Patellofemoral Pain Syndrome

and Front Knee Pain

Treatment NYC

Anterior or front knee pain is a pain occurring underneath or around the kneecap. Most people usually refer to it as a kneecap pain front knee pain. However the right medical term is anterior knee pain. In the past there has been many names given to this condition.

Chondromalacia patella – the softening and destruction of knee cap cartilage (patellar cartilage).

Runner’s knee pain – Runner’s knee is a loose term for many specific disorders with different causes, which cause pain around the kneecap. As the name implies it is more prevalent in runners, however other athletes who repetitively bend their knee also get it.

In most recent consensus scientist came to conclusion that the most proper term for this condition is: patella femoral pain syndrome (PFPS).


PFPS (patella femoral pain syndrome) is a variety of structural and functional pathologies or anatomical abnormalities leading to front knee pain (anterior knee pain).


Due to variety of causes the movement of patella on the trochlea as well as the femur under the patella becomes abnormal. A very good analogy to this anatomical scenario is the train (kneecap) moving on the track (trochlea of the femur bone). In the case of PFPS it is usually both. The train is skewing on the track, but the track is also uneven.


The pain is usually diffuse.

It may feel inside the knee or under the kneecap. Frequently there is also pain and tenderness around the kneecap. The knee may have popping or grinding sounds when bending or squatting.

The most classic sign with PFPS is called a “movie” sign. Pain is present during seating.

PFPS is most common in teenage girls and overweight women


1. Being female
(different pelvic architecture)

2. Knee extensor strength deficit


Pain in PFPS is due to compression of the cartilage on the underside of the kneecap as well as in the cartilage of the femur. The increased pressure between the kneecap and the articulating surface of the femur leads to wear in the cartilage. The continued compression within patella-femoral articulation eventually causes subchondral bone stress. The bone gets irritated and inflamed. The pain is actually coming from the bone itself.


The following causes are the only ones proven by research

  • Structural misalignment
  • Hip muscle power deficit
  • Thigh muscle imbalance
  • Calf muscle tightness
  • Flat feet or excessive foot pronation
  • Soft tissue dysfunction around the knee joint capsule
  • Poor motor contro


Since PFPS is a multifactorial disorder, treatment must be comprehensive. Each patient with PFPS has unique presentation, which requires thorough analysis and individual approach.

At NYDNR we use comprehensive approach to eliminate the causes described above. Based on thorough clinical evaluation we create an individual treatment plan. In runners we use technological gait or running analysis.

In athletes who jump or play sports, which involve cutting we use video force plate analysis to analyze motion and forces acting on the knee while athlete jumps or performs other athletic maneuvers.

We use manual release techniques to restore gliding and alignment of patella (knee cap).
We use specific taping techniques to realign patella.
We use CAREN (Computer Assisted Rehabilitation Environment) multisensory environment technology to train motor control.
We also use sophisticated video feedback with surface EMG for runners and athletes. Most athletes with PFPS don’t have to stop training or running because they can run on our antigravity AlterG treadmill


Front Knee Pain Treatment

Front knee pain is an injury of the knee in which pain is experienced at the front and center of the knee. It is the most common form of injury to knee in adolescents and young adults, and in both athletes and non-athletes. Over 9 percent of young, active adults have suffered from anterior knee pain, and it accounts for a quarter of all knee problems treated at sports injury clinics. It is especially common in women and is one of the more debilitating injuries of the knee; if left untreated, it can create chronic disability.

Anatomy of the Knee

The patella, or kneecap, is a large, triangular bone at the front of the distal femur (the thigh bone) that protects the knee joint and strengthens the patellar tendon. The patellofemoral joint is formed by the patella resting on the front of the thigh bone. It is a “floating” bone, and as the knee bends, it moves.

Causes and Symptoms

Anterior knee pain is an overuse injury. One study found that 73 percent of patients undergoing anterior knee pain treatment had participated in sports like volleyball, basketball, football, or hockey. Moreover, the severity of the condition was directly related to the patient’s level of engagement in those activities. Repeated and excessive engagement in strenuous physical activity can result in micro-trauma, small microscopic injuries that eventually overcome the healing powers of the body. Micro-trauma produces micro-lesions in the collagen fibers. Overuse can also result from poor training, bad techniques, and faulty equipment.

Some common causes of anterior knee pain are patellofemoral syndrome, patellar dislocation, pre-patellar bursitis, patellar tendinitis, meniscal injury, and Osgood-Schlatter disease.

Patellofemoral syndrome, also known as “runner’s knee,” occurs as a result of repetitive and prolonged compression on the patellofemoral joint. The excess pressure causes gradual thinning of the articular cartilage under the patella. This, in turn, results in bone bruises and synovial inflammation. Symptoms of runner’s knee may include tenderness in the patellar area; anterior knee pain, sharp crackling noises, and a sense of the knee “giving way.”

Patellar dislocation occurs when the kneecap is displaced from its normal location. This may occur either as a result of a sudden, abrupt change in direction during movement or a direct and traumatic blow to the patella. Symptoms of patellar dislocation include immediate anterior knee pain and an inability to move the knee. The kneecap may be visibly misaligned, and as it moves the patient may experience tenderness and swelling. Often dislocation of the patella can make the patella even more susceptible to future dislocation, creating a cycle of pain and instability. If the patella is only partially dislocated, this is known as patellar subluxation.

