Cracking Achy Knee Pain or Chondromalacia Patella – Treatment and Prevention Tips from The Barefoot Running Doctor


Chondromalacia Patella ICD-9 733.92

What is chondromalacia patella?

Athletes and trainers call it runners or jumpers knee.

Non-athletes call it cracking knees.

Doctors call it chondromalacia patella.

Knee Pain

It has many names which confuse people.  Some people even split up the word as chondro malacia patella but it should be chondromalacia patella. chondromalacia patella or CMP, sometimes called anterior knee pain; patellofemoral pain syndrome; patellar tendinitis; patellar tracking dysfunction; patella femoral syndrome; tendonitis of the knee; patellar dysfunction; patellofemoral arthralgia and chondromalacia patellae, is the softening and breakdown of the tissue (cartilage) that lines the underside of the kneecap (patella).

People come into Team Doctors and say “My knee hurts” or “I have a swollen knee, a bad knee, achy knees or bad knees.”  

Patients ask questions like:

Why is my knee sore and especially pain behind, under or below the knee cap?

Why do I have a sore knee cap and when is it chronic, why is my knee swelling?

Why is my knee popping or why do I have cracking in the knees?

Why is it my knee hurts when I bend it?

Why does my knee hurt when I squat down?

Why do I have, after running, knee pain?

When patients ask these kind of questions I am always thinking chondromalacia knee.

What is chondromalacia patella (walkers) or runners knee (runners)?

Patello-Femoral Syndrome or Chondromalacia Patella (of Greek origin meaning “softening of the cartilage”) or “Runner’s Knee”

Runners Knee refers to pain on the inside of the knee, although pain on both sides  of the knees or pain beneath the kneecap can also occur. It is more commonly seen in runners as opposed to walkers due to a higher level of activity, particularly mileage.

The key element in this injury is due to over pronation causing a repeated stress of the patella bone moving abnormally from side to side over the groove of the thigh bone (femur), gradually softening the cartilage under the kneecap.

The result is the surface of the joint can become rough. Kneecap pain may be just a prelude to further destruction of the surface (traumatic arthritis). This injury can be confused with “Patella tendonitis” which is usually pain beneath the patella bone. In either case it is the “tracking” of either the bone or tendon which needs to be addressed.

The patient commonly has no history of a knee injury like a twisted knee, nor can they pinpoint any particular event that initiated the pain in the knee cap.

Do you have patella pain,  achy knee pain or cracking or popping in the knee? Is your knee swollen or do you haven chronic knee pain? Do you have patella groove pain or patellar joint pain?  has your knee doctor or knee surgeon told you that you need knee surgery or injections for knee pain?

If you hear your knee cracking or if you have knee pain when you walk up the stairs, knee pain after running, knee pain while running, knee pain when getting up from a chair or knee pain when bending, infraptatellar pain, you might have chondromalacia patella.

Some other symptoms of chondromalacia patella are;  knee pain when you do lunges, knee pain when squatting, knee pain when doing extensions, a feeling of water on the knee, dislocated knee cap or dislocated patella.

What I have found in treating patients with pain in the knee is that knee inflammation and  intense knee pain could be caused by a locking of the Human Spring. Over pronation could be a factor so LOOK AT THE FEET FIRST!

The first thing we need to do is look at the anatomy of the knee.

What tendons are in the knee?

As you know, the patella is a pulley mechanism. (see picture to the right)  I observe many coaches looking at hamstring and quad strength as the key to patella motion in the patellofemoral groove or the trochlear grove.

note: The trochlear groove is the concave surface where the patella (kneecap) makes contact with the femur (thighbone). Also called the ‘trochlea’.

The way I see it is that the hamstrings and quads are in the middle of the kinematic chain or spring mechanism of the body. So therefore, they don’t influence. They are influenced by the way the mass transitions across the foot spring mechanism.

The answer to your Cracking Achy Knee Pain is not to pop an advil, ice pack or to do some hamstring stretches. That is like putting a bandaid over a bullet wound.


