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Signs and symptoms of patellofemoral pain include:
A dull, achy pain in the front of your knee
Increased pain when you walk up or down stairs (the most common symptom)
Pain in your knee when kneeling or squatting
Knee pain after sitting for long periods of time
A grating or grinding sensation when you extend your knee
Knee stiffness
Pain around the knee. The pain is usually located at the front of the knee, around or behind the knee cap. The pain is typically worse when going up or down stairs. It may be brought on by sitting (with the knees bent) for long periods.
A grating or grinding feeling or noise when the knee moves knee (‘crepitus’).
Rarely, some fluid swelling (‘effusion’) of the knee joint.

What is the treatment for chondromalacia?
Avoid strenuous use of the knee – until the pain eases. Symptoms usually improve in time if the knee is not over used.
Painkillers – paracetamol or anti-inflammatory painkillers such as ibuprofen may be advised to ease the pain.
Physiotherapy – improving the strength of the muscles around the knee will ease the stress on the knee. Also, specific exercises may help correct problems with alignment and muscle balance around the knee. For example, you may be taught to do exercises which strengthen the inner side of the quadriceps muscle.
Taping of the patella – is a possible treatment which can reduce pain. This is where adhesive tape is applied over the patella, to alter the alignment or the way the patella moves. Some people find this helpful. Some physiotherapists can offer patellar taping treatment.

Surgery
Surgery is not usually necessary, but may be advised if the above treatments have not helped.

Arthroscopic surgery is the usual operation. A tiny flexible camera is inserted into the knee. The surgeon sees the inside of the knee joint and the cartilage, and may then operate through the camera tube, using very fine instruments. Possible surgical treatments are:

Tight ligaments on the side of the patella may be cut to allow the patella to align better and move more smoothly.
Smoothing or ‘shaving’ the cartilage behind the patella.
Rarely, if all other options do not help, the patella can be removed (the knee can still function without it).

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Exercises Can Prevent Injury

Strengthening the muscles that support the knee with knee exercises is most important in protecting your knees from injury and knee pain.

Weak or fatigued muscles cannot adequately support the knee joint or absorb shock before it gets to the knee and the extra stress placed upon the knee can cause injury to the structures of the knee. Strengthening exercises can make the muscles tight, so follow strength exercises with stretching exercises.

Stretching the muscles that support the knee with knee exercises is also important in preventing injury. Flexible muscles are not as easily injured as tight muscles. Tightness of muscles connected to the knee can also pull the knee out of alignment.

When doing stretching knee exercises, be careful to go slowly and not to overstretch. You do not want to tear a muscle.

You need to increase the duration of your knee exercises gradually to avoid overuse injuries and knee pain. Be patient. You will see results.

Strength must be built up gradually. When muscles, tendons or ligaments are stressed slightly beyond their limits, microscopic tears occur. This is normal, and as these tears heal the muscles actually become bigger, firmer and stronger. These microscopic tears must be given adequate time to heal or chronic problems can develop. Try not to exercise the same muscle groups two days in a row to give your body a chance to recover. Doing strengthening knee exercises three or four times a week is enough. Stretching knee exercises can be done more often.

The goal is to prevent injury and knee pain, not cause it.
Don’t ignore pain. Pain is your body’s way of protecting you from hurting yourself further. It is not unusual to experience mild stiffness and aching of the muscles that lasts up to a day after exercising. But hardly being able to move for a few days after exercising means you have overdone it. It’s difficult to know when to quit when you doing knee exercises. Often, the pain doesn’t’ set in until a day or two later. It happens. If it does, you will have a greater understanding of your body’s limitations.

When you have overdone your knee exercises.
Rest is important for inflamed muscles/tendons. Applying ice wrapped in a cloth can help reduce inflammation and pain and speed up healing. See Treatment for Overuse Injuries. Knee pain should be completely gone before fully resuming your knee exercises program, however, lightly exercising the sore muscle may help decrease muscle soreness.

If you are currently experiencing knee pain and/or have a very limited range of motion, or are not sure which knee exercises are safe for you to do, see a physical therapist (physiotherapist). A doctor or physical therapist can assess your condition and give you a customized treatment / exercise plan.

Main Muscle Groups Affecting Knee Stability

Several muscle groups support the knee. The two main muscle groups that control knee movement and stability are the quadriceps and the hamstrings.

THE QUADRICEPS is a four-part powerful muscle that run along the front of the thigh and attach to the front of the shinbone, just below the knee. The quadriceps control the straightening of the knees and movement of the kneecap. The quadriceps is used to extend the leg, and is essential for standing up, walking upstairs, walking uphill, and running.

THE HAMSTRINGS are muscles that run make up the back of the thigh, and attach to the back of the shinbone, just below the knee. The hamstrings are used to bend the knee and are also needed when you are pushing against something.

