Treating Chondromalacia Patella – Patellofemoral Pain Syndrome
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Treating Chondromalacia Patella – Patellofemoral Pain Syndrome
In this article, we will explore the various treatment options that can help people with chondromalacia patella, patellofemoral pain syndrome, or “runner’s knee” get back to their sport or activities.
In this article, you will see that problems of the kneecap and the degeneration of its protective articular cartilage are injuries that do not happen in isolation. They are part of an entire knee degenerative cycle. To fix the problems of the patella, you must fix the whole knee.
You started experiencing knee pain
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.
- If you are athletic, run and workout, you may have suffered a spike in pain and discomfort especially after running or playing in sports involving jumping.
- You may have suffered a spike in pain during exercises involving the use of “squats.”
- Pain may have become intense if you decide to drastically change your sports activity or exercise to be “more challenging.” At some point, intensive workout or running had to be stopped.
But I am not an athlete, it hurts just the same:
- In non-athletic patients, a vicious cycle may have started. You had knee pain and the knee pain makes you sit for prolonged periods of time.
- The pain is getting worse and your sitting becomes much more frequent. When you try to get up from a chair your knee pops and cracks and there can be intense pain on standing. You sit back down.
- Your situation is in a downward spiral of intense and frequent knee pain. Worse, your doctor may not believe how bad your knee hurts. See below…
You seek treatments and they are not working and your knee pain goes on and on
At some point, you decide that you can no longer manage this pain on your own with over-the-counter pain relief medications and ace bandages so you go to a health care provider.
You may have a discussion with your health care provider, in it, 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.
So what do you do about it? You may be surprised that the health care provider is recommending over-the-counter pain medications and knee braces, treatments you tried on your own that did not work for you.
Suggested treatments that you may be recommended to:
- RICE and PRICE
- The RICE Protocol is Rest, Ice, Compression and Elevation
- The PRICE Protocol adds Protection (brace or cast), Rest, Ice, Compression and Elevation
- For many athletes, a doctor’s recommendation of the RICE protocol for healing their sports-related soft tissue issue injury was seen as the gold standard of care. However, this treatment is now under criticism. Please see our article for why we do not typically recommend RICE or PRICE.
- NSAIDs is also something we would not typically recommend as chronic non-steroidal anti-inflammatory drugs (NSAIDs) usage can make the pain worse in the long-term. Please see our article, When NSAIDs make the pain worse.
Regardless, you may have tried to give these treatments one more chance. When they continue to fail, then you decide something more needs to be done. You get a prescription for physical therapy.
- 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 includes leg extensions and stretching exercises to help strengthen the thigh muscle, so the patellae or kneecap, tracks better on the femur – it doesn’t scrape the thigh bone.
- Physical therapy seeks to strengthen the quadriceps as these muscles are the main stabilizers of your kneecap. Physical therapy will have limited or no success if the quadriceps tendon, the tendon that connects the “quads,” the vastus lateralis, vastus medialis, vastus intermedius, and the rectus femoris muscles to the knee cap are weakened. For physical therapy to work, there must be some resistance between muscle and bone. If the quadriceps tendon is damaged, injured, stretched, or harmed in a significant way, physical therapy will have limited if no success.
- Physical therapy will also not work if the ligaments of the knee are compromised or weakened. Ligaments, such as the ACL. MCL, PCL hold the knee together by connecting the bones.
- Muscle-strengthening exercises may improve the relative location of the patella upon movement, but do not improve the tendons, ligaments, or cartilage.
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:
There is research to suggest that you may benefit from a knee brace or some type of elastic knee sleeve for your patella related knee pain.(1).
Doctors at Queen Mary University of London wrote in the medical journal Sports Medicine (2) that doctors “with appropriate caution,” should consider brace and taping:
- Offer taping for those patients with greater pain,
- Offer orthoses (knee braces) for older individuals and exercise for younger individuals, and
- Offer orthoses (foot inserts) intervention for patients with greater forefoot and rearfoot abnormalities.
