What is the recommended treatment for patellofemoral knee pain?

Treatment of Patellofemoral Knee Pain

Knee-targeted exercise therapy combined with education should be the primary treatment for patellofemoral knee pain, with additional supporting interventions tailored based on individual assessment findings. 1

First-Line Treatment Approach

Exercise Therapy

• Knee-targeted exercise therapy: High certainty evidence supports quadriceps strengthening exercises for short-term pain reduction (SMD 1.16) and functional improvement (SMD 1.19) 1, 2

  • Include both open and closed chain quadriceps exercises
  • Progressive loading is essential for optimal outcomes

• Hip-targeted exercise therapy: Should be combined with knee exercises 1, 2

  • Focus on hip abductors and external rotators
  • Particularly beneficial when poor tolerance to loaded knee flexion is present

Education Components

• Explain the diagnosis and expected recovery timeline
• Address misconceptions about pain and tissue damage
• Teach load management strategies
• Build confidence in movement to reduce fear-avoidance behaviors 2

Supporting Interventions

Prefabricated Foot Orthoses

• Moderate certainty evidence supports their use 1
• Most beneficial when biomechanical factors contribute to pain
• Can provide immediate symptom relief while other interventions take effect 1, 2

Manual Therapy

• Moderate certainty evidence for lower quadrant manual therapy for functional improvement 1
• Helps address specific movement restrictions
• Can facilitate participation in exercise therapy 2

Patellar Taping

• McConnell-style patellar taping can be effective when combined with other interventions 1
• Provides short-term pain relief to facilitate exercise participation
• Medially directed taping is recommended for immediate pain relief 2

Treatment Algorithm

1. Initial Assessment:

   • Evaluate pain triggers and irritability
   • Assess quadriceps and hip muscle strength
   • Check for biomechanical factors (foot posture, patellar alignment)
   • Determine functional limitations

2. Core Treatment:

   • Prescribe progressive knee-targeted exercises (quadriceps strengthening)
   • Add hip strengthening exercises (especially abductors and external rotators)
   • Provide comprehensive education on condition management

3. Add Supporting Interventions Based on Assessment:

   • If biomechanical factors present: Add prefabricated foot orthoses
   • If movement restrictions present: Add lower quadrant manual therapy
   • If pain limits exercise participation: Consider patellar taping

4. Reassessment:

   • Evaluate progress at 6-8 weeks
   • Adjust interventions based on response
   • Consider referral for orthopedic consultation if no improvement after 3 months of consistent therapy 2

Pharmacologic Considerations

• Acetaminophen can be used as first-line for pain management (max 4,000 mg daily)
• Consider topical or oral NSAIDs if acetaminophen is ineffective 2

Important Caveats

• Avoid ineffective interventions: Evidence shows no additional benefit from combining prefabricated foot orthoses with exercise therapy plus taping, or adding dry needling or vibration therapy to exercise 1

• Surgical options: Should be reserved only for patients who fail conservative management after at least 3 months of consistent therapy 2

• Weight management: Should be included in the treatment plan for overweight patients 2

• Activity modification: Essential during the acute phase, with gradual return to activities as symptoms improve 1, 2

By following this evidence-based approach focusing on active interventions (exercise therapy) supported by education and selective use of adjunctive treatments, most patients with patellofemoral pain can achieve significant improvement in pain and function.