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86 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 2 0 ASSESSMENT When taking a history, ask your client if there are any particular patterns to the pain they experience. Clients with chondromalacia often report knee pain that occurs after sitting for long periods. This is sometimes called a positive movie sign because it happens after sitting still in a movie theater for a couple of hours. Clients are also likely to report pain during weight-bearing flexion and extension movements. The pain may not be present during passive flexion or extension because there is not sufficient load on the patellar tendon to press the patella against the femoral condyles. Therefore, having the client attempt to do an activity like squatting is more likely to produce pain than having them on the treatment table and passively flexing or extending the knee. The client may report crepitus—a sensation of grinding—under the patella during knee movements. Just as with the knee pain, crepitus sensations are much more likely during movement with some load than during passive movement when there is no load on the patella. The practitioner may also feel grinding sensations under the patella during movement by resting the palm on the patella during the movement. It is not necessary to use significant pressure with the palm; even a light contact with the patella may reveal these grinding sensations in many cases. Sometimes the pain felt in the knee during flexion or extension may be sharp and sudden. An immediate sharp pain can also accompany a sensation of the knee giving way. This knee instability involves a process called reflex muscular inhibition. The brain is trying to cease the mechanical load that caused the pain, so it inhibits the contraction stimulus to the quadriceps muscles. It is the muscular inhibition that produces the sensation of giving way. If chondromalacia has been present for some time, there may be some atrophy of the quadriceps that is apparent during physical examination. It is not clear why, but some primary antigravity muscles like the quadriceps are prone to relatively quick atrophy from disuse. Pain avoidance and decreased movement are the reasons for disuse. The atrophy is apparent by measuring the circumference of the quadriceps just proximal to the patella and comparing that with the unaffected side. Assessing Similar Conditions Several other conditions that cause anterior knee pain can often be confused with chondromalacia. Patellar tendinosis has a similar pain pattern that results from overuse and is also aggravated with resisted knee extension. However, in patellar tendinosis, it is usually easy to reproduce the client's pain by palpating the infrapatellar tendon. In chondromalacia, pain is generally not reproduced with palpation of the tendon, as the primary problem is on the patella itself and not the associated tendon. Massage therapy can play an important role in the management of chondromalacia. While massage cannot directly repair the cartilage degeneration, it is helpful to reduce and balance the forces that created the problem in the first place. Resource Ozdemir, Meltem, and Rasime Pelin Kavak. "Chondromalacia Patella Among Military Recruits with Anterior Knee Pain: Prevalence and Association with Patellofemoral Malalignment." Indian Journal of Orthopaedics 53, no. 6 (November 2019): 682–88. https:// pubmed.ncbi.nlm.nih.gov/31673166/. Lateral pull on patella. Image from 3D4Medical's Complete Anatomy application. 3