What is chondromalacia?

chondro malacia patella; Anatomy of Chondromalacia Patella:

  • Chondro = cartilage
  • Malacia = softening of tissues
  • Patella = knee cap

Chondromalacia patella is abnormal softening of the cartilage of the underside the kneecap (patella) or patellar joint. It is a cause of pain in the front of the knee (anterior knee pain). Chondromalacia patella is one of the most common causes of chronic knee pain. Chondromalacia patella results from degeneration of cartilage due to poor alignment of the kneecap (patella) as it slides over the lower end of the thighbone (femur). This process is sometimes referred to as patellofemoral syndrome.

What causes chondromalacia patella?

I have treated thousands of patients with chondromalacia patella. A patient might come in with complaints of  knee cap pain or knee osteoarthritis. The pain in the knee cap goes away without any training of the quads or hams. What I find is that on the involved side of infra patellar pain is an abnormal foot plant (over supination/ over pronation).

When transitioning the impact forces of the landing, the foot adjusts for the impacts two ways:

The 33 joints of the foot and ankle spread across the force of the landing. When this happens the impact is received as a “negative” by the tendons of the landing muscles.

The problem with the current mechanical model being used for the study of biomechanics (the lever system)–the way most podiatrists, etc., look at the body–is they look at it as a rigid lever when it is not rigid at all.

Assuming the human body ambulates, protects itself from impacts and recycles energy through a lever system is illogical and actually defies the laws of physics. A lever cannot protect an object from a lifetime minimum of 250,000,000 collisions with the earth. The body must be a spring mechanism.

The Human Spring

The body springs off the ground when its working the way its designed. The natural spring mechanism occurs at the arch and transfers its protection and spring energy through the 7 floors of the human spring.

The body is a giant spring with 7 floors of springs:

  1. The arch
  2. The subtalar joint
  3. The ankle mortise
  4. The knee and the knee cap
  5. The hip
  6. The spine
  7. The head-neck

When your spring mechanism is weak it collapses into a lever mechanism. When it collapses, the brain senses the abnormal movement patterns and tries to protect you from the stress and strain by muscle spasms. spasms compress the spring further.

Weakness, stiffening and or locking of the human spring mechanism could cause widespread chronic pain, chronic fatigue, misdiagnosed fibromyalgia, chronic inflammation as well as Chondromalacia Patella, knee cap pain, knee osteoarthritis and knee inflammation.

We must first gain an understanding of overpronation and oversupination


Safe and Unsafe Range

The foot rolls from supination to pronation. Have you ever heard of over pronation?  That is where to foot rolls too far inward outside the green safe range for foot rolling in the graphic above.

When this happens, the limb internally rotates on impact. That does not put the patella (knee cap) in a good position to allow for stress and strain free motion.

What is a knee cap?

A knee cap is like a wire in a pulley mechanism.  So the key to understanding this is simple. If the foot rolls out of the safe range the knee cap will also rotate out of the safe range in its grove as well.  Does that make sense?

If I have an athlete with patella groove pain or infra patellar pain I always do a simple gait study.

During a normal gait cycle, the femur and the tibia (thigh bone and shin bone) rotate together (i.e. outward when your foot first lands on the outside then inward when it rolls to the inside).

However, chondromalacia occurs when a person over-pronates (over rolls the foot out of the safe range) because the tibia (shin bone) is locked into the talus (ankle bone) and therefore continues to rotate inward the femur receives its orders from the brain and begins to rotate outward when your foot is planted.

This seems complex but simply stated patellar tendon pulls the knee cap out of the groove it is supposed to be in causing grinding of the undersurface cartilage leading to pain in the knee cap, patella pain, knee pain below the knee, and just general pain around the knee.

The resulting counter rotation of the femur and the tibia causes the patella to rub against the cartilage in the grove instead of moving smoothly up and down in its normal track, which causes the pain felt by the patient and the damage to the cartilage.

