Chondromalacia Patella

Do you have pain underneath your knee cap with walking, running, or stairs?

Ever have popping, crunching, or clicking behind the knee when you move or go from a straight leg to a bent leg? All of these things may be due to a wearing down of the cartilage under the knee cap called chondromalacia patella (CPM).

As a physical therapist and past long distance runner who has chondromalacia patella in my left knee, I’ll say that this is a fairly common injury in people who do a lot of repetitive walking, running, or stairs throughout the day or while playing sports. As someone who has this injury or diagnosis, I’ve spent a good deal of time learning how to best live with it - symptom free. I’m here to save you! I want you to feel better, just like I have.

It’s super common in runners which is why it’s also called “Runner’s knee” - oh!

What is Chondromalacia Patella?

Let’s start by looking deeper at the anatomy of the knee. The knee cap is called the patella and underneath that is a layer of cartilage. Cartilage is flexible connective tissue that acts as a lubricant or cushion between bones - it’s smooth and slippery. So within the knee joint, it’s the cushion between the patella and the end of the femur (thigh bone).

Let’s think about it. If you were to have a 10hr flight on a wooden chair with no cushion, you’d most certainly have an achy booty after that flight. But if you have a regular, cushioned plane seat, you’ll be more comfortable. When there is turbulence and you’re sliding a little bit forward or side to side, there will be less friction and discomfort with the cushioning.

In a healthy knee, the cartilage between the patella and femur is super important because every time the knee bends or straightens, it can act as a buffer and maintain some space between the bones. With damaged cartilage that has flattened, dried up, and degenerated over time there is less protection and space which results in… grinding, friction, popping, cracking, etc.. Ouch!

Common Causes of Chondromalacia Patella

What often happens is there can be overuse as a result of repetitive activity or microtrauma due to physical activity. For example, if someone had an injury nearby like a fracture or dislocation, they’d be more prone to cartilage wear and tear.

This injury is more common in females, as are most knee injuries due to our anatomy (the Q angle). Speaking of angles, someone who has abnormal patellar alignment/positioning or leg length discrepancy is also more prone to this injury due to poor patellar tracking.

Weakness of the quadriceps and glutes can also make one more prone to this injury due to the resulting muscle imbalances and poor patellar tracking.

In my clinic, I saw this most often in young basketball players, runners, cyclists, rowers, dancers, and soccer players. Why? They do a lot of the same, repetitive movements over and over and over... and there’s high impact forces upon that knee.

What caused it for me? Excessive running. I had gained some weight in undergrad so I decided to train for my first marathon. That marathon never ended up happening due to this injury. However, I trained like it was going to up until that point. I was running >3 days per week with 2 short runs and 1 long run per week. I was brand new to running and had never run for fun or with a goal in mind before. I had crappy Nikes, little body awareness, no warm-up routine, and a lack of knowledge about injuries (at the time).

After a few months, the stabbing knee pain began. At first it was very intense and after a few weeks off from running it slowly began getting better. But it never quite got better all the way. After 2-3 miles it would always return and be super noisy with every little movement. I learned quite a few lessons from this experience that I’ll share later in this blog so keep reading. 

What activity causes or creates this injury?

• Running
• Going up or down stairs
• Bending the knee
• Going up or downhill
• Long periods of sitting still or standing (without movement)

What does the research say about chondromalacia patella? Common causes of poor patellar tracking include muscle imbalances, abnormal patellar or femoral angle, knee valgus or varus, leg length discrepancy, patellar dislocation/subluxation, ligament laxity, and more. [Reference]

Location & Muscles Affected by Chondromalacia Patella

We’ve already covered that this is an injury to the cartilage under the patella, but what other structures can it impact? And how can you feel it?

When asked to point where the pain is, a person may grab the entire area around their knee called the "grab sign". [Reference]

Well since the cartilage is under the patella, you can’t really feel it. But you can feel around the patella and also apply pressure downward onto the patella to see if that compression causes pain. So sit down and then feel for your knee cap with two fingers. Then run your fingers all around the knee cap. Next, press your fingers straight down on the knee cap (see the testing video below for more details). If you are suffering from chondromalacia patella, you’d definitely have pain and possibly hear or feel some grinding/cracking there - and maybe even feel some warmth and swelling. This is a shrug test or Clarke’s sign.

