What are the treatment options for patellofemoral osteoarthritis (OA)?

Treatment Options for Patellofemoral Osteoarthritis

Quadriceps strengthening exercises should be the first-line treatment for patellofemoral osteoarthritis (OA), combined with patient education and self-management strategies to improve pain and function. 1

First-Line Treatment Approach

Exercise Therapy

• Quadriceps strengthening exercises: Strong evidence supports this as the cornerstone of patellofemoral OA management 1

  • Focus on both open and closed chain exercises
  • Progressive loading based on patient tolerance
  • Can be done with or without professional supervision

• Hip muscle strengthening: Should be combined with quadriceps exercises 1, 2

  • Target hip external rotators and abductors
  • Helps improve patellofemoral alignment and tracking

Bracing and External Supports

• Patellofemoral braces: Conditionally recommended for patients with sufficient impact on ambulation, joint stability, or pain 1

  • Most beneficial for those with patella maltracking or instability
  • May help reduce pain during activities

• Kinesiotaping: Conditionally recommended for symptom relief 1

  • Permits range of motion while providing support
  • Can be used for short-term pain relief and functional improvement 1

Second-Line and Adjunctive Treatments

Manual Therapy and Modalities

• Patellar taping: Provides short-term relief of pain and improved function 1

  • Medial taping technique shows better outcomes
  • Most effective when combined with exercise therapy

• Prefabricated foot orthoses: Consider for patients who respond favorably to treatment direction tests 1

  • Can be customized for comfort by modifying density and geometry
  • Most beneficial in the short term

Pharmacological Management

• Topical NSAIDs: Strongly recommended for knee OA 1

  • First choice for patients with more limited disease
  • Lower risk of systemic side effects compared to oral NSAIDs

• Oral NSAIDs: Strongly recommended when multiple joints are involved 1

  • Consider cardiovascular, renal, and gastrointestinal risk factors
  • Use lowest effective dose for shortest duration

• Intra-articular glucocorticoid injections: Strongly recommended for knee OA 1

  • Can provide short to medium-term pain relief
  • Consider for flare-ups or when other treatments are insufficient

Advanced Treatment Options

Movement Retraining

• Running/movement retraining: Consider for those with symptoms associated with specific movement patterns 1
  • May include increasing cadence or step width for runners
  • Should be tailored to individual assessment findings

Surgical Options

• For refractory cases with severe symptoms despite conservative management:
  • Arthroscopic assessment: To address mechanical symptoms and evaluate lateral soft tissue 3
  • Tibial tubercle osteotomy (TTO): Consider for patients <50 years or active patients >50 years 3
  • Patellofemoral arthroplasty (PFA): For severe PFJ OA refractory to other treatments 3

Common Pitfalls and Caveats

1. Avoid focusing solely on the patellofemoral joint: Treatment should address the entire lower extremity kinetic chain

2. Don't rely on passive treatments alone: Patient empowerment through active interventions is crucial for long-term success 4

3. Beware of overemphasis on imaging findings: Clinical symptoms may not correlate with radiographic severity

4. Avoid lateral wedged insoles: These are conditionally recommended against for knee OA 1

5. Don't rush to surgery: Exhaustive conservative management should be attempted first, as many patients can achieve significant improvement without surgical intervention 5

The evidence strongly supports a treatment approach that begins with quadriceps and hip strengthening exercises, supplemented by bracing or taping as needed, with progression to pharmacological treatments and consideration of surgical options only for those who fail to respond to comprehensive conservative management.