Over Pronated Foot

Therefore, if the foot rolls outside the safe range (green-black-green) then the limb rolls in or outside the safe range this causes the knee to be in a position where the knee cap will grind against the pulley mechanism gro0ve (trochlear gro0ve) This can cause irritation to the cartilage, chronic inflammation and knee pain.

Pain at the front/inner side of the knee is common in young adults, especially soccer players, gymnasts, cyclists, rowers, tennis players, ballet dancers, basketball players, horseback riders, volleyball players, and runners.

Knee Pain

The pain of chondromalacia patellae is typically felt after prolonged sitting, like for a movie, and so it is also called “movie sign” or “theater sign.” Snowboarders and skateboarders are prone to this injury, particularly those specializing in jumps where the knees are under great stress.

Skateboarders most commonly receive this injury in their non-dominant foot due to the constant kicking and twisting that is required of it during skateboarding. The condition may result from acute injury to the patella or from chronic friction between the patella and the groove in the femur through which it passes during motion of the knee.

Other possible causes include a tight iliotibial band, neuromas, bursitis, overuse, malalignment, core instability, and patellar maltracking.

Chondromalacia Treatment

The problem with trying to adjust the position of the patella with the training of muscles above the patella is that the most common abnormalities of limb position that effect the glide of the patella come from below, in the foot and ankle.

We all know that if we have poor posture it is because the muscles don’t have a balance of strength with respect to what role they are supposed to play. Obviously you know long term chondromalacia treatment involves chondromalacia exercises to strengthen the muscles so there is a balance of strength in the foot rolling mechanism so the foot, shin bone and thigh dont over rotate causing chondromalacia symptoms.

However, patients with a sore knee cap dont want to exercise because some exercises like knee extensions actually track the knee cap leading to under the kneecap pain the next day.

We know that we can change the position and motion of bones by training. Is it possible to train muscles when the joints they affect are locked? Its not safe for many reasons


That is why we must first stabilize the foot rolling within the safe range to stop the stress and strain that is leading to the wear and tear under the knee cap that is leading to the sore knee cap.

We do this with a shoe that has a strong medial extended counter support.

Safe and Unsafe Zone

I have treated some of the most amazing dancers from Dancing with the Stars, So You Think You Can Dance, national broadway touring companies and over 100 other tours of top entertainers.  Many are fitted for $500 custom shoes for performances and wonder why they are still in pain.

What did you do Saturday after rehearsal?

I went shopping on the sidewalk with flip flops for four hours.

Oh!  Well why do you wonder why your knee hurts?

Read these video tutorials to understand what shoes are required and why:

Video Tutorial #97 On Your Feet All Day? Fatigued? Achy? Over Pronation? I Recommend Footwear with Extended Medial Counters

Video Tutorial #86 Dr James Stoxen DC Recommends The Best Shoes To Prevent The Foot From Deforming

Why is it any different from the elbow joint where we demand form and technique be perfect during exercise to maintain limb alignment and prevent stress or strain?

If I have an athlete with patella groove pain or infra patellar pain you should do a simple gait study.

watch above as Dr. Stoxen evaluates a gait study with a patient at Team Doctors

Get a $140 HD flip video camera. Video the athlete walking barefoot 10 steps toward the camera and back. Do this while the athlete is walking, fast walking, and running. Download it and watch the video frame by frame and you will see why the patella is not in the groove. It is obvious and enlightening.

 Here is a blog post you may like that talks about “foot lock” which is when joints of the foot are locked causing abnormal movement patterns (compensations) which effect patella position and a lot more! click here to view

If you hold a curl at 90 degrees of flexion for 30 minutes the muscles go into a spasm, the joints stiffen and sometimes there is pain and altered motion. Why wouldn’t you think this same locking would happen in the foot and ankle spring when you stand for 30 minutes?

It does!

