What is the appropriate management for a young, active individual with bilateral knee pain suggestive of patellofemoral pain syndrome?

Management of Patellofemoral Pain Syndrome in a Young Basketball Player

Knee-targeted exercise therapy combined with hip exercises should be the foundation of treatment for this patient with patellofemoral pain syndrome (PFPS). 1, 2

Diagnosis

The patient's presentation is consistent with patellofemoral pain syndrome based on:

• Gradual onset of bilateral knee pain without trauma 1
• Pain aggravated by activities involving knee flexion (basketball, stairs, standing) 1, 3
• Positive patellar grind and Clarke's tests 3
• Absence of ligamentous instability (negative Lachman, McMurray, varus/valgus tests) 3
• Peripatellar tenderness on examination 3, 4

Treatment Plan

Primary Interventions

1. Exercise Therapy

   • Knee-targeted exercises: 2, 1, 5

     • Progressive quadriceps strengthening (straight leg raises, terminal knee extensions)
     • Closed kinetic chain exercises (squats, step-ups) with proper form
     • Vastus medialis oblique strengthening

   • Hip exercises: 2, 1, 5

     • Hip abductor strengthening (side-lying leg raises, clamshells)
     • Hip external rotator strengthening
     • Core stability exercises

2. Education 2, 1

   • Explain PFPS pathophysiology and that pain doesn't indicate structural damage
   • Set realistic expectations about recovery timeframes (may take 6-12 weeks)
   • Advise on activity modification during rehabilitation (reduce basketball intensity temporarily)
   • Emphasize importance of exercise adherence (over 50% report persistent pain after 5 years despite treatment) 1

Adjunctive Interventions

1. Taping 2, 1

   • Patellar taping to improve patellar tracking and reduce pain during exercises
   • Can be used initially to facilitate exercise therapy when pain limits participation

2. Prefabricated Foot Orthoses 2, 1

   • Consider if patient responds favorably to treatment direction tests
   • Particularly beneficial in the short term to reduce pain and improve function

3. Manual Therapy 2

   • Soft tissue mobilization of lateral retinacular structures and iliotibial band
   • Joint mobilizations to improve patellofemoral mechanics

4. Short-term NSAIDs 3, 6

   • For initial pain management to facilitate exercise participation
   • Not for long-term use

Implementation Algorithm

1. Initial Phase (Weeks 1-2):

   • Begin with pain-free exercises focusing on proper form 1, 5
   • Apply taping before exercise sessions if needed 2
   • Educate on activity modification and pathophysiology 1
   • Consider short-term NSAIDs if pain limits exercise participation 3

2. Progressive Phase (Weeks 3-6):

   • Gradually increase exercise intensity and duration 5
   • Incorporate more functional movements specific to basketball 1
   • Begin sport-specific training with proper biomechanics 6

3. Return to Sport Phase (Weeks 7-12):

   • Progressive return to basketball activities 1
   • Continue maintenance exercises to prevent recurrence 5, 6
   • Monitor for symptom exacerbation and adjust activity accordingly 1

Monitoring and Follow-up

• Reassess pain levels and functional ability every 2-4 weeks 1
• If no improvement after 6-8 weeks of consistent therapy, consider:
  • Reassessment of diagnosis 2
  • Imaging (radiographs, MRI) to rule out other pathologies 2
  • Referral to sports medicine specialist 3

Common Pitfalls to Avoid

• Relying solely on passive treatments without addressing muscle strength 1
• Returning to full basketball activity too quickly 1, 6
• Focusing only on knee exercises without addressing hip strength 2, 5
• Neglecting proper footwear and biomechanics during sports 6
• Overemphasis on imaging without adequate trial of conservative management 2