Treating Patellofemoral Pain Syndrome and chondromalacia patella

In this article, we will explore the various treatment options that can help people today with chondromalacia patella, patellofemoral pain syndrome, or “runner’s knee” get back to their sport or activities.

You started experiencing knee pain, your kneecap is sliding out of place, you can no longer exercise or walk down a flight of stairs without pain. You need help.

If you are like the many patients we see, you started experiencing knee pain. At first, it was not quite a sharp pain but rather a chronic dull pain that seemed to center on the front of your knee around the knee cap. Then it started to get worse and it started to affect the way you move, work, and participate in sport or exercise.

But I am not an athlete, it hurts just the same:

At some point, you decide that you can no longer manage this pain on your own with over-the-counter pain relief medications, knee braces, and ace bandages so you go to a health care provider.

You may have a discussion with your healthcare provider, in this discussion, he/she may discuss with you chondromalacia patella. (Chondro means cartilage, malacia means breakdown, and patella means kneecap.) Thus, chondromalacia patella refers to cartilage breakdown underneath the kneecap. Your health care provider may also call this, patellofemoral dysfunction or patellar-tracking dysfunction. If your pain is severe, he/she may discuss with you Patellofemoral Pain Syndrome.

If you are an athlete, your clinician may call your condition “runner’s knee,” which is simply a broad description of knee pain that is coming from the knee cap area attributed to overuse.

Whatever it is called, this problem you have is a problem that began as a patellar-tracking problem. You are having pain when the underside of the kneecap is abnormally rubbing against the thigh bone.

I don’t understand what my problem is. “No matter what you call it, you have pain.”

People who have patella related pain are sometimes confused by diagnosis, treatment plan, and general understanding of what is going on in their knee. Their frustration in multiple diagnoses and a lot of testing is in fact displayed in the statement, “whatever you call it, I have pain.”

A study in the journal Clinics in sports medicine (1) offered this challenge to doctors and patients in understanding problems of the knee centered on the patella.

“Patellofemoral pain syndrome is a frequently encountered overuse disorder that involves the patellofemoral region and often presents as anterior (front) knee pain. Patellofemoral pain can be difficult to diagnose. Not only do the etiology, diagnosis, and treatment remain challenging, but the terminology used to describe Patellofemoral pain is used inconsistently and can be confusing. Patellofemoral pain syndrome (PFPS) seems to be multifactorial, resulting from a complex interaction among intrinsic anatomic and external training factors. Although clinicians frequently make the diagnosis of Patellofemoral pain syndrome, no consensus exists about its etiology or the factors most responsible for causing pain.”

That study was published in 2010, and reflects a problem in 2010. Certainly things have changed in ten years. Perhaps what has changed is that doctors are more aware that Patellofemoral pain is a confusing diagnosis. But confusion is still there.

Doctors are more aware that Patellofemoral pain is a confusing diagnosis

In 2017, building on this theme, doctors wrote in the Open access journal of sports medicine,(2) of the problems that need to be recognized in athletes.

“Patellofemoral pain is a very common problem in athletes who participate in jumping, cutting and pivoting sports. Several risk factors may play a part in the pathogenesis of Patellofemoral pain. Overuse, trauma and intrinsic risk factors are particularly important among athletes. Physical examination has a key role in Patellofemoral pain diagnosis. Furthermore, common risk factors should be investigated, such as hip muscle dysfunction, poor core muscle endurance, muscular tightness, excessive foot pronation and patellar malalignment. Imaging is seldom needed in special cases. Many possible interventions are recommended for patellofemoral pain management. Due to the multifactorial nature of patellofemoral pain , the clinical approach should be individualized, and the contribution of different factors should be considered and managed accordingly. In most cases, activity modification and rehabilitation should be tried before any surgical interventions.”

The many problems in the knee that surround a patella diagnosis

Typically a patient with knee problems will include among the problems just mention in the above research study, other problems including a meniscus tear, a knee bursitis, a developing osteoarthritis along with a patella diagnosis in their medical history. They will also have, in many cases, a corresponding treatment program for each individual problem.