Why the caution? Because there is not good evidence that these treatments work. Further taping and bracing provides a false sense of stability and can lead to greater knee damage.
“Unsatisfactory long-term prognosis of conservative treatment of patellofemoral pain syndrome”
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. (3)
- In this study, the Danish team looked at military personnel, athletes, and the general public to offer doctors a clue to how well or unwell conservative treatments work for patellofemoral pain syndrome.
- Only 29% of soldiers,
- Only 27.8% of sports-active and
- Only 24,7% of the general public will become pain-free after they are diagnosed with patellofemoral pain syndrome.
- 21.5% of sports-active and 23% of the general public diagnosed with patellofemoral pain syndrome will stop participating in sports because of knee pain.
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 (4) that found that MRI was ineffective in helping doctors determine the extent of injury in instances of Chondromalacia Patellae.
In 2018. the problem remained. In The Eurasian Journal of Medicine, (5) 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, (6) wrote that what your son or daughter are 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 to the management of PFP (Patellofemoral Pain Syndrome) in adolescent athletes as worst functional status is linked with poor prognosis in patients with PFP.”
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:
“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.”(7)
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.(8) These published 2018 findings are similar to what we see in patients here are Caring Medical and Rehabilitation Services. Something is going on beyond normal biomechanical problems. Here is the UK research:
- Participants offered rich and detailed accounts of the impact and lived experience of Patellofemoral Pain Syndrome, including:
- loss of physical and functional ability;
- loss of self-identity;
- pain-related confusion and
- difficulty making sense of their pain;
- pain-related fear, including fear-avoidance and ‘damage’ beliefs;
- inappropriate coping strategies and fear of the future.
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, (9) 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).
- Let’s sidetrack for a moment. The person with patellofemoral pain may have gotten that way because of repeated overload, as in running. He/she may have embarked on an aggressive physical therapy campaign to get themselves back to running. Their symptoms got worse. See below on how this impacts women runners.
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.”
- In women, the pain became more generalized and pain spread beyond the knee.
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,(10) 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.
- What this all means is that continued stress on the knee accelerated pain sensitivity. You feel more pain than the damage to the knee should be causing.
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 were examined:
- “Anxiety, depression, catastrophizing and fear of movement may be elevated in individuals with Patellofemoral Pain Syndrome and correlate with pain and reduced physical function.”(11)
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.
- Women who had a lower pain threshold in their knee found themselves with heightened pain throughout their body.
- Additionally, this heightened pain, which is related to self-reported knee function, appears to be increased by greater running volumes.(12)
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:
- Little is understood of how pain processing is changed with Patellofemoral Pain Syndrome and how a patient can suffer from hyperalgesia or hypoesthesia (a reduced sense of pain) and what type of alterations to natural knee movement can cause these changes.
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.
- This suggested that Patellofemoral Pain Syndrome is characterized by an increase in both localized and centralized pain sensitivity that is related to movement mechanics. Knee pain and knee instability caused greater and heightened pain.(13)
Treatment: Regenerative repair of knee damage or patellofemoral cartilage surgery?
The surgery option
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 the medical research.
In June 2018, research led by Harvard Medical School published in the journal Current Reviews in Musculoskeletal Medicine (xxx) warned surgeons and patients, especially athletes, to have a realistic expectation of what the 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.”
In the journal Sports Medicine and Arthroscopy Review, (March 2017) (15) 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:
- Patella-medial patellofemoral ligament reconstruction
- This is a surgery usually reserved for knee cap dislocation. As patella pain syndrome may have patellar maltracking as a cause, this is where the patella moves out of its groove resulting in damage to the cartilage that covers its back, it is thought that surgical replacement of the patella-medial patellofemoral ligament will provide ample stability to the knee cap and alleviate pain.
- While we agree that the patella-medial patellofemoral ligament plays a major role in providing pain-free knee movement. We do not agree that surgery is the best way to repair it unless there is a complete “disintegration” injury. In this type of injury, the ligament literally explodes and there is nothing left to repair.