The next step in the protocol for the human spring model is the release the tension on the human spring suspension system and the mechanism throughout the entire flooring system of this integrated spring mechanism.  We start at the foot and work out way up.

watch the video tutorials below to release the human spring with my deep tissue release tips:

Be sure to start on Video Tutorial # 78 and go through Video Tutorial #89:

Watch above as Dr James Stoxen DC Demonstrates Self-Help, Deep Tissue Treatment Of The Knee Popliteus Muscle

Watch above as Dr James Stoxen DC Demonstrates Self-Help, Deep Tissue Treatment Of The Gluteus Medius Muscle of the Hip

Watch above as Dr James Stoxen DC Demonstrates How To Self-Help Deep Tissue Treatment Of The Ankle (Subtalar Joint Inside)

Watch above as Dr James Stoxen DC Demonstrates How To Self-Help Deep Tissue Treatment Of The Ankle (Subtalar Joint Outside)

Watch above as Dr James Stoxen DC Demonstrates Self-Help Deep Tissue Treatment Under The Big Toe And Second Toe

Watch above as Dr James Stoxen DC Demonstrates Self-Help Deep Tissue Treatment Above The Big Toe And Second Toe

Watch above as Dr James Stoxen DC Demonstrates Scissor Stretching Of The Feet

Watch above as Dr James Stoxen DC Demonstrates Stretching Great For Mortons Neuromas And Narrow Heels

Watch above as Dr James Stoxen DC Recommends The Best Shoes To Prevent The Foot From Deforming

Watch above as Dr James Stoxen DC Demonstrates Self-Help Deep Tissue Of The Ankle Mortise

Watch above as Dr James Stoxen DC Demonstrates Stretching Of The Foot While Sitting At Your Chair

Watch above as Dr James Stoxen DC Demonstrates A Stretch To Increase The Flexibility Of The Arch Of Your Foot

What exercises strengthen the knee?

Chondromalacia Exercises – People are always asking about what exercises strengthen the knee when it is really what exercises strengthen the feet and ankles.  The position of the 3 dimensional foot determines how the knee tracks.  In other words the knee is a victim of foot and ankle react to the landings.

The next step is to train the foot and lower extremities as lever systems in all ranges of motions with strength training 

To learn more about strengthening the human spring mechanism please read these two tutorials:

Video Tutorial #12 Is Running Bad For Your Knees? How Does The Body Spring Back Safely From Impacts Of Running and Walking?

Video Tutorial #28 Self-Tests & Exercises To Reduce Over Pronation and Over Supination From Impacts During Walking and Running

The foot is a 3-dimensional structure that has to be trained in all ranges of motion and without a binding or motion altering device.

This article and the articles that are linked to this article will give you a step by step action plan to reducing chondromalacia patella or cracking knee pain.  In order to get the best results you need to do all the steps and not miss any.

In patients with obvious over pronation I have not been able to resolve their choncromalacia pain without counter support footwear.  You can try it but I will save you the effort of making the mistake. I have never been able to do it and I doubt you will either.

Good luck treating the snap crackle pops of the cracking knee syndrome. If you need any help, please contact me in the comments section of this article and I will do my best to help you.

Thank you for sharing this article with your friends!  Dr James Stoxen DC

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About Dr James Stoxen DC (282 Posts)

Dr. James Stoxen, D.C., owns and operates Team Doctors Treatment and Training Center. and Team Doctors Sports Medicine and Anti-aging Products. He has been the meet and team chiropractor at many national and world championships. He has been inducted into the prestigious National Hall of Fame, the Personal Trainers Hall of Fame and appointed to serve on the prestigious, Global Advisory Board of The International Sports Hall of Fame. He is also a member of the Advisory Board for the American Board of Anti-Aging Health Practitioners. Dr. Stoxen is a sought after speaker, internationally having organized and /or given over 1000 live presentations around the world.(full bio)

  • Chez

    I’m mad keen to watch your gait analysis video, but unfortunately there is no audio coming from it. I’ve checked at my end and all seems to be o.k. audio wise. Do you think you could have a quick check at your end please and possibly re-send ? That would be Brill 🙂

