneration and repair once it is injured are minimal. Atleast that is what we have been told at university. This does not necaserily mean that glucosamine, chondriotin or msm will be useless, infact some studies seem to show that it may be effective.

There is no harm in seeing whether they work or not. Although I have similar injuries and am not taking these supplements I would be taking them if I had the money. There was an article here at t-mag a little while back that said that glucosamine may not be the best because it may decrease insulin sensitivity etc but I think that in your case I would not worry and would use it.

As far as other things you can do... Just stick to what he said AND KEEP UP THE STRETCHING. Also Poliquin I think actually recomended getting back to full squats, he mentioned using 1 and 1/4 squats as a method of rehabilitating some injured athletes VMO with great success. This would be something that you would definetly work up to and not rush into. I have had a similar injury for a while now and while I can deadlift 450+ can not full squat the bar without pain.

Here are some studies that I found that may be of interest. There were several others you will need to go to pub med and do a search though.

Correlation between radiographic severity of knee osteoarthritis and future disease progression. Results from a 3-year prospective, placebo-controlled study evaluating the effect of glucosamine sulfate.

Bruyere O, Honore A, Ethgen O, Rovati LC, Giacovelli G, Henrotin YE, Seidel L, Reginster JY.

WHO Collaborating Center for Public Health Aspect of Osteoarticular Disorders, Liege, Belgium

Objective To investigate the relationship between baseline radiographic severity of knee osteoarthritis (OA) and the importance of long-term joint space narrowing.DesignSub-analysis from a three-year randomized, placebo-controlled, prospective study, of 212 patients with knee OA, recruited in an osteoarthritic outpatient clinic and having been part of a study evaluating the effect of glucosamine sulfate on symptom and structure modification in knee OA.Material and Methods Measurements of mean joint space width (JSW), assessed by a computer-assisted method, were performed at baseline and after 3 years, on weightbearing anteroposterior knee radiographs.Results In the placebo group, baseline JSW was significantly and negatively correlated with the joint space narrowing observed after 3 years (r=-0.34, P=0.003). In the lowest quartile of baseline mean JSW (<4.5mm), the JSW increased after 3 years by (mean (S.D.)) 3.8% (23.8) in the placebo group and 6.2% (17.5) in the glucosamine sulfate group. The difference between the two groups in these patients with the most severe OA at baseline was not statistically significant (P=0.70). In the highest quartile of baseline mean JSW (>6.2mm), a joint space narrowing of 14.9% (17.9) occurred in the placebo group after 3 years while patients from the glucosamine sulfate group only experienced a narrowing of 6.0% (15.1). Patients with the most severe OA at baseline had a RR of 0.42 (0.17-1.01) to experience a 0.5mm joint space narrowing over 3 years, compared to those with the less affected joint. In patients with mild OA, i.e. in the highest quartile of baseline mean JSW, glucosamine sulfate use was associated with a trend (P=0.10) towards a significant reduction in joint space narrowing.Conclusion These results suggest that patients with the less severe radiographic knee OA will experience, over 3 years, the most dramatic disease progression in terms of joint space narrowing. Such patients may be particularly responsive to structure-modifying drugs. Copyright 2003 OsteoArthritis Research Society International. Published by Elsevier Science Ltd.

Glucosamine sulfate use and delay of progression of knee osteoarthritis: a 3-year, randomized, placebo-controlled, double-blind study.

Pavelka K, Gatterova J, Olejarova M, Machacek S, Giacovelli G, Rovati LC.

Department of Medicine and Rheumatology, Charles University, Prague, Czech Republic. pavelka@revma.cz