- We have an extensive article Surgery and non-surgical treatments for acute and chronic knee cap dislocation that explains this procedure further.
- Tibial tubercle osteotomy
- In this surgery, the patella tendon is moved by slicing off the bone it attaches to, moving it on the shin bone (tibia), and then reattaching the bone with the tendon to the shin bone with a screw.
- The goal of this surgery is to provide stability to the knee by using the re-positioned tendon to hold the patella in the correct position on the knee.
The non-surgery option
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. 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.(16) This theory was tested among 12 women aged 20-30 years with a diagnosis of patellofemoral pain.
- What is this study suggesting the knee brace provides stability so the muscles could function correctly. Of course, knee braces are not long-term treatments for knee cap instability. Treatments that stabilize the knee by strengthening the ligaments and tendons are.
You must treat the whole knee
A November 2017 study in the journal Radiology and oncology (17) discussed what radiological findings revealed in 100 patients with patella problems.
- Mild osteoarthritis (grade I and II) was determined in 55 patients
- Severe osteoarthritis (grade III and IV) in 45 cases.
- The cartilage behind the knee cap at the retropatellar joint:
- 25 patients were assessed as normal cartilage,
- 29 patients were diagnosed with mild chondromalacia patella (grade I and II) and
- 46 with severe chondromalacia patella (grade III and IV).
- Medial meniscus tear was determined in 51 patients.
- Severe osteoarthritis and chondromalacia patella were positively correlated with a meniscal tear. (If you have chondromalacia patella you likely have a meniscus tear).
- The researchers observed a greater prevalence of bursitis in the medial compartment of the knee in patients with severe osteoarthritis and medial meniscus tear.
So now that we have the idea that something holding your knee more stable would get your knee to work properly. Let’s explore more long-term and possibly curative treatments.
Comprehensive Prolotherapy for Patellofemoral Pain Syndrome – The whole knee
“. . . 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.”(19)
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 knee cap 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. (18)
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:
- Patients experienced statistically significant decreases in pain
- Stiffness and crepitus decreased after Prolotherapy,
- Range of Motion increased.
- Patients reported improved walking ability and exercise ability after prolotherapy.
- No side effects of prolotherapy were noted.
- Only 3 of 69 knees were still recommended for surgery after Prolotherapy.
- Prolotherapy decreased chondromalacia patella symptoms and improved physical ability.
- Patients experience long-term improvement without requiring pain medications.
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.(19) Here we found:
- In summary, the outcomes of this study illustrated that Prolotherapy may be an effective treatment for reducing the symptoms of chondromalacia patella.
- The observed decreases in symptoms of patients who received Prolotherapy were shown to be highly significant.
- The patients in this study who received Prolotherapy improved in the overall level of pain, function, and mobility in the case of chondromalacia patella.
- These improvements were seen in varying durations of initial pain and treatment and gender.
- Improvements observed with Prolotherapy were seen in patients of all ages, making the potential benefits of Prolotherapy generalizable to the majority of the U.S. adult population.
