by Michael Emmerling September 27, 2022

"Anterior knee pain (AKP) is a common musculoskeletal complaint among people of all ages and activity levels. Symptoms associated with AKP can have a significant adverse impact on a person’s function, overall health, and quality of life. AKP encompasses multiple clinical conditions with patellofemoral pain being the most common."[1]

"The onset of AKP is associated with changes in physical activity, personal traits such as weight, and prior injury." [1]

AKP is pain that occurs at the front and center of the knee (around or under the kneecap). The knee pain often increases when you run, walk up or down stairs, sit for long periods, or squat. It can be caused by many different problems, including [5] [6]:

  • Chondromalacia of the patella -- the softening and breakdown of the tissue (cartilage) on the underside of the kneecap (patella).
  • Patellofemoral Pain -- often referred to as Runner's Knee. Common in people who participate in sports that involve running.
  • Patellar tendinitis - often referred to as Jumper's Knee, an injury to the tendon connecting your kneecap to your shinbone. Common in people who participate in sports that involve jumping.
  • Lateral compression syndrome -- the patella tracks more to the outside part of the knee.
  • Quadriceps tendinitis -- pain and tenderness at the quadriceps tendon attachment to the patella.
  • Patella maltracking -- instability of the patella on the knee.
  • Patella arthritis -- cartilage breakdown underneath your kneecap.

To better understand the causes of AKP, let's first review the basic anatomy of your knee joint. Your kneecap (patella) sits over the front of your knee joint. As you bend or straighten your knee, the underside of the patella glides over the bones that make up the knee (known as the femoral groove). Strong tendons help attach the kneecap to the bones and muscles that surround the knee. [5]

These tendons are called:

  • The patellar tendon (where the kneecap attaches to the shin bone)
  • The quadriceps tendon (where the thigh muscles attach to the top of the kneecap)

Anterior knee pain begins when the kneecap does not move properly and rubs against the lower part of the thigh bone. [5]

This may occur because:

  • The kneecap is in an abnormal position (also called malalignment).
  • The joint space between your patella and femur has deteriorated (which is associated with osteoarthritis).


The above conditions are often caused by:

  • Tightness or weakness of the muscles on the front and back of your thigh.
  • Too much activity (overuse) that places extra stress on the kneecap (such as running, jumping, squatting).

Now that you have a better understanding of the causes associated with AKP, we can begin our discussion about treatment.

The current clinical guidance recommends "Non-operative approaches with an emphasis on physical therapy management as the initial course of care. Successful physical therapist management involves a combination of individualized patient education, pain management, and load control and progression, with an emphasis on exercise therapy."[1]

The prognosis for the recommended initial course of care however, is poor. "55% and 40% of patients have an unfavorable recovery at 3 and 12 months respectively! To improve outcomes, it's essential for practitioners to "utilize interventions with known efficacy in reducing pain." [2]

As the clinical guidance advises, emphasis must be placed on managing pain throughout exercise therapy because managing pain is the key to a successful outcome.

Throughout the rehab process, it is critical to limit pain. Failure to limit pain will delay, or even prevent, a positive outcome.  Below is a guide of the pain levels that are acceptable and pain levels that should be avoided throughout the rehab process.[1]



Managing pain levels is precisely where patellar distraction with NuNee comes into play.

To help you understand why NuNee is highly effective at relieving pain, let's begin with a quick review of what joint distraction is, along with its benefits.

Most of the joints that we use for movement and exercise are synovial Joints, which contain synovial fluid that acts as lubrication between the articulating (moving) surfaces inside the joint. When the surrounding soft tissue is too tight and/or our movement mechanics are of a poor quality, the articulating surfaces inside the joint can get compressed (pushed together) and cause an array of problems, one of which is that this synovial fluid gets pushed out of the joint and other joint structures (mainly cartilage) are damaged because there is no ‘space’ in the joint. [7]

"Joint Distraction is a technique that applies a vector (a force in a specific direction) to the Joint Complex in order to help separate (and restore the space between) the joint surfaces to improve the sliding or rotating capabilities, which will inherently enhance the mechanical action of the joint. This promotes a separation of the articulating surfaces which creates more ‘space’ for synovial fluid to fill the joint, reduce the amount of friction and allows for much more fluid motion." [7]

Research has shown that knee joint distraction results in significant improvements in pain, function, joint space, and cartilage thickness. These benefits were found to last at least 9 years. [8]

Recent clinical studies conducted by Nazareth College School of Physical Therapy researchers revealed that patellar distraction with NuNee significantly and immediately reduced pain for 89% of participants with AKP. [3] Studies also revealed that NuNee allowed participants to immediately resume exercise and tolerate greater loads without pain.[4]

Because NuNee provided immediate pain relief along with the ability to tolerate greater loads, 89% of study participants were immediately able to perform exercise (run, squat) without pain. Of those participants, 100%  reported no pain after using NuNee for 6 weeks during exercise. In comparison to exercise therapy alone (without NuNee), this represents a significant improvement in the outcome for treatment of AKP.

The findings of this research suggest that anyone treating or being treated for AKP should incorporate NuNee into their exercise rehab plan.










Michael Emmerling
Michael Emmerling


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