What is the initial management for patellar femoral tracking syndrome?

Initial Management for Patellofemoral Tracking Syndrome

The initial management for patellofemoral tracking syndrome should focus on a comprehensive knee rehabilitation program that includes quadriceps and hip strengthening exercises, flexibility improvements, and technique refinements, with patellofemoral braces serving as an adjunctive therapy rather than primary treatment. 1

Assessment Components

Key Physical Examination Findings

• Palpation of lower extremity pulses (femoral, popliteal, dorsalis pedis, posterior tibial)
• Inspection of legs and feet for abnormalities
• Assessment of patellar tracking during knee flexion and extension
• Evaluation of quadriceps strength and hip muscle strength (particularly abductors)
• Observation of movement patterns during functional tasks (e.g., single leg squat)

Functional Assessment

• Pain levels during activities (especially during squatting, stair climbing, prolonged sitting)
• Fear of movement and avoidance behaviors
• Self-efficacy relating to symptoms
• Perceived joint resilience during activities

Primary Treatment Components

1. Exercise Therapy

• Quadriceps Strengthening:

  • Begin with open chain exercises after 30° of knee flexion 2
  • Progress to closed chain exercises (squats, leg press) at 0-20° of knee flexion
  • Focus on vastus medialis oblique activation

• Hip Muscle Strengthening:

  • Target hip abductors and external rotators
  • Include exercises like clamshells, side-lying leg raises, and band walks

• Exercise Parameters:

  • Modify based on symptom severity and irritability
  • Gradually progress intensity, duration, and complexity
  • Ensure proper technique to avoid compensation patterns

2. Education

• Explain patellofemoral mechanics and tracking issues
• Discuss pain mechanisms and that pain doesn't necessarily indicate tissue damage
• Set realistic expectations for recovery timeframes (minimum 6 weeks)
• Promote self-management strategies

3. Activity Modification

• Temporarily reduce activities that exacerbate symptoms
• Modify exercise technique to reduce patellofemoral stress
• Gradually reintroduce provocative activities as symptoms improve

Adjunctive Treatments

1. Patellofemoral Braces

• Indicated when knee pain significantly impacts ambulation, joint stability, or causes substantial pain 1
• Select appropriate brace size based on measurements (3 inches above/below mid-patella)
• Ensure proper fitting with patella centered in cutout if applicable
• Monitor for migration, strap loosening, or material fatigue

2. Taping Techniques

• Consider McConnell-style patellar taping for immediate pain relief
• May help improve patellar tracking during rehabilitation exercises
• Should not be used as a standalone treatment 3

3. Manual Therapy

• Consider when rehabilitation is hindered by elevated symptom severity
• Focus on soft tissue mobilization around the patellofemoral joint
• Use as a short-term intervention to facilitate exercise participation

4. Foot Orthoses

• Consider prefabricated foot orthoses for patients who respond favorably to treatment direction tests 1
• May be particularly helpful for those with foot biomechanical issues
• Customize for comfort by modifying density and geometry

Treatment Algorithm

1. Initial Phase (0-2 weeks):

   • Begin with pain management strategies
   • Introduce low-load quadriceps and hip exercises
   • Consider patellofemoral bracing if significant functional limitation exists
   • Educate on activity modification

2. Progressive Phase (2-6 weeks):

   • Increase exercise intensity and complexity
   • Gradually reduce reliance on bracing/taping
   • Introduce more functional movement patterns
   • Begin sport-specific or activity-specific training

3. Maintenance Phase (6+ weeks):

   • Continue strengthening program
   • Gradually return to full activities
   • Monitor for symptom recurrence
   • Adjust program as needed

Common Pitfalls to Avoid

1. Overreliance on passive treatments: Bracing and taping should supplement, not replace, active exercise therapy 1

2. Ignoring hip mechanics: Hip muscle weakness contributes significantly to patellofemoral tracking issues

3. Premature return to aggravating activities: Rushing rehabilitation can lead to symptom recurrence

4. Focusing only on pain relief: While important initially, long-term management requires addressing underlying biomechanical factors

5. Neglecting patient education: Understanding the condition improves adherence and outcomes

If no improvement is observed after 6 weeks of appropriate therapy, reassessment is warranted to ensure interventions align with the initial clinical reasoning and to evaluate patient engagement with the program 1.