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
1 Uboldi FM, Ferrua P, Tradati D, Zedde P, Richards J, Manunta A, Berruto M. Use of an Elastomeric Knee Brace in Patellofemoral Pain Syndrome: Short-Term Results. Joints. 2018 Jun 22. [Google Scholar]
2 Lack S, Barton C, Vicenzino B, Morrissey D. Outcome predictors for conservative patellofemoral pain management: a systematic review and meta-analysis. Sports Medicine. 2014 Dec 1;44(12):1703-16. [Google Scholar]
3 Rathleff MS, Rasmussen S, Olesen JL. Unsatisfactory long-term prognosis of conservative treatment of patellofemoral pain syndrome. Ugeskrift for laeger. 2012 Apr;174(15):1008-13. [Google Scholar]
4 Mattila VM, Weckström M, Leppänen V, Kiuru M, Pihlajamäki H. Sensitivity of MRI for articular cartilage lesions of the patellae. Scandinavian Journal of Surgery. 2012 Mar;101(1):56-61. [Google Scholar]
5 Aysin IK, Askin A, Mete BD, Guvendi E, Aysin M, Kocyigit H. Investigation of the Relationship between Anterior Knee Pain and Chondromalacia Patellae and Patellofemoral Malalignment. The Eurasian journal of medicine. 2018 Feb;50(1):28. [Google Scholar]
6 Ferreira AS, de Oliveira Silva D, Del Priore LB, Garcia CL, Ducatti MH, Botta AF, Waiteman MC, de Azevedo FM. Differences in pain and function between adolescent athletes and physically active non-athletes with patellofemoral pain. Physical Therapy in Sport. 2018 Sep 1;33:70-5. [Google Scholar]
7 McConnell J. Management of a difficult knee problem. Man Ther. 2012 Jun 27. [Google Scholar]
8 Smith BE, Moffatt F, Hendrick P, Bateman M, Rathleff MS, Selfe J, Smith TO, Logan P. The experience of living with patellofemoral pain—loss, confusion and fear-avoidance: a UK qualitative study. BMJ open. 2018 Jan 1;8(1):e018624. [Google Scholar]
9 van der Heijden RA, Rijndertse MM, Bierma-Zeinstra SM, van Middelkoop M. Lower Pressure Pain Thresholds in Patellofemoral Pain Patients, Especially in Female Patients: A Cross-Sectional Case-Control Study. Pain Medicine. 2017 Apr 6;19(1):184-92. [Google Scholar]
10 van der Heijden RA, Rijndertse MM, Bierma-Zeinstra SM, van Middelkoop M. Lower Pressure Pain Thresholds in Patellofemoral Pain Patients, Especially in Female Patients: A Cross-Sectional Case-Control Study. Pain Med. Epub 2017 Apr 6 Jan 2018 [Google Scholar]
11 Maclachlan LR, Collins NJ, Matthews MLG, Hodges PW, Vicenzino B. The psychological features of patellofemoral pain: a systematic review. Br J Sports Med. 2017 May;51(9):732-742. [Google Scholar]
12 Pazzinatto MF, de Oliveira Silva D, Pradela J, Coura MB, Barton C, de Azevedo FM. Local and widespread hyperalgesia in female runners with patellofemoral pain are influenced by running volume. J Sci Med Sport. 2017 Apr;20(4):362-367. [Google Scholar]
13 Noehren B, Shuping L, Jones A, Akers DA, Bush HM, Sluka KA. Somatosensory and Biomechanical Abnormalities in Females With Patellofemoral Pain. Clin J Pain. 2016 Oct;32(10):915-9. [Google Scholar]
14 Mestriner AB, Ackermann J, Gomoll AH. Patellofemoral Cartilage Repair. Current reviews in musculoskeletal medicine. 2018 Jun 1;11(2):188-200. [Google Scholar]
15 Caplan N, Nassar I, Anand B, Kader DF. Why do patellofemoral stabilization procedures fail? Keys to success. Sports medicine and arthroscopy review. 2017 Mar 1;25(1):e1-7.
16 Sker FS, Anbarian M, Yazdani AH, Hesari P, Babaei-Ghazani A. Patellar bracing affects sEMG activity of leg and thigh muscles during stance phase in patellofemoral pain syndrome. Gait & Posture. 2017 Jun 29. [Google Scholar]
17 Resorlu M, Doner D, Karatag O, Toprak CA. The relationship between chondromalacia patella, medial meniscal tear and medial periarticular bursitis in patients with osteoarthritis. Radiology and oncology. 2017 Nov 29;51(4):401-6. [Google Scholar]
18 Hauser RA. Outcomes of Prolotherapy in Chondromalacia Patella Patients: Improvements in Pain Level and Function. Clin Med Insights Arthritis Musculoskelet Disord. 2014; 7: 13–20. [Google Scholar]
19 Maddela HS, Hauser RA. The Use of Prolotherapy for Chondromalacia Patella (Patellofemoral Pain Syndrome). Journal of Prolotherapy. 2018;10:e1000-e1008.