What is the recommended treatment for patellofemoral pain syndrome?

Treatment for Patellofemoral Pain Syndrome

Knee-targeted exercise therapy combined with education should be the primary intervention for patellofemoral pain syndrome, with additional supporting interventions tailored to the patient's specific needs. 1

Primary Treatment Approach

Exercise Therapy

• Knee-targeted exercises: High certainty evidence supports quadriceps strengthening as the foundation of treatment 1

  • Progressive loading of quadriceps in both open and closed chain exercises
  • Adjust exercise prescription based on pain severity and irritability

• Hip-and-knee-targeted exercises: Consider adding hip exercises, particularly for patients with poor tolerance to loaded knee flexion 1

  • Hip strengthening can improve outcomes when combined with knee exercises
  • Moderate certainty evidence supports this combined approach

Education

Education should underpin all interventions and be adjusted to the patient's needs 1:

• Challenge inaccurate beliefs about the condition
• Build confidence in understanding the diagnosis
• Explain that pain doesn't necessarily correlate with damage
• Develop insight into recovery timeframes
• Guide load management
• Promote autonomy and reduce fear

Supporting Interventions

Based on thorough assessment findings, consider these additional interventions:

1. Prefabricated foot orthoses 1

   • Prescribe to patients who respond favorably to treatment direction tests
   • Customize for comfort by modifying density and geometry
   • Most beneficial in the short term

2. Lower quadrant manual therapy 1

   • Moderate certainty evidence supports this for improving function
   • Can be used to address specific impairments identified during assessment

3. Movement/running retraining 1

   • Consider for patients whose symptoms align with specific movement pattern issues
   • Examples include increasing cadence or step width for runners

4. Taping 1

   • Consider when rehabilitation is hindered by high symptom severity
   • Can provide short-term relief to facilitate exercise progression

Assessment Framework to Guide Treatment Selection

When evaluating patients with patellofemoral pain, focus on:

1. Understanding patient background:

   • Population factors (e.g., in-season athlete)
   • Impact of symptoms on daily life and activities
   • Symptom history and pattern
   • Patient goals

2. Objective evaluation of physical impairments:

   • Muscle strength (hip and knee)
   • Movement patterns of the lower extremity
   • Tissue tolerance to load
   • Patellofemoral joint structure/function
   • Contextual factors (e.g., fear avoidance)

Common Pitfalls to Avoid

• Overreliance on passive treatments: While supporting interventions like taping or orthoses can be helpful, they should complement rather than replace active exercise therapy 1

• Ignoring education: Education is not just an add-on but a fundamental component that should be integrated into all aspects of treatment 1

• Failing to reassess: If favorable outcomes are not observed after a reasonable period, revisit assessment findings and adjust the intervention approach 1

• Overlooking multifactorial etiology: Patellofemoral pain often results from an imbalance of forces acting on the joint due to multiple factors including overuse, quadriceps weakness, and soft-tissue tightness 2

Treatment Algorithm

1. Start with knee-targeted exercise therapy and education for all patients
2. Assess for specific impairments that might benefit from additional interventions
3. Add hip exercises if indicated by assessment findings
4. Consider supporting interventions (orthoses, taping, manual therapy, movement retraining) based on individual presentation
5. Reassess regularly and adjust treatment approach as needed

The evidence strongly supports this approach, with a best practice guide based on synthesis of high-quality randomized controlled trials, patient perspectives, and expert clinical reasoning 1.