Other Muscles Affecting Knee Stability
Other muscles that affect knee stability, to a lesser degree than the quadriceps and hamstrings are the calf muscles, the hip abductors located on the outer thigh, and the hip adductors located on the inner thigh. The body functions as a unit (remember – the hip bone’s connected to the knee bone) and even muscles not near the knee can contribute to knee stability.

The iliotibial band (fibrous tissue on the outer thigh, extending front the hip to below the knee) also affects knee stability. The glutes (back of hip muscles / buttocks) inserts into the thigh bone and iliotibial band and also help stabilize the knee.

*It is important to do strengthening exercises for all the muscles that support the knee. For example, if you concentrate on strengthening exercises for the quads, and neglect strengthening exercises for the hamstrings a muscle imbalance can be created.

Imbalances in Muscles Supporting the Knee
A physical therapist (physiotherapist) can help determine if you have a muscle imbalance in the muscles supporting the knee and create a personalized exercise program.

Imbalance of the quadriceps is common, especially in women – The quadriceps is divided into 4 divisions. If the inner division if weak, the stronger outer division tends to pull the kneecap toward the outer side of the leg. Tightness of the quads can also pull the knee towards one side so stretching as well as strengthening of muscles that support the knee is important.

In some cases, the quadriceps is significantly stronger than the hamstrings. (The quadriceps should only be about 25% stronger than the hamstrings). This can cause weakness of the knee. If this is the case, concentrating on strengthening exercises for the hamstrings, and stretching exercises for the quadriceps are very helpful.

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Knee Exercises
*NOTE: Only do one exercise per muscle group on the same day. There are several exercises to choose from for some muscles.

Strengthening Knee Exercises
Warming up with 5 minutes of low-impact aerobics, such as walking or riding a stationary exercise bike, increases blood supply to the muscles to help prevent injury and stiffness.

Quadriceps Strengthening
Quad Strengthening Contractions:
Sit in chair. Extend legs, heels to floor. Keep knees straight (or as straight as possible if you have arthritis.) Tighten thigh muscles. Hold for count of 10. Relax for count of 3. Do 10 repetitions. You can do this several times throughout the day. You can build up to 2 or 3 sets of 10 repetitions at a time.

Quad Strengthening Leg lifts:
Lie flat on back. Bend left knee at 90-degree angle, keeping foot flat on floor. Keeping the right leg straight, slowly lift it to the height of the left knee. Hold for a count of 3. Repeat 10 times. Switch sides. Work up to 10 sets of 10 over several weeks.

Safety Tip:
Leg lifts: Lifting both legs at the same time causes excessive stress on your lower back so
only lift one leg at a time; the opposite leg should be kept slightly bent with foot on floor.

Quad Strengthening Short-Arc Leg Extensions:
Sit or lie on floor. Place a rolled up towel under your thigh for support. Keep you leg straight and raise your foot about six inches off the floor. Hold for 5 seconds. Slowly lower your foot, bending your knee. Do 10 repetitions. Switch sides.

Quad Strengthening Knee Dips:
Stand with knees slightly flexed. Point your toes straight ahead.
Make sure your kneecaps are also pointed straight ahead.
Lift one leg up and balance on the other leg. Slowly lower yourself up and down ONLY a few inches. Keep the knee of the leg you are balancing on slightly flexed. Your knees must remain pointing straight forward. Do not let them turn inward. Stand straight, do not lean you body to one side. Do 10 dips. Switch sides.
If you feel pain in your knees, start with fewer dips.

Quad Strengthening Partial Squats:
Double leg partial squat: Stand. Keep Back Upright. Knees pointing straight ahead – inline with feet and hips. Slowly lower yourself. Don’t bend your knees beyond a 90-degree angle, if 90 degrees is too difficult bend even less.

Safety Tip: Make sure your knees do not extend beyond your toes when doing partial squats. Keeping your weight behind your knees reduces the pressure on the knee joint during the squat. Bending the knees beyond 90 degrees (a right angle) places excessive strain on the knee.

Hamstring Strengthening
Hamstring Strengthening Contractions:
Sit in chair, heels on floor. Don’t move heels but pull back on them. You will feel tension in you hamstrings. Hold for count of 10. Relax for count of 3. Do 10 repetitions.

Hamstring Strengthening Curls:
Lie on stomach. Place left foot onto the back of the right heel. Slowly pull your right heel toward your buttocks – resisting with the left leg. This contracts the hamstrings. Hold for a count of 10. (Keep pressing your left foot and right heel against each other) Hold for a count of ten and relax for count of 3. Do 10 repetitions.

Walking backwards helps to develop the hamstrings. When walking backwards, your weight is distributed more evenly, resulting in less strain on your knees.

