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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