Chondromalacia: Symptoms, Causes, Treatment

Chondromalacia patella is damaged or softened cartilage underneath the kneecap (patella). This condition typically occurs from playing sports that irritate the kneecap due to long-term overuse or injury. However, wear from age or the structure of your knee joint can contribute to developing the condition.

People with chondromalacia typically experience a dull pain under or around the kneecap. This pain is usually worse when walking down stairs or rising after sitting. You may also experience a grinding sensation and swelling.

It can take months or years for chondromalacia knee pain to go away. However, treatments are available to help the knee heal and eliminate pain. Depending on the severity of your knee cartilage damage, you can treat chondromalacia with rest, physical therapy, or surgery. 

Chondromalacia can be minor or severe depending on the extent of knee cartilage damage and inflammation. Different grades of chondromalacia severity include: 

• Grade I: Smooth (articular) cartilage is intact but looks soft and swollen. There may also be some fraying or splitting cartilage.
• Grade II: Articular cartilage has narrow cracks and splits (fissures) that are up to half an inch in diameter.
• Grade III: Cartilage splits or cracks are partially through the knee cartilage. Fissures are larger than half an inch in diameter. 
• Grade IV: Cracks and defects go through the full thickness of kneecap cartilage. These fissures also extend into the subchondral bone, the layer of bone underneath smooth cartilage. 

Some researchers consider grades I-II to be the early stage and grades III-IV to be the advanced stage. Early stages of chondromalacia are more likely to self-repair. Advanced stages can cause permanent damage and progress into arthritis of the knee joint.

The most common symptoms of chondromalacia are knee pain and inflammation. Flexing or extending the knee can lead to pain as the joints or bones rub together. This friction also leads to visible swelling and inflammation of the knee. Swelling may contribute to knee stiffness when the knee is bent or moving.

Knee pain from chondromalacia can be minor or severe, depending on the severity of cartilage damage. Most people report a dull ache under or around the kneecap. This type of pain is also referred to as runner’s knee, or patellofemoral pain syndrome. When you move, it may feel and sound like your knee is grinding or cracking, known as crepitus. 

Pain from this condition usually increases during sporting activities and exercises that put pressure on your knee. Other movements that can make pain worse include:

• Walking up or down stairs
• Sitting or standing in place for long periods
• Moving from a seated to a standing position

Chondromalacia occurs when the underside of the kneecap becomes irritated, worn, or cracked. Healthy smooth cartilage helps protect your knee joint and bones from impact and friction. When the underside of the knee cartilage begins to wear down or is damaged, the bones can’t easily move. As a result, the knee joint becomes rough and irritated.

Wear-and-tear on the knee joint from age or improper knee alignment can both cause chondromalacia. However, younger people typically get chondromalacia from falling or sports-related injuries caused by long-term overuse that wears down cartilage.

Chondromalacia caused by improper knee alignment also has a few different causes, including:

• Being born with an abnormal knee joint 
• Having flat feet
• Putting continuous stress on the knee joint from running or jumping
• Having weak quadricep or hamstring muscles (located on the front and back of the thighs)
• Having imbalanced adductor and abductor muscles (located on the sides of the thighs)
• Experiencing uneven bone and muscle development during a growth spurt (this usually resolves as adolescents grow)

If you think you have chondromalacia, your healthcare provider will refer you to an orthopedist—a medical doctor who specializes in bones, muscles, joints, and connective tissues. The orthopedist will perform a physical exam and imaging tests to make a diagnosis. Imaging tests allow the orthopedist to see inside the knee to better understand the extent of your cartilage damage. 

During the physical exam, your provider will evaluate the alignment of your knee joint and perform knee mobility tests to spot any abnormalities. They will also assess your knee pain and listen for any popping or clicking noises.

Clark’s test (patellar grind test) is specifically used to help diagnose chondromalacia by assessing any grinding or pain. During this test, you’ll lie down and squeeze your quad muscles (front thigh muscles) as you try to extend your knee. 

If you have signs of chondromalacia from your physical exam, your provider may also order diagnostic tests like: 

• X-ray: This imaging test puts electromagnetic waves into the body to create pictures of the bones. It can help reveal bone damage caused by severe chondromalacia. 
• Magnetic resonance imaging (MRI) scan: This imaging test uses strong magnets to create 3D images of the inside of the body. This test can help diagnose abnormal cartilage and the grade of chondromalacia wear.  
• Arthroscopic exam: This surgical evaluation involves inserting a tiny camera through small incisions in the knee. Using the camera, the surgeon looks inside the knee for cartilage wear and bone damage. 

The main goal of chondromalacia treatment is to relieve and prevent symptoms like pain and inflammation. In some cases, this can help the cartilage heal. You can typically treat the early stages of chondromalacia with rest, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs). If cartilage damage is severe, your healthcare provider may suggest surgery and physical therapy.