Other Strengthening Exercises for Knee Stability

Hip Adductors (Inner Thigh) / groin muscle and inner quad muscle (VMO) Strengthening:
Sit in chair, put fist between knees, squeeze together knees. Hold for count of 10. Relax for count of 3. Do 10 repetitions.

Lie on floor on your right side, shoulder and hips aligned. Use your right hand to prop up your head. Place the left hand on floor in front of you to help balance yourself. Bend left leg and bring it to the floor in front of you. Slowly raise your right leg about 10 inches off the floor then, hold for a second, then slowly lower leg to ground. Lift 10 times on each side.

Hip Abductors (Outer Thigh) strengthening:
Lie on floor on your right side, shoulder and hips aligned.
Bend right leg (leg on floor) to 90 degrees.
Slowly raise you left leg about 18 inches, hold for a second, then slowly lower leg.
Do 10 repetitions. Repeat on other side.

Glutes Strengthening Backward leg swing:
Hold onto back of chair for support. Swing leg back at a diagonal until you feel your buttocks tighten. Tense muscles as much as you can and swing leg back a couple more inches. Return leg to floor. Repeat 10 times.
Switch sides.Do 10 repetitions. Repeat on other side.

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Balancing Knee Exercises
(helps in knee stability)
Hold onto back of chair or counter top for support. Stand on one leg for one minute. Switch sides.

As your balance improves, use one hand only for support. Next use one finger only for support, then progress to letting go, but keeping your hands within a couple of inches above chair in case you lose your balance. Do not lean your trunk to one side.

To increase difficulty, shift weight onto the ball of the foot.

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Stretching Knee Exercises
No bouncing, slow & controlled fashion, 5-10 minutes aerobics warm up first (e.g. walking, stationary bike) Muscles warmed up are more responsive to stretches and less likely to tear.

Calf Muscles Stretch:
Step back with left, forward with right, lean forward with hips. Do not roll foot out to side. Keep heel flat, foot forward. Bend knees for alternate stretch. Hold 30 – 60 seconds.

Quad Muscle Stretch:
Bring heel to hip with hand. Keep knees together. Do not arch back. Do not leg go to side.
Hold for 30 seconds. Repeat on other side.

Hamstring Stretch:
Standing position
Keep one leg on ground; put one foot on chair with leg straight. Bend forward at the hip. Do not attempt to touch your toes as this will stretch your back, and the goal of this exercise is to isolate your hamstring muscles in the leg that is being supported by the chair.

Sitting in chair hamstring: Straighten one leg, keeping heel on floor. Lean forward at hips, keeping back straight. Don’t try to touch your toes. Hold for 30 seconds. Repeat on other side.

Iliotibial Band Stretch:

Standing position:
Stand up. Cross right leg behind left leg moving crossing knee beyond the midline of the body. Lean from the hips to the left, the stretch being felt on your right hip, side of the leg and knee. Hold for 30 seconds. Repeat on other side.

Sitting position: Sit in chair: Bring right foot to outside of left leg, bringing knee towards opposite shoulder so that the knee crosses the midline of the body. Hold for 30 seconds. Repeat on other side.

Hip Adductors (Inner Thigh) Stretch:
Standing: Step off to the side with the right leg. Then lean away from the leg (bending your left knee)

Sitting position: Sit on floor, spread legs into a v position. Slowly lean forward from your hips, keeping your back straight, until you feel the stretch. Do not bounce. Then lean towards the right, foot then left foot. Hold each position for 30 seconds.

Hip Abductors (Outer Thigh) Stretch:
Sit on the floor,legs extended in front of you.
Bend right leg and place right foot on floor on outside the left knee.
Twist upper body to right and use left elbow to gently push against outside of right nee until you feel a gentle stretch in the right hips, buttocks, and lower back.
Hold for 30 seconds. Repeat on other side.

Hip flexors (front of hips) Stretch:
Tightness in these muscles can affect the alignment of the knee bones.
Standing Exercise: Step forward with the right leg, bending right knee. Keep back upright. This stretches the front of the hip on the left side. Keep left knee slightly bent also.
Hold for 30 seconds. Repeat on other side.

Gluteal Stretch (back of hips / buttocks):
Stand in front of chair, about two feet away from chair. Place left foot on chair, leg bent. Bring your chest towards your knee, keeping back straight. Hold for 30 seconds. Repeat on other side.

*Of all the above knee exercises, the quadriceps strengthening contraction is probably the easiest, safest and most important exercise you can do to prevent knee pain and injury. Those who have trouble fitting in exercises into their schedule can always do this exercise while watching television.

Knee-Safe Aerobics. Low-impact exercises with minimal risk to the knee joint.