Testing for Chondromalacia Patella

Testing for patellar tendonitis typically begins in Physical therapy with some range of motion (ROM) tests, manual muscle selective tissue tensioning tests (testing tendon strength), muscle length tests (testing flexibility), manual muscle testing, palpation tests, and special tests.

How to Test for Patellar Tendonitis: The most widely used diagnostic test for this is an Xray. It’s difficult to differentiate this diagnosis from other knee issues. So in Physical therapy, you may be diagnosed with the catch-all phrase of patellofemoral syndrome. But later with imaging, a more specific diagnosis can be concluded.

MRIs are what best show the wearing of the cartilage to diagnose CMP. MRIs allow the degree of CMP to rated from Grade I-IV. Obviously a knee arthroscopy can diagnose even better but is invasive and expensive. So they concluded that MRI is the gold standard for diagnosing CMP.  [Reference]

But keep in mind that it’s typically suggested you perform 6-8 weeks of Physical therapy and that often yields great results. Then if there is no improvement, your Physician may suggest further testing like getting an Xray, MRI, or ultrasound to determine if there is more extensive damage near the patella or something else going on. 

Note: Most insurances won’t cover imaging until you try PT first.

Conservative Treatment for Chondromalacia Patella

Disclaimer: The information provided is not intended to be a substitute for professional medical advice, diagnosis or treatment.  Never disregard professional medical advice, or delay in seeking it, because of something you have read on this website.  Never rely on information on this website in place of seeking professional medical advice.

Now that you better understand what chondromalacia patella is, what causes it, and which structure is involved, let's now cover what you’re likely most interested in learning about: chondromalacia patella treatment. Yes!

Physical therapy treatment should always be 100% customized to you: the stage of your injury (recent/acute or chronic), your history, your activity level, your job, your impairments, your abilities, and your goals. 

With that said, the below treatments are general treatments often prescribed by Physical therapists for patellar tendonitis. Always consult your Physician before beginning any new exercise program.

Treatments for Chondromalacia Patella (from basic to advanced):

• Rest (less or modified repetitive aggravating activity)
• Joint mobilization (level depends on stage of injury; plus mobilization with movement (MWM)) [this typically involves doing medial patellar glides]
• Range of motion exercise (without a pain-free range) 
• Stretching (plus contract-relax technique)
• Strengthening exercise (including isometrics)
• Functional exercise (form training for squats, jumping, and running)
• Manual/Massage: soft tissue massage, deep tissue massage, cross friction massage (if not an acute injury), dry needling
• Modalities: Ice, Ultrasound
• Brace (if prescribed and more severe)
• Taping (of the patella for improved alignment/positioning) [typically to pull the patella medially]
• Strap (to wear only while active near the insertion at the tibia)

With improper treatment and no exercise modification, this injury could bother you and cause you pain for years, so it’s important to address it properly as it’s something that will always exist. Once the cartilage degenerates, there’s no turning back unless you undergo surgery.

If those conservative treatments don’t help then PRP injections, corticosteroid injections, or even surgery may be needed (especially if there are tears or more severe injuries included). 

Surgery for chondromalacia patella is an arthroscopic procedure in which damaged cartilage is removed. Sometimes an osteotomy is done in which bone is cut or shaved down to reduce the pressure/grinding of bones within the knee joint. Depending on what’s found the surgeon may also perform other techniques like a lateral release (lateral ligaments are cut), ligament tightening (medial ligaments are shortened), or realignment of the patellar tendon.

Below are some products from Amazon that are often useful for addressing knee pain:

Physical Therapy Exercises for Chondromalacia Patella

In the following videos, I share how to test for chondromalacia patella, how to feel for tenderness, and how to improve range of motion, flexibility, and strength.

How to Palpate for Chondromalacia Patella

Mobility, Range of Motion, and Stretching Exercises for Chondromalacia Patella

Below is a video for patellar tendonitis, but the recommended exercises for chondromalacia patella are exactly the same so these still apply:

The Best Chondromalacia Patella Strengthening Exercises

Below is a video for patellar tendonitis, but the recommended exercises for chondromalacia patella are exactly the same so these still apply:

Note: Don’t ignore the hips and ankles! You should also strengthen above and below in the kinetic chain, so strengthen those glutes and ankles, too for better shock absorption.