Other patients we see will simple report that want to be treated for “patellofemoral syndrome,” or “chondromalacia in my patella.” Usually they contact us after conservative treatments and physical therapy have not helped enough. Sometimes they even contact us after a surgery such as a patella debridement, a tibial tubercle osteotomy, or a patellofemoral ligament reconstruction were tried. (We discuss these procedures below). So their medical history up until the point of contacting our center is one of continued and in some cases severe knee pain, chronic knee swelling, walking difficulties, problems walking up and down stairs and the near or total inability to run or jump.

A pain that no one understands and in some cases, no one believes

Sometimes people will report pain that no one understands and in some cases, no one believes. While we will discuss this at length below, we want to touch on a November 2020 study (3) here to highlight and address this problem.

In this study, researchers at the University of Wisconsin-Milwaukee, Concordia University Wisconsin, and Marquette University outlined the problems of “more pain than the patient with patella disorder should have,” and what may cause it.

Learning points:

This study’s aim was to “determine whether evidence supports manifestations of central sensitization in individuals with Patellofemoral pain. (Simply, is this real?)

The findings?

So what do you do about it? You may be surprised that the health care provider is recommending the same over-the-counter pain medications and knee braces, treatments you tried on your own that did not work for you.

Some patients report the frustration of going from specialist to specialist and still getting the same recommendations for treatment, or better understood as “apin management,” that has not worked for them before and is in fact part of the reason they are going from specialist to specialist.

Suggested treatments that you may be recommended to over and over.

Physical therapy? Physical therapy will typically fail if the strong connective ligament and tendons needed to provide resistance to maximize muscle gain and knee stability are not strong enough.

The patella is pulled and pushed in all directions. It is pulled by the Iliotibial band, it is stabilized in place by the lateral patellar retinaculum and the medial patellar retinaculum. The quadriceps move the patella upwards, the patellar ligament moves it downward. When one of these structures is weakened or damaged through degenerative wear and tear, the knee cap becomes unstable.

The patella is pulled and pushed in all directions. It is pulled by the Iliotibial band, it is stabilized in place by the lateral patellar retinaculum and the medial patellar retinaculum. The quadriceps move the patella upwards, the patellar ligament moves it downward. When one of these structures is weakened or damaged through degenerative wear and tear, the knee cap becomes unstable.

Physical therapy is a very appealing option because it is exercise and people believe exercise is always beneficial. If you are reading this article physical therapy has likely failed you as well.

Physical therapy will typically fail if the strong connective ligament and tendons needed to provide resistance to maximize muscle gain and stability are not strong enough. We will address this problem and offer our evidence for regenerative medicine injections to correct this problem below.

Will a knee brace or tape hold my knee together, even with “appropriate caution?”

In physical therapy, strong connective ligament and tendons are needed to provide resistance. In normal everyday movement, strong connective ligaments and tendons are needed to hold the knee stable and together. Some believe an external brace or tape may help do this job:

Research in the medical journal Joints, (4) suggest that you may benefit from a knee brace or some type of elastic knee sleeve for your patella related knee pain and help you return to your sport. Many of you reading this article are probably behind a knee brace or sleeve helping.

Doctors at Queen Mary University of London wrote in the medical journal Sports Medicine (5) that doctors “with appropriate caution,” should consider brace and taping:

Why the caution? Because there is not good evidence that these treatments work for everyone. Further taping and bracing provides a false sense of stability and can lead to greater knee damage.

Knee braces do provide relief from fear

Some people will need a knee brace but it may be more of a physiological than functional need. In April 2020, researchers published in the Archives of Physical Medicine and Rehabilitation (6) the outcomes of people with patellofemoral pain wearing a knee brace for two weeks compared to a group of people who had patellofemoral pain and did not wear a knee brace for two weeks. Results found that knee braces reduced kinesiophobia (fear of movement) in people with patellofemoral pain after two weeks of wearing one and at six-week follow up. The researchers concluded that “a knee brace may be considered within clinically reasoned paradigms to facilitate exercise therapy interventions for people with Patellofemoral Pain.” In other words, if the knee brace gives them the confidence to exercise, that would be okay.