BACKGROUND: Conventional symptomatic treatments for osteoarthritis do not favorably affect disease progression. The aim of this randomized, placebo-controlled trial was to determine whether long-term (3-year) treatment with glucosamine sulfate can modify the progression of joint structure and symptom changes in knee osteoarthritis, as previously suggested. METHODS: Two hundred two patients with knee osteoarthritis (using American College of Rheumatology criteria) were randomized to receive oral glucosamine sulfate, 1500 mg once a day, or placebo. Changes in radiographic minimum joint space width were measured in the medial compartment of the tibiofemoral joint, and symptoms were assessed using the algo-functional indexes of Lequesne and WOMAC (Western Ontario and McMaster Universities). RESULTS: Osteoarthritis was of mild to moderate severity at enrollment, with average joint space widths of slightly less than 4 mm and a Lequesne index score of less than 9 points. Progressive joint space narrowing with placebo use was -0.19 mm (95% confidence interval, -0.29 to -0.09 mm) after 3 years. Conversely, there was no average change with glucosamine sulfate use (0.04 mm; 95% confidence interval, -0.06 to 0.14 mm), with a significant difference between groups (P =.001). Fewer patients treated with glucosamine sulfate experienced predefined severe narrowings (>0.5 mm): 5% vs 14% (P =.05). Symptoms improved modestly with placebo use but as much as 20% to 25% with glucosamine sulfate use, with significant final differences on the Lequesne index and the WOMAC total index and pain, function, and stiffness subscales. Safety was good and without differences between groups. CONCLUSION: Long-term treatment with glucosamine sulfate retarded the progression of knee osteoarthritis, possibly determining disease modification

Oh yeah and if you could please outline the exercises and stretches I would greatly appreciate it.

Ohh yeah on the supertraining list it was mentioned that leg adduction exercises have been shown to increase activation of the VMO relative to the lateral musculature of the thigh.

Something was also mentioned about squats with the thighs slightly rotated inwards also preferentially recruiting the VMO.

This got me thinking...What if you combined these two exercises with the end range leg extensions that most physios will prescribe.

Now this is just a hypothesis of MINE and I am not a physio or a doctor or a internationally renowned strength coach but...what if you did the leg presses etc while squeezing a small ball (small soccer ball perhaps) between your knees. You would be getting the benefits of the adduction, the internally rotated squat and the leg extension...possibly .... on the other hand you may injure yourself more...

Also backwards running I have heard is good but this hurt me. I guess that means I over did it a little. I have tried walking backwards against resistance (uphill or dragging a tire with a rope) also and found that I could definetly feel it in my VMO. Not very scientific I know but the best I coud come up with.

Like Chris said, keep up with your stretching. When I had PFS, I was stretching usually about an hour a day for 3 months before the pain went away. Now, I usually stretch at least 20 minutes before I train/wrestle, whatever. For me, holding a stretch 30 seconds for 4-5 sets worked well. Also, although I never tried glucosomine/chondritin, I think it would be worth a try. It can’t hurt, so you might as well try it for a few weeks and then evaluate.

the “Thomas” strech is a great strech for the IT band and Quads

Thanks, a lot, Chris! To answer your questions: Stretching - 1) lying on my stomach, pulling foot towards my butt with my hand so that stretch is felt in quad. I do this with alternating hands to get two different stretch angles. 2) “lunge” stretch, again pulling rear foot towards butt. Or alternatively you can put foot to a low chair behind you, take a step forward with your free foot and then lower your knee to floor and push your pelvis down and forward to create stretch (http://www.womenonthegreen.com/clubhouse/stretch-quad.htm but rear knee is lower) 3) This is too difficult to describe, but it is done lying on my side and using my other leg to “lock” painful lower knee immobile, and again pull foot backwards so that stretch is felt in the IT band near/above the knee. I also do some other stretches, but mainly those, once a day, using PNF method. Go to google and type iliotibial stretch to picture search to get several stretches (but not the one my physio told me).

The strengthening exercise is, as you guessed, leg extension machine with limited 30 degree arc, with emphasis on contracting VMO. Also another exercise where you sit on a chair, lock lightly bent legs under support and use VMO to raise your butt off the seat. Perhaps I’ll also do backwards walking for warmups, as we have that machine at our gym. BTW, there was no talk of taping the knee.

I can squat, no problem, no pain, no grinding feeling or noise etc. The pain I felt earlier came from irritated tendons, but now that the worst tension is stretched away, there is no pain. So the situation is not bad at all…yet. There was no narrowing of joint space visible in the x-rays or nothing serious in ultrasound, diagnosis of the physio was based on the symptoms I described and the feeling he got when moving my kneecap around.

