What is the initial treatment for patellofemoral syndrome of the left knee?

Initial Treatment for Patellofemoral Syndrome of the Left Knee

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

Core Treatment Approach

Exercise Therapy (First-line)

• Quadriceps strengthening exercises - High certainty evidence supports both open and closed chain quadriceps exercises with progressive loading 1
• Hip-targeted exercises - Should be combined with knee exercises, focusing on hip abductors and external rotators, particularly when poor tolerance to loaded knee flexion is present 1
• Start with low-intensity exercises and gradually progress as symptoms improve
• Exercise parameters should be modified according to symptom severity and irritability 2

Education (Essential Component)

• Provide explanation of 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 1
• Education should underpin all interventions, providing rationale for the specific treatment plan 2

Adjunctive Treatments

Activity Modification

• Temporarily reduce activities that aggravate symptoms (e.g., running, squatting, stair climbing)
• Gradually reintroduce activities as symptoms improve 1

Prefabricated Foot Orthoses

• Consider when biomechanical factors contribute to pain
• Provides immediate symptom relief while other interventions take effect
• Should be customized for comfort by modifying density and geometry 2, 1

Patellar Taping

• McConnell-style patellar taping can provide short-term pain relief
• Medially directed taping recommended for immediate pain relief
• Most effective when combined with exercise therapy 1
• Consider when rehabilitation is hindered by elevated symptom severity or high fear of movement 2

Manual Therapy

• Helps address specific movement restrictions
• Facilitates participation in exercise therapy
• Consider when symptoms are severe or limiting exercise participation 2, 1

Patellofemoral Braces

• May be considered as a supportive intervention
• Patients often report subjective improvements in pain and disability with brace wear 2
• Off-the-shelf versions are suitable for most people 2

Pharmacologic Management

• Acetaminophen - First-line pharmacologic option (maximum daily dose of 4,000 mg)
• NSAIDs - Consider if acetaminophen is ineffective
  • Topical diclofenac preferred due to fewer gastrointestinal side effects
  • Topical NSAIDs preferred over oral for patients ≥75 years 1

Treatment Algorithm

1. Initial Phase (0-2 weeks):

   • Begin knee-targeted exercises (quadriceps strengthening)
   • Provide comprehensive education
   • Implement activity modification
   • Consider taping or bracing for immediate pain relief

2. Progressive Phase (2-6 weeks):

   • Add hip strengthening exercises
   • Progress quadriceps exercises as tolerated
   • Consider foot orthoses if biomechanical factors contribute
   • Incorporate manual therapy if needed to facilitate exercise participation

3. Functional Phase (6+ weeks):

   • Progress to more functional exercises
   • Gradually reintroduce aggravating activities
   • Reassess at 6-8 weeks to determine progress
   • Consider referral for orthopedic consultation if no improvement after 3 months 1

Common Pitfalls and Caveats

• Avoid excessive rest - Complete rest can lead to muscle atrophy and prolonged recovery
• Don't rush progression - Advancing exercises too quickly can exacerbate symptoms
• Don't rely solely on passive treatments - Active exercises are essential for long-term success
• Don't ignore biomechanical factors - Assess for foot pronation, hip weakness, and movement patterns
• Don't neglect patient education - Understanding the condition improves adherence and outcomes
• Don't continue ineffective treatment - If no improvement after 6 weeks, reassess and modify the approach 2, 1

The evidence strongly supports a structured approach focusing on exercise therapy and education, with adjunctive treatments used strategically to facilitate participation in the exercise program. While older research suggested simple rest and avoidance of activities 3, current high-quality evidence emphasizes active rehabilitation with progressive loading to address the underlying factors contributing to patellofemoral pain.