“Unsatisfactory long-term prognosis of conservative treatment of patellofemoral pain syndrome”

Why consider these treatments if your chances are 1 in 4 that they will work for you and less that they will get you back to your sport?

In 2018, these same researchers made clear in the journal Physical Therapy in Sport (7)  that: “Long-term (traditional) treatment outcomes of (Patellofemoral pain) are poor, with estimates that more than 50% of people with the condition will report symptoms beyond 5 years following diagnosis. Additionally, emerging evidence indicates that PFP may be on a continuum with patellofemoral osteoarthritis.”

So why are these things not working? The heading above is the title of a research paper from Danish researchers published in the Journal of the Danish Medical Association.(8)

These are very low numbers. Why consider these treatments if your chances are 1 in 4 that they will work for you and less that they will get you back to your sport?

As mentioned above, supportive knee braces, arch supports, and taping may also be recommended to improve the alignment of the kneecap. The problem with this approach is that they do not repair the deteriorated cartilage in the patellae.

The MRI will not see your knee pain getting worse and it will confuse you and your doctor

When we talk about MRIs it is often best to listen to radiologists and the surgeons that rely on the MRI for the surgical or non-surgical recommendation. In 2012 Doctors at the Finish Institute of Military Medicine published research (9) that found that MRI was ineffective in helping doctors determine the extent of injury in instances of chondromalacia patellae.

In 2018, as well as in 2020, the problem remained. In The Eurasian Journal of Medicine, (10) doctors in Turkey announced: “as chondromalacia stage advances, the symptom severity worsens and knee functions decline; however, MRI measurements do not show the difference between early and advanced stage chondromalacia patella patients.”

Unexplained and significant elevation in knee pain that your doctor may not believe

Something is going on beyond normal biomechanical problems

Your doctor is looking at your MRI. Your knee does not look worse. But your pain is. You are confusing your health care providers as nothing seems to work for you. Maybe this is “all in your head?” because it is not on your MRI.

You may also be researching for your son or daughter who is confusing their doctors with a description of elevated pain that “should not be there.”

Doctors writing in the journal Physical Therapy in Sport, (11) wrote that what your son or daughter is trying to describe as heightened pain, is real. Read this:

Adolescent athletes presented higher levels of pain and lower physical function status compared with physically active non-athletes. This provides an important insight into the management of (Patellofemoral Pain Syndrome) in adolescent athletes as the worst functional status is linked with poor prognosis in patients with Patellofemoral Pain Syndrome.”

Something is causing more pain in the athletes than the non-athletes.

“The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms”

Physiotherapist Jenny McConnell wrote in the medical journal Manual Therapy:(12)

“Although the management of Patellofemoral Pain has improved greatly, there is still a category of patient who tends to have recalcitrant (non-responsive) symptoms, which are difficult to manage. The patient often bounces from practitioner to practitioner, physiotherapist as well as surgeon, for some relief of symptoms. However, often the underlying source of the pain is not well understood, so treatment can aggravate the symptoms.”

When knee pain is worse than it should be and nothing is working, what next?

Leading university researchers in the United Kingdom and Denmark, working within the UK’s National Health Services at Derby, made some observations of the patient’s mindset in regard to his/her diagnosis of Patellofemoral Pain Syndrome. (13) These published 2018 findings are similar to what we see in patients here at Caring Medical. Something is going on beyond normal biomechanical problems. Here is the UK research:

The researchers concluded: “The current consensus that best-evidence treatments consisting of hip and knee strengthening (physical therapy and exercise) may not be adequate to address the fears and beliefs identified in the current study.

Hip and knee strengthening (physical therapy and exercise) may not be adequate to heal the problem. Are they actually making it worse? Especially in women?

Doctors in the Netherlands writing in the medical journal Pain Medicine, (14) reviewed the theory that repeated stress and overloading on a knee with patellofemoral pain may sensitize nociceptors (nerve cell endings) to be even more sensitive to painful stimuli (hyperalgesia).

Here is the conclusion from this research: “Local and generalized pressure hyperalgesia, suggesting alterations in both peripheral and central pain processing (you feel pain more), were present in patients with patellofemoral pain, though females with patellofemoral pain were most likely to suffer from generalized hyperalgesia.”