  • Hi I will put up gait analysis videos up soon. This was just a video Debbie found that talks about how it is done in our office. I will start putting in gait analysis videos soon. That is a great idea Its time to do it! Thank you


    @Robert Marchetti I agree with Robert in the sense that imbalances in muscle strength between joints are what causes stress that strains tissues leading to micro tears, scar tissue formation and reduction in the elasticity of the tissue. We all know that elastic recoil mechanisms are what allow maximum efficiency and snap to the joints. a perfect example of that is when we teach athletes to relax during the performance of sports, an attempt to get the muscle contraction of the way to allow the elastic mechanisms to have maximum expression

    One thing I have been looking into for the last six or seven years, is barefoot training. It just seems that tying the foot up with a binding device, or movement altering device should have negative effects on the biomechanics of the human body based on the very basic principles of training. Some people have difficulty with thinking about training barefoot but then come to realize that gymnasts and martial arts athletes would look pretty silly doing flips and fancy moves with running shoes on.

    In my practice, the majority of conditions that are non-traumatic as in drama from falls or direct, from implements hitting the body I find trace down to the foot. Even with lifting injuries such as herniated discs or injuries from lives or stopping and starting, Cox or directional changes, I find it can be traced to abnormal internal forces within the mechanism that preloaded the human spring mechanism. There is a predictable painful muscle spasm pattern that predictable based upon the findings on GE valuations and not only that but what I have found is that the human body actually weakens in a very predictable manner because of the effect of various types of footwear.

    I know it may be hard for you to understand because you are possibly looking at 20 to 50 athletes year, whereas I am evaluating several thousand patients and athletes for various injuries in the weight bearing joints and all of them have had a gate examination and examination of the kinematic chain for peace muscle spasms that are tripped by the brain with the abnormal movement patterns outside of the safe range being the stimulus to trip these spasm patterns.

    I bring up some of the teachings of Verhkoshansky, whose work I have studied since I was 24 years old traveling to Moscow meeting him at that and Central Institute of physical culture and sport sciences. one of the most important lessons to be learned at athletes coaches and doctors don’t get is the concept of abnormal internal forces which are non-painful that predispose the athlete to decrease performance pulls and injuries such as hamstring pulls me injuries, herniated discs and other conditions that athletes get.

    Oftentimes athletes will say I just stepped wrong or I lifted it wrong or it was too heavy and in reality these injuries are caused by internal forces that are not detectable in initially because there is no pain associated with them however an astute trainer or doctor can find them if they know how to look what to look for them

    I have found that pulls in the lateral hamstring come from excessive internal rotation of the lower extremity or locking of the human spring mechanism which don’t allow the impact to load safely into the human spring mechanism and not weakness or tightness The eccentric phase of or loading phase of impact leaves the body in a position prime for injuries like a hamstring pull.

    Normal Internal Forces – Normal internal forces are the forces that are required to keep bones and joints together. They are minimum.

    Normal External Forces – external forces are those forces coming from clothing, implements like weights for instance.

    Abnormal External Forces – The most common external force on the human body that has a negative effect is anything that binds the human body and compresses it, which is footwear.

    Also any implement that forces the body to move in a way to preload the spring mechanism reducing its ability to safely load lifting or impact forces into the mechanism. I.e. an example of this might be a flip-flop or sandal that would fall off the foot if we don’t lift the toes causing internal force on the spring from foot to spine. as experiment while standing, dorsi flex your foot and feel the internal force that causes tension on the spring – kinematic chain.

    Mental stress can stiffen the kinematic chain – human spring mechanism too.

    Abnormal Internal Forces – These are abnormal internal preload forces that compress the human spring mechanism with a compression force that you are unaware of Anytime there is a weakness in the ability to accept the load into the spring suspension system or the landing muscles of the foot and leg we can have jamming of the limb leading to strain on the lateral hamstring.