Now to the abstracts you sent. The first certainly looks promising - if I understood correctly, the most beneficial time to supplement with GC would be now. The other seems to promise basically the same things - no repairing of the cartilage, but GC keeps it from getting worse. On the other hand, I assume that those studies were made with older people - I still have hope that due to my sports activities and relatively young age, there might be some repairing going on there as well…

Don’t read anything into the question on taping. I was just curious. I heard that taping lacks scientific backing but is still prescribed mainly due to tradition… I guess not.

Good to see that the injury is not as bad as it could have been.

Good luck with it all and please update us of any note-worthy occurs in your rehab.

Chris & others, unfortunately the only way to really tell what is happening inside the knee would be to take frequent magnetic imaging pics, and that is insanely expensive. (No insurance will cover it at this phase.) But, I’ll let you know what the physio says when I have a control visit next month. I expect to have corrected some of the imbalance by then, as I have good experiences with PNF stretching. As is stands now, there is no pain, but a slightly “odd” feeling that the knee is not tracking quite as it should be. But it is getting better all the time - I guess those quads were tight as piano strings!

JF: A couple of years ago (I think I was 27 too) I was diagnosed with chondromalacia as well. It had developed to the point that it was nearly impossible for me to walk down a flight of stairs (which made getting home on the subway a real treat). I laid off any leg traning for a long time, but I’m now back full force, squats included.

My PT gave me a stretch and an exercise which i think worked wonders. For the stretch, lay on your back and bring your knee up to your chest like a normal glute stretch, then from that position gently pull your knee across your body sort of toward your opposite shoulder and you’'ll feel a stretch through the outside of your quad and the outer portion of your glute. That was the tight area for me that was pulling the kneecap out of alignment.

To strengthen the VMO, try this: it’s sort of a lunge. Put your foot on a step or block or whatever with the toe pointed slightly outward. Then lunge diagonally in the same direction as the toe is pointing, but keep your body facing forward. I’ve never felt my VMO work that hard.

And I stay away from the leg ext, regardless of range of motion…too much shear strain on the knee for my taste.

sorry for the long reply…hope it helps.

just wanted to respond (unfortunately with less scientific information than moral support…) as a former chondromalacia sufferer. my condition lasted thru a decade of abuse from improper exercise science in martial arts training. i had chronic pain that was blamed on growing pains when i was a pre-teen or the genetic pre-predisposed sissy condition of being a girl (naturally!). when i finally ventured into the therapy lab, my patella was running damn near horizontally across my femur, and wearing the sheath to nothing.

you sound like dream patient. i was a horribly recalcitrant patient, and i didn’t do any of the initial stretching and rehab prescriptions with any regularity until my therapist put those E.T. (the movie)/EKG sucker things on my quads! he had them connected to a little machine that demonstrated the electrical activity of the muscles and helped me learn to contract my muscles in a different order and counteract the unbalance strength of of the v. lateralis versus medialis.

with “the box” (a little LED indicator that looked like the volume meter on my stereo) i could see which muscle was working and to what extent, with intention of training myself to recruit the v. medialis FIRST when doing regular movements. with the medialis pulling the patella closer to correct position, i could do the rehab exercises (all various forms of extensions and stretches) without discomfort and simultaneously strengthen the medialis separately, eventually pulling the patella all the way back into proper placement. <<unfortunately, i can’t remember what they damn thing was called (hell, it was a long time ago).>>

admittedly, the process was frustratingly meditative at first. basically, you had to “think” to yourself to get one muscle to contract first when you habitually (and successfully) have been doing it differently your whole life. but after a few weeks of mind games and therabands, i was able to take “the box” with me to the gym and do weight-bearing leg extentions without pain. i progressed from there and soon had full range of motion and strength of my knee. then, that meant i could return to competition form and NOW it means i can sit comfortably @ the movies, drive performance cars and do deads when it damn well pleases me! this is several years later… and i’m in good, athletic condition. (note: the whole rehab process probably took eight months to a year to complete, if i’m being totally honest)

i never had the discipline to take glucosamine, so i can’t speak on it from personal experience, but i have other athlete friends who swear by it (as a maintenance regime, not regeneration).

whether or not arthiritis is in your future is moot if you are still living in discomfort today. my suggestion, do all you can to try different techniques that will help understand your specific problem and then use them in combination to make the discomfort go away. if you take it a day at a time (wake up check: what hurts?) and address each problem as you encounter it, one day you’ll wake up as an extraordinarily healthy, happy eighty-year old with healthy, happy knees!

best wishes!

p.e.a.r.l.

