What are the symptoms and treatment options for Patellofemoral syndrome?

Symptoms and Treatment of Patellofemoral Syndrome

Patellofemoral pain syndrome (PFP) is characterized by gradual onset diffuse retropatellar and/or peripatellar pain during activities such as squatting, stair ambulation, and running, which requires a targeted approach of exercise therapy and education for optimal management. 1

Key Symptoms

• Pain behind or around the patella (retropatellar and/or peripatellar) that develops gradually rather than suddenly 1
• Pain that worsens during activities that load the patellofemoral joint, particularly:
  • Squatting 1, 2
  • Stair climbing and descending (especially going downstairs) 2
  • Running 1, 2
• Pain that intensifies when the knee is flexed during weight-bearing activities 2
• Pain that worsens with prolonged sitting (theater sign) 2
• Functional limitations in daily activities, sports participation, and quality of life 1
• Potential anxiety or depression (people with PFP are six times more likely to experience these conditions) 1

Physical Examination Findings

• Pain with squatting (most sensitive physical examination finding) 2
• Varying degrees of patellar mobility (from limited to hypermobile) 3
• Potential quadriceps weakness, particularly vastus medialis oblique 4
• Possible hip muscle weakness 1
• Abnormal movement patterns during functional tasks like single leg squats 1
• Fear avoidance behaviors during functional tasks 1

Treatment Approach

Primary Interventions

• Knee-targeted exercise therapy should be the foundation of all treatment plans for patellofemoral pain, with hip exercises added based on individual assessment findings. 1

  • For patients with quadriceps atrophy who tolerate loaded knee flexion: focus on knee-targeted exercises 1
  • For patients with poor tolerance to loaded knee flexion: begin with greater focus on hip exercises 1
  • Modify exercise parameters (load/intensity/frequency) based on symptom severity and irritability 1
  • Continue for a minimum of 6 weeks before reassessing effectiveness 1

• Education must underpin all interventions 1

  • Explain the diagnosis and pathophysiology in accessible terms 1
  • Clarify that pain does not necessarily correlate with tissue damage 1
  • Set realistic expectations about recovery timeframes 1
  • Provide guidance on activity modification and load management 1
  • Build confidence and reduce fear of movement 1

Supporting Interventions (Based on Assessment Findings)

• Prefabricated foot orthoses when patients respond favorably to treatment direction tests (e.g., symptom improvement during functional tasks with orthoses in place) 1

  • Customize for comfort by modifying density and geometry 1
  • Most beneficial in the short term 1

• Taping when rehabilitation is hindered by high symptom severity/irritability or fear of movement 1

  • Can provide short-term pain relief 2
  • May help improve exercise tolerance 1

• Manual therapy when rehabilitation is hindered by high symptom severity/irritability or fear of movement 1

  • Can be used as an adjunct to facilitate exercise therapy 1

• Movement/running retraining when symptoms appear related to task-specific biomechanics 1

  • Examples: increasing cadence or step width for runners 1

• Short course of NSAIDs may provide symptomatic relief 2

  • Not recommended for long-term use 3

Assessment Framework

1. Understand the patient's background:

   • Impact of symptoms on daily life, work, and recreational activities 1
   • Symptom history and pattern 1
   • Goals and expectations 1

2. Evaluate key subjective factors:

   • Pain levels and tolerance 1
   • Fear of movement 1
   • Self-efficacy related to symptoms 1
   • Perceived joint resilience 1

3. Perform objective evaluation:

   • Hip and knee strength assessment 1
   • Movement pattern analysis (e.g., single leg squat) 1
   • Tissue tolerance to load 1
   • Patellofemoral joint structure and function 1

Common Pitfalls and Caveats

• Failure to persist with exercise therapy: Exercise therapy requires at least 6 weeks before reassessing effectiveness 1
• Over-reliance on passive treatments: Supporting interventions should complement, not replace, active exercise therapy 1
• Inadequate education: Patients need clear understanding of their condition and realistic expectations about recovery 1
• Poor prognosis if not properly managed: Over 50% of people report persistent pain more than 5 years post-diagnosis despite receiving treatment 1
• Potential progression to patellofemoral osteoarthritis: PFP is thought to be a precursor to patellofemoral osteoarthritis, making optimal management essential 1
• Unnecessary imaging: For most patients with clinical diagnosis of PFP, imaging studies are not necessary before beginning treatment 3, 2
  • Consider radiography only for patients with history of trauma/surgery, joint effusion, age >50 years, or if pain doesn't improve with treatment 3