    Also anytime there is a force that overwhelms the ability to safely roll the mass from supination to pronation the limb will internally rotate or externally rotate out of the safe range straining the hamstrings

    The mechanism that safely rolls the foot from supination of pronation with a spring loading of the 33 individual joints and tendons that suspend the arch mechanism. I call that the spring suspension system muscle group.

    What I find is that this abnormal movement pattern trips the brain to lock or spasmed the kinematic chain in a predictable way. So let’s save that creates a compressive force of 40 pounds on the kinematic chain on one side that you are unaware of. The athlete squats 300 pounds of which 150 pounds is on the left side and 190 pounds is on the right side because of the external force of the hundred and 50 pounds on the right plus the 40 pounds of internal force on the right from the spasm pattern.

    Another example of how this happens is when athletes are running, attempt to cut or change directions, plant the foot, load the force of the impact into the foot and kinematic chain, because of the internal force plus the external force of the impact, directional change, than meniscus tears, the hamstring strains or there’s a herniated disc or an ankle sprain.

    If it is a hamstring pull, the typical standard care treatment is to stretch the hamstring because it’s tight or pulled and ice it. When in reality optimum treatment approach is to look for weakness or locking of joints in the human foot that won’t allow the force of the impact to load into the 33 joints or the suspension system of the foot spring suspension system mechanism.

    What I do is a very grueling series of treatments doing deep tissue work on the three layers of muscles in the foot, release of the 33 joints of the foot, release of the tibialis posterior TFL gluteus medius and adductor muscles of the hip. Treatments have been known to take 10 – 20 hours on severe cases.

    Is the body a spring or a lever? Id like to hear your opinion

  • I have always maintained that the patella position cannot be changed from the top as much as from below. The variation in foot plant from either supination or pronation out of the safe range, to if the foot is planted with the second toe pointing towards the target or otherwise, if the person overstrikes with a heel landing position or “breaking”

    Why is it that we train every region of our bodies without binding devices and think it is ok not to train the foot with a binding device when it is restricted all day as it is. Also why is it ok not to train the foot barefoot in the COMPLETE RANGE OF MOTION movements in eversion, inversion, adduction and abduction?

    What I have found clinically over and over is that the foot plant determines patella position and not the quad and definitely not the hamstring strength comparatively. Also footwear now days is designed with curved lasts when the foot is straight and vice versa. People wear all kinds of strangely designed footwear.

    They don’t alter the quad or hamstring with any artificial movement altering devices and not to the extreme as the foot which is a minimum 8 hours a day adding up to at least 3 million impact movements a year or 100 million in our first 30 years of our lives

  • Cas

    what running shoes do you recommend for someone with chondromalacia and over pronation?

  • Carlos

    Hi Dr. Thank you for your article. Very informative. I have been diagnosed with Chondromalacia Patella and a “mild tilting patella”. My ortho, who specializes in knees, told me that he could do nothing for me… Told me I need to see a good PT. So, I have been going to a “good PT” for the past 2 weeks. My PT has recommended that I do 1.) Foam rolling, 2.) isometric knee extensions, 3.) lunges, and 4.) squats. After 2 weeks (granted, this isnt a long time), I feel absolutely ZERO improvement (they claim that after 4 weeks, I would be pain free). I have been suffering with this for 2 years now, and I am absolutely frustrated beyond belief. I have seen 2 PTs, 2 Chiro, and 2 Orthos… All of them say different things, and none of them have helped me even a bit. Any recommendations? I would do just about anything to get my legs back!! I would greatly appreciate any and all feedback, Dr. Thanks so much!

  • Valerie Hansen

    Thank you for the informative article. I was a bit confused as one article says that you should train barefoot and this one says that you should get proper shoes. I notice that I can even do stairs with no cracking/pain if I am either barefoot or wearing FiveFingers. However, I have not done much running barefoot. Would training barefoot be advised? How can I retrain my brain to alter my gait? I miss running so much. My doctor says I should never run again. Please help!


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