Rest, Restriction, and Pain Management

Initial treatment for chondromalacia includes conservative treatments—like resting the knee joint, restricting movement, and managing pain. These treatments can help give the cartilage and knee joint time to heal. You may need to wear a knee brace to help immobilize the knee during healing and keep the knee joint in place.

Your healthcare provider may suggest you take NSAIDs like Advil (ibuprofen) or Aleve (naproxen). These medications help reduce pain and inflammation.

You can also treat and manage pain with intraarticular injections—injections into the knee joint. Traditionally, these injections consisted of corticosteroids to help manage pain and swelling. This is sometimes still used, but research has shown corticosteroid injections can start to kill cartilage tissue over time.

Hyaluronate injections are a more promising treatment. Since hyaluronic acid is naturally found in the synovial fluid of the knee joint, it can help your knee joint move more effectively. 

Physical Therapy

Most people with chondromalacia will need to attend physical therapy in addition to other conservative treatments. Physical therapy can help reduce pain, correct muscle imbalances, and correct knee joint misalignments.

Your physical therapist will help create exercises that strengthen the quadriceps muscles, reduce the Q angle (the angle between the quadriceps and patella tendon), and reduce knee joint grinding. Strengthening muscles surrounding the knee can help protect the joint from further injury and pain. 

Your healthcare provider may also prescribe orthotics like supportive insoles for your shoes if you have flat feet or ankle misalignment that puts pressure on the knee.

Surgery

Surgery is considered a last resort when treating chondromalacia. Depending on the extent of cartilage damage, surgical options can include:

• Arthroscopic debridement: A minimally invasive procedure in which a surgeon inserts a tiny camera into the knee joint. Using the camera as a guide, the surgeon uses tiny instruments to remove any loose material in the knee joint and smooth surfaces inside the knee.  
• Lateral release (patellar realignment surgery): This surgery focuses on realigning the kneecap back into its groove. This is typically done using arthroscopic surgery techniques, but it may require more invasive open knee surgery.  
• Patellectomy: A surgeon may opt to partially or fully remove the knee cap for severe cases where the patient still has good quadriceps function. However, this surgery can cause more damage and complications to the knee joint.   

Alternative Therapies

Alternative therapies are not considered standards of care. However, your healthcare provider may suggest these treatments to help reduce pain and inflammation that other treatments couldn’t relieve. Researchers are exploring alternative treatments for chondromalacia like:

• Mesenchymal stem cells (MSCs) therapy: A healthcare professional injects stem cells into the knee joint to help promote healing and reduce pain. Research has found this therapy is typically safe and effective.
• Platelet-rich plasma (PRP) therapy: A healthcare professional removes the person’s platelets (cells in the blood) from a blood sample and injects it back into the person’s knee joint to help promote healing. However, the results are inconsistent.  
• Prolotherapy: A healthcare professional injects a dextrose (sugar) solution into the knee joint to irritate the body and kickstart an immune response to promote healing. Research on results is mixed, and prolotherapy is not usually recommended to treat chondromalacia.  

There are no proven ways to prevent chondromalacia. However, taking steps to help correct knee misalignment and avoid overuse may help keep your knee joint healthy. For example:

• Wear kneepads: If you spend a lot of time on your knees while gardening, cleaning, or doing home construction work, padding your knees can help reduce pressure and wear. 
• Strengthen the muscles around your knee: Building strong quadriceps, hamstring, abductors, and adductors can help you avoid muscle imbalances that can misalign the knee.
• Wear shoes with proper arch support: This helps reduce knee pressure, especially if you have flat feet. 
• Tape your knee: Use special athletic tape to help correct your kneecap alignment if you have any misalignment.

If you don’t treat chondromalacia, it can progress into grade IV cartilage damage, which can lead to patellofemoral osteoarthritis. This form of arthritis—inflammation and swelling of the joints—occurs when the knee cap cartilage is completely worn down and the bones of the knee joint rub together. 

Over time, patellofemoral osteoarthritis causes the knee joint to break down. The bone structure also begins to change. This can cause severe pain, stiffness, swelling, and decreased range of motion. In some people, patellofemoral osteoarthritis can make walking extremely difficult or impossible. 

Some people may also experience aggravated knee pain from physical therapy. Taking NSAIDs to manage knee pain can also cause gastrointestinal symptoms, like stomach pain. In addition, continuously wearing a knee brace can irritate the skin around the knee, causing skin rashes.

Depending on the severity of cartilage damage, recovery can take months to years. Chondromalacia treated in the early stages is often reversible with treatment. Conservative treatments like rest, NSAIDs, and physical therapy typically help heal cartilage and reduce inflammation, which can help eliminate knee pain. Children and teenagers are more likely to have long-term recovery since their bones are still growing.  

However, severe cartilage damage often does not heal well and can result in permanent damage and pain. In these cases, your healthcare provider may suggest surgery to help repair damage. Still, surgery is not always effective at solving knee pain and mobility issues. To help manage long-term chondromalacia pain, your provider may suggest injections to help lubricate the knee and reduce inflammation.