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The hallmark features of this syndrome are poorly developed fingernails, toenails, and patellae (kneecaps). Sometimes, this disease causes the affected person to have either no thumbnails or a small piece of a thumbnail on the edge of the thumb. Other common abnormalities include elbow deformities, abnormally shaped pelvis bone (hip bone), and kidney (renal) disease. Also, some research shows that people with NPS are more prone to glaucoma and scoliosis, due to poorly developed spines.

People with nail-patella syndrome may display only a few or many of the recognized signs of this disease. Symptoms vary widely from person to person. Signs even vary within a single family with multiple affected members.

Treatment

Medical Care
Unless the patient presents with acute findings, perform the evaluation on an outpatient basis.
Suggest knee replacement if the patient develops osteoarthritis in the knees.
Dialysis and transplantation are necessary in patients who develop ESRD. Approximately 30-55% of patients have renal involvement.
The use of diuretics in patients with nephrotic syndrome depends on the glomerular filtration rate. Any therapy for edema requires an assessment of intravascular volume status.
Surgical Care
Renal transplantation has proven successful in patients with nail-patella syndrome (NPS) who develop ESRD.
Avoid excision of the radial head to correct elbow arthrodysplasia. This excision forces the ulna into the wrist, creating a painful condition.
MRI is necessary to reveal the abnormal muscle and nerve insertions that may complicate orthopedic procedures.
Consultations
Dentist
Geneticist
Nephrologist
Ophthalmologist
Orthopedist
Rheumatologist
Diet
No dietary restrictions are necessary unless hypertension or nephrotic syndrome develop. At this time, a salt-free diet is appropriate.
Activity
Joint abnormalities generally do not limit physical activity.

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“Runner’s knee” often affects young and otherwise healthy athletes. One of the most important treatments is to avoid the activity that caused the problem. Use of RICE – rest, ice, compression, elevation – should help , as well as exercise such as cycling or swimming, straight leg raises, achilles tendon stretches.

Treatment 1:
The treatment will depend on the specific source of a person’s pain. Most sportspersons will use variations on the RICE method and anti-inflammatories, to rule out a simple overuse injury. If the pain is very severe or does not pass, they may consult a doctor. As noted above, “chondromalacia” and “patello femoral syndrome” are not diagnoses, as they do not help explain the source of pain. If pain is due to a tight iliotibial band, treatment will be focused on stretching of that band. If a person suffers from irritation of the infrapatellar branch of the saphenous nerve, treatment might consist of a small injection. If core stability is the issue, treatment might consist of physical therapy focused on the abdomen, pelvis and hips. If the condition is exacerbated by flat feet, these can be treated by orthotics[9].

Treatment 2:
What treatment options are available?

Nonsurgical Treatment
Nonoperative treatment is usually recommended for this problem. Getting the pain and inflammation under control is the first step. The overall goals for a rehab plan are to improve muscle function and flexibility while providing pain relief or pain control.

Your physician may suggest rest and anti-inflammatory medications, such as aspirin or ibuprofen, especially when the problem is coming from overuse. Acetaminophen (Tylenol®) may be used for pain control if you can’t take anti-inflammatory medications for any reason. Activity modification, flexibility, and strengthening are key parts of the rehab program. Physical therapy can help in the early stages by decreasing pain and inflammation. Your physical therapist may use ice massage and ultrasound to limit pain and swelling.

Bracing or taping the patella can help you do exercises and activities with less pain. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. You slide them onto your knee like a sleeve. A small buttress pads the side of the patella to keep it lined up within the groove of the femur.

An alternative to bracing is to tape the patella in place. The therapist applies and adjusts the tape over the knee to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove. This in turn is thought to improve the pull of the quadriceps muscle so that the patella stays lined up in the groove. Patients report less pain and improved function with these forms of treatment.

As the pain and inflammation become controlled, your physical therapist will work with you to improve flexibility, strength, and muscle balance in the knee. Quadriceps strengthening exercises to address deficits in knee extension strength include non-weight-bearing single-joint (e.g., knee extension) and weight-bearing multiple-joint exercises (e.g., seated leg press).

Non-weight bearing exercises are also known as open kinetic chain exercise. Weight-bearing exercises are referred as closed-chain exercise. Closed-chain exercises place less stress on the patellofemoral joint and may be used first to achieve improved function before progressing to open kinetic chain exercises. Studies also show greater VMO activity with closed kinetic chain exercise. And a closed-chain exercise program also addresses hip muscle weakness at the same time as knee muscle deficits.

The therapist will adjust your rehab program to provide you with the most pain free and effective method of treatment. The overall rehab program will include a home exercise program of stretching, agility exercises, balance activities, and strengthening designed to return you to your former level of pain free participation in sports and other activities.

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