Again, thanks all. This forum really is something - hope that it does not degenerate over time…

Yes, I also have MA (aikido, Wing Tsun) background - only a couple of years, and it’s several years since I was really active, but it seems to be extra hard on your knees. I’m practicing WT at most one day a week, and reconsidering to give it a short break for rehab.

jdav1, that sounds a bit like standard glute stretch, but perhaps with some emphasis on hip abductors and also IT band. I’ve been doing that stretch every now and then as part of my hip stretches, but perhaps I’ll notch up the frequency. BTW, it seems to improve hip mobility as well, and prevent my hip from “locking”. (It feels little tight sometimes, inside, and only releases when I get it to “pop” open by doing this stretch. Might be related to painful knee as hip movement is related to knee stresses also, and to way quad muscles are used.)

pearl, my knee cap is tracking diagonally up and outside, instead of up and down. Same thing as with you but less severe. I have a feeling that lateralis/ITB tightness is to blame rather than weak VMO, as my VMO is rather well-developed :slight_smile: There is a clear tearshape visible, thanks to moderately wide stance squatting and deadlifting. It could also be incorrect muscle triggering, but my physio did not mention that.

Left hip tightness is a constant problem, but I am working on it with a series of hip stretches. BTW, stretching seems to be a large part of my life these days, the rest is filled with logging the food for T-dawg 2.0 :slight_smile:

hey, I’ve been through almost everything you’ve been through. Stopped all squatting, leg pressing etc for a year and a half ugh!!!.. Anyway, I took tons of glucsmne. etc in a number of forms. Did nothing.

I heard an infomercial on coral calcium and totally skeptically ended up ordering from dpsnutrition and took 3-4 grms/day (a big dose… recommended for problems) and voila!.. within 10 days the pain was gone. I started squat leg presses… NO PAIN! The coral is absorbed unlike any other calcium form and inaddition to the many benefits of alkalizing the body (a HUGE benefit to bodybuilders), it is extrememly effective for bones and joints.

Hi guys, it is me (I started this thread). I’m happy to tell that my physio said that there has been great progress on the mobility of the kneecap. Actually this problem concerns whole hip-knee -area - my hips are very tight and just beginning to loosen up along with quads.

My knees have not been painful - one thing that still bothers me is the strange "pressure" above kneecap. It is caused by kneecap still riding a bit too high but I assume stretching will correct this, given enough time. Otherwise, no problems at all. Clicking has decreased a lot as knee apparently moves more freely now. Additionally I have been supplementing with glucosamine but it seems that stretching has been the main factor.

Only thing that annoys me is that quad stretches have been hard on my hip flexors! They have been a bit sore for a while now, and frequent quad stretching seems to keep them that way. Also, with increasing hip/thigh mobility, my left hip has began to pop! I think it called popping hip syndrome and is related to IT band somehow and also contributing to flexor soreness. Apparently, something in changed joint movement arcs is making my iliopsoas area sore - this is a mystery to me...

JF,

i can sympathize, being a chondro sufferer for the last 15 years (long before i started resistance training). you are extremely lucky as there is really good advice available here on the forum. i will tell you that in my situation, the thing that has helped me the most is stretching and massage. i suffer from an extremely tight IT band, and being rather difficult to stretch properly, i’ve found massage has helped quite a bit. also, since incorporating overhead squats and hip mobility exercises/stretches, i have noticed a marked improvement. my condition still flares up now and again, but not enough to impair performance or everyday activities. hope this helps.

Scott Tribby
Waterloo, On.

If you dont go get art you are crazy. Tight muscles can be fixed in five minutes by art. look into it.

No ART here, I’m living in northern Europe…otherwise would certainly pay a visit to a therapist.