Patellofemoral pain syndrome impacting the whole body

In a third 2018 study, doctors at the Erasmus University Medical Center in The Netherlands published findings that help understand patellofemoral pain syndrome impacting the whole body. Publishing in the journal Pain Medicine,(15) the Dutch team found knee and generalized (whole body) stress and overload hyperalgesia in these patients suggesting the knee pain caused alterations in both peripheral (musculoskeletal nerves outside of the brain and spinal cord) and central pain (nerves in the central nervous system) processing.

These troubling findings were expanded on in research published in May 2017 in the British Journal of Sports Medicine where the physiological component of Patellofemoral Pain Syndrome was examined:

Patellofemoral Pain Syndrome – Why women feel more pain

In April 2017,  Brazilian and English researchers combined to publish research in the Journal of science and medicine in sport suggesting a serious problem for female runners.

We touched on this briefly above, overtraining, physical therapy, the continuance of running may make for more pain than the damage should be creating.

A combined research team from the University of Kentucky and the University of Iowa wrote in the Clinical Journal of Pain:

In their study, the researchers looked at twenty females diagnosed with Patellofemoral Pain and 20 age-matched pain-free females participated in this study. What they found was the frontal plane knee angle (an unnatural knee alignment)  existed in the Patellofemoral Pain group which was not present in the control group.

Patellofemoral cartilage surgery?

For many people, surgery may or “will have to be recommended.” For many people surgery will be a success procedure and meet their expectations and hope. We typically do not see patients who had successful surgery. We see the patients who did not, have lingering complications or a general sense of instability about the knee.

For a frustrated athlete, the call of surgery is strong. Surgery, however, is usually not indicated for Patella Pain Syndrome unless the non-surgical treatment options we explored earlier in this article have been exhausted.

When we discuss surgery it is always best to bring in surgical consults from medical research.

“Unrealistic expectations are common and will lead to disappointment.”

In June 2018, research led by Harvard Medical School published in the journal Current Reviews in Musculoskeletal Medicine (19) warned surgeons and patients, especially athletes, to have a realistic expectation of what cartilage repair in the patellofemoral joint surgery can really offer them:

“Cartilage repair in the patellofemoral joint has demonstrated increasingly good outcomes in patients with patellofemoral cartilage defects after conservative treatment has failed. . . It is of utmost importance to discuss with the patient current functional limitations in sports and activities of daily living, to elucidate the patient’s goals and expectations, and to go over the rehabilitation and recovery time.

Unrealistic expectations are common and will lead to disappointment.

Careful evaluation of the knee and lower extremity, through physical examination and imaging studies, is crucial. This will allow planning a comprehensive treatment approach for the cartilage repair procedure, as well as any additional pathology that needs to be addressed in a staged or concomitant fashion.”

What is being said here is that the surgery is usually successful as far as surgery goes. But it is usually not successful in helping the patient/athlete with their goals have had the surgery. To get back to sports or work quickly. “Unrealistic expectations are common and will lead to disappointment.”

“This rise in surgical intervention has brought about various complications.”

In the journal Sports Medicine and Arthroscopy Review, (March 2017) (20) Dr. Nick Caplan Ph.D., wrote:

“In recent years, surgical interventions for patellofemoral joint instability have gained popularity, possibly revitalized by the recent advances in our understanding of patellofemoral joint instability and the introduction of a number of new surgical procedures. This rise in surgical intervention has brought about various complications.”

Dr. Caplan and his associates went on to describe the various complications associated with certain surgeries including:

Younger patients better surgical results, but what do you do with older patients? Patellofemoral arthroplasty?

In November 2019, (21) orthopedists at the State University of New York at Buffalo published a study suggesting “that patients have improved clinical outcomes after microfracture of symptomatic patellofemoral chondral lesions at midterm follow-up. Our review also found some evidence to suggest that younger patients may have improved clinical outcomes that are more durable over time compared with older patients. However, we could not draw any definitive conclusions regarding the effect of location, size, or severity of the chondral lesion.”