Pre-patellar bursitis, also known as “housemaid’s knee,” is a condition in which the bursa in front of the patella becomes inflamed. Over-use or injury of the joint may cause the bursa to fill up with fluid, creating pressure on the surrounding tissue that results in pain and tenderness. Left to itself, this may ultimately lead to inflammation of the soft tissue and restricted range of motion. Symptoms include anterior knee pain and stiffness during bending or kneeling. Athletes who participate in sports where falling is common, such as basketball and football, are especially susceptible to this condition.

Patellar tendinitis is an inflammation condition of the patellar tendon. This condition may result from overuse during activities like running or cycling. Constant contraction of a muscle places pressure on the tendon that may eventually result in inflammation. Not all tendinitis is the result of intense physical activity, however. Because tendons can sometimes harden and deteriorate as we get older, patellar tendinitis may sometimes occur as a result of aging. Symptoms include tenderness at the insertion point of the tibia or surrounding the patella. Patients may experience pain while running, walking, or jumping.

Meniscal injury is caused by damage to the meniscus, the cushioning tissue within the knee joint, between the tibia and femur, that operates as a shock absorber. The two menisci are especially susceptible to injury from sudden rotations of the knee while pressure is being placed on it. This can occur when an athlete twists his or her thigh while leaving the rest of the leg firmly planted on the ground. Typically patients with minor meniscal injuries can continue to function normally, although if the pain is ignored it may eventually lead to further degeneration. Severe injuries will result in extreme pain and possible swelling or inner-knee bleeding. Over time a patient with severe meniscal injury may develop arthritis.

Osgood-Schlatter disease is caused by repetitive pressure on the tibial tuberosity, a growth area of the upper tibia just below the knee. This condition is especially common in children and adolescents who play games that involve running and jumping. A patient will develop inflammation of the patellar tendon and surrounding tissues. He or she will experience pain that is exacerbated with activity and alleviated with rest. In some cases a bony protrusion will develop just below the kneecap. Pressing on this bump will cause pain. The pain may recur until the child finishes growing. Once the patient is healed, the protrusion will linger, though pressing on it will no longer be painful.

How to Treat Knee Pain

The first priority of patients with meniscal injury or patellar dislocation should be to rest and recovery. As painful symptoms diminish, it becomes important to pursue a muscle-strengthening exercise program. For dislocation, electrical stimulation may help to relieve pain and swelling. If the patella does not reinsert itself of its own accord, a doctor may be needed to relocate it. Once this is done, the knee should be immobilized in a cast for at least three weeks.

Those suffering from patellofemoral syndrome should reduce activity and rest as much as possible, applying ice to relieve painful symptoms. A strap under the knee can hold the patella in place during exercise. Certain exercises can help strengthen the vastus medialis oblique muscle, a quadriceps muscle on the inner thigh, which may pull the patella back into place. Cross-training exercises can also be helpful. Patients with tendinitis should also follow a physician-assisted exercise program to strengthen the quadriceps muscles and prevent future injuries.

How We Treat Injury Knee Pain at the New York DNR

Because injuries to the knee joint are some of the most common sports-related injuries, having a physician who knows how to treat knee injuries is essential. Offering the most advanced treatment options for patellar tendinopathy, anterior knee pain, and a host of other injuries in the knee, the New York DNR combines expertise in conservative orthopedics with the use of diagnostic modalities such as gait analysis and dynamic functional movement screens performed with the force plate and high speed motion capture. We begin by using technological gait analysis to evaluate the kinetic chain of the lower extremities. Under conventional treatment, a patient suffering from knee injury will undergo an MRI. The MRI will reveal the structural damage to the knee by showing an image of the femur and surrounding tissues. However, it will be a static image, unable to show the complex interaction of bones and muscles and the relationship between bones within the joint during movement.

Gait analysis is different. Beyond just showing pictures of the structures and tissues, this technology records the behaviors of those structures in motion, making it an ideal treatment for musculoskeletal conditions such as hip, knee, and lower back problems.

Typically injured patients are brought into the lab and placed on a treadmill surrounded by several cameras. Markers are placed on strategic areas of the body such as the condyles of the knee. As the patient moves, the computer calculates and displays the trajectory of each marker, producing a model to calculate the movement of bones and create a breakdown of each joint’s movement. Moreover, we use a “force platform,” a floor-mounted load transducer, to measure ground reaction forces, and “pedobarography equipment” to measure the spatial distribution of forces, which enables us to calculate the net forces for each joint throughout the gait cycle. This, in turn, reveals to us the nature of the functioning of relevant muscle groups and their contribution to the cycle. Our physicians study the diagnostic findings for aberrations that may reveal undetected pathologies, giving us a better understanding of how to treat knee injury.

In addition to gait and running analysis, we also employ force-plate video feedback training, extracorporeal shockwave therapy (ESWT), and Alter-G, an anti-gravity treadmill for knee rehabilitation. Several of these approaches can be used in conjunction with Computer-Assisted Rehabilitation Environment (CAREN), an advanced method of treatment for anterior knee pain and tears to the meniscus and ACL. CAREN is an immersive virtual-reality program combining force plate , moveable platform and high-speed cameras to analyze the effects of running and jumping on the knee area. It’s tremendously beneficial in diagnosing and rehabilitating non-athletic and athletic anterior knee pain.

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