Mission: Mobilize, Modify, Move

It’s my goal to ensure you learn three things with every blog post: how to mobilize your body, how to modify exercise, and how to optimize your movement. 

Above I shared a video for knee mobility and stretching. I also shared some great knee strengthening exercises. Strengthening the knee helps stimulate blood flow to the muscles and tendons and repair the tendon.

Now, let’s cover some ideas for how to modify exercise if you have Chondromalacia. Some of these are things I’ve learned over the years to keep my chondromalacia pain at bay:

• The #1 game changer for me: mobility exercises for my knees. I always do mobility warm-ups prior to lifting or running - no matter what.
• The #2 game changer for me: glute strengthening 2-3x/week. I prioritize hip thrusts, glute bridges, frog pumps, and abductions to help me avoid knee caving (genuvalgus) so when I squat, lunge, step-up, or run my knee alignment is normal now.
• #3 Consider adjusting your workout split to focus more on the upper body and core more often versus lower body. For lower body workouts, put more focus on the posterior chain (glutes and hamstrings). For quad-focused exercises, modify them if needed and choose specific exercises from the video shared above (see below). Remember, there’s wear and tear on the cartilage so you don’t want to wear it down more than you have to.
• #4 Modify lower body exercises if needed by working within a comfortable range of motion, using lighter loads, slowing things down, and adjusting your stance. For example, if you’re doing a squat try these things:
• #5 Throughout the day, move more. Sitting still in a chair during class (in college) and then getting up after that was killer. So I learned to kick my leg out during class to keep it moving so it wouldn’t stiffen up. Same thing goes for standing long periods. Fidget! If you sit all day your hip flexors and quads may feel tight by the end of the day. So maybe you should set an alarm every hour to take a 1-minute break and stretch your thighs out and move those legs.
• #6 For any kneeling activity during the day or kneeling exercises, you may need to add padding, foam, or a towel under your knee for comfort or sub out the exercise. This is the only thing that still causes me discomfort is kneeling. So I’m not ashamed to pull out a foam pad at the gym when I’m kneeling. No need to be in pain when you can prevent it with a quick and easy fix.

Finally, if you plan to continue to strength train, I suggest you try these things out to move more optimally:

• Warm-up appropriately prior to lifting. Try using ankle weights or a machine to do some light leg extensions before lower body exercises.
• Definitely modify or skip these exercises temporarily if you have >4/10 discomfort: squat, any type of lunge, step-up, split squat, and leg extensions. Remember your knee will likely feel fine with all hinge pattern (deadlift variations) and bridge pattern (bridge, thrust, and frog variations) exercises still so focus more on those for the time being. 
  • Then once you feel better, you can introduce those squat pattern exercises back in slowly to increase tendon tolerance, as tolerated. One of the best ways to load the patellar tendon is to do a squat on an decline with the heels-elevated above the toes - I showed that in the strengthening exercises video FYI. 
• While choosing strengthening exercises, consider doing more unilateral work so you can go lighter on the injured side temporarily. For example, lunges, Bulgarian split squats, step-ups, or single-leg leg extensions are unilateral. Whereas squats, box squats, or split squats are bilateral.
• During cardio, temporarily decreased volume or intensity of training. For example, if you like to jog everyday, maybe you’re doing too much. Consider scaling back the distance to ⅓ or ½ of your normal distance temporarily as that may not flare up your knees as quickly. Or you could also decrease the intensity but slowing down from 9min/mi to 10min/mi. Or another option is to switch to a lower impact form of cardio like cycling, elliptical, rowing, etc..
• During sports, you may need to scale back the intensity and frequency of your training temporarily. Take time off jumping and high impact work - yes, rest. Use that time to do rehab-based exercises until your symptoms subside. Then, you can build back up with more advanced strengthening exercises that load the tendon and eventually work on speed training and plyometric work.

If any of what I said is confusing or you want additional help with addressing your impairments, be sure to watch the webinar “Outsmart your Injury” to learn more about exercise modification and how you can take control of your injury instead of letting it control you. Then reach out and let’s chat!

Thanks for reading!

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