Older patients may not fare as well. So what do we do with them? Knee cap replacement?

Patellofemoral arthroplasty or “knee cap replacement,” is a surgery that can be performed in isolation if the patella osteoarthritis is the main cause of a patient’s pain. It is usually reserved for older patients for whom microfracture or arthroscopic patella surgery was not or is deemed to not be successful.

Solving Patellofemoral Pain Syndrome is recognizing the problem of knee instability

We are going to look at the problem of Patellofemoral Pain Syndrome as a problem of knee instability. A problem that can be treated with regenerative medicine injections.

In the research above we mentioned that knee braces or sleeves could provide some temporary relief especially psychologically. Medical university researchers shared their observations on what a knee brace could do for patellofemoral pain symptoms.

Writing in the European journal Gait Posture published by Oxford University, the researchers discovered that the most beneficial aspect of wearing a brace was during walking and that the brace helped coordinate muscle activity around the knee.(22) This theory was tested among 12 women aged 20-30 years with a diagnosis of patellofemoral pain.

You must treat the whole knee to fix the problem of patella pain

A November 2017 study in the journal Radiology and oncology (23) discussed what radiological findings revealed in 100 patients with patella problems.

Comprehensive Prolotherapy for Patellofemoral Pain Syndrome – treating the whole knee

Research: “. . . patients with chondromalacia patella who received Prolotherapy reported a significant decrease in their levels of pain at rest, normal activity, and exercise, in addition to an improvement of range of motion, decrease in knee stiffness, and reduction in crepitus.”(18)

In this section, we will explain the regenerative injection treatment Prolotherapy

When we examine a patient with patellofemoral pain syndrome, we can see that the patella is usually “tracking laterally.” This means that the knee cap is slightly out of the central groove it normally sits in and has moved to one side. This is reflected on x-ray such as the one below.

We explain to the patient that our goal of treatment is to get the kneecap back into its groove with simple dextrose injections targeting the muscle attachments that connect the muscle to the knee cap (the quadriceps tendon at the patella tendon). We also explain that we want to target the various ligaments in the knee, to strengthen them, and help pull the knee back into correct anatomical alignment.

The treatment is demonstrated and explained in the video above.

In 2014, our staff at Caring Medical published research findings in a paper entitled: Outcomes of Prolotherapy in Chondromalacia Patella Patients: Improvements in Pain Level and Function in the medical journal Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. (24)

In this paper, our team evaluated the effectiveness of Prolotherapy in resolving pain, stiffness, and crepitus, and improving physical activity in chondromalacia patients. We examined and treated Sixty-nine knees with Prolotherapy in 61 patients (33 female and 36 male) who were 18–82 years old (average, 47.2 years).

Following Prolotherapy treatments:

Demonstration of the treatment with Ross Hauser, MD

A summary explanation and learning points of this video are presented below:

The treatment begins at 1:50 of the video

Sunrise imaging of the knees before and after Prolotherapy treatments. The alignment in this patient's knees after Prolotherapy is much improved. The patient suffered from chondromalacia patellae and patellofemoral pain syndrome. Prolotherapy helped this patient get back to pain free running.

Sunrise imaging of the knees before and after Prolotherapy treatments. The alignment in this patient’s knees after Prolotherapy is much improved. The patient suffered from chondromalacia patellae and patellofemoral pain syndrome. Prolotherapy helped this patient get back to pain-free running.

PRP and Prolotherapy

PRP as we perform it, is NOT a single injection. It is a comprehensive treatment that addresses problems, weakness, and instability of the whole knee capsule.

Continuing research 2018, The Use of Prolotherapy for Chondromalacia Patella (Patellofemoral Pain Syndrome)

In 2018, our research team published new findings in the Journal of Prolotherapy.(25) Here we found:

Since traditional treatments for this condition are often ineffective and sometimes detrimental to the health of the knee, serious consideration should be placed on using Prolotherapy as a first-line treatment for chondromalacia patella.

If this article has helped you understand treating Chondromalacia Patella – Patellofemoral Pain Syndrome and would like to explore your treatment options, you can get help and information from our specialists

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