What are the diagnosis and management options for patellofemoral pain syndrome?

Diagnosis and Management of Patellofemoral Pain Syndrome

Best practice for patellofemoral pain syndrome should include delivering knee-targeted exercise therapy underpinned by education, with additional supporting interventions tailored to the patient's specific presentation following a thorough assessment. 1

Diagnosis

Clinical Presentation

• Patients typically report gradual onset diffuse retropatellar and/or peripatellar pain during activities such as squatting, stair ambulation, and running 1
• Pain is often exacerbated by activities that involve knee flexion under load 2
• Poor prognosis with over 50% of patients reporting persistent pain more than 5 years post-diagnosis despite treatment 1
• Associated with increased anxiety, depression, reduced physical activity, and poorer health-related quality of life 1

Physical Examination

• Evaluate hip and knee strength using hand-held dynamometry to identify quadriceps weakness, a key risk factor 1
• Assess movement patterns and foot biomechanics through observation of single leg squat or treadmill running 1
• Test tissue tolerance to load through pain provocation tests and check for presence of effusion 1
• Evaluate patellofemoral joint structure/function, looking for issues like patella alta or hypermobility 1
• Findings may range from limited patellar mobility to hypermobile patella 2

Management Approach

Primary Interventions

1. Knee-targeted Exercise Therapy

   • High certainty evidence supports knee-targeted exercise therapy for short-term pain reduction 1
   • Focus on strengthening quadriceps muscles, particularly with the knee extended to reduce patellofemoral pressure 3
   • Individualize exercise parameters based on symptom severity and irritability 1
   • Progressive loading is essential for effective rehabilitation 1

2. Hip-targeted Exercise Therapy

   • Combine with knee exercises for better outcomes 1
   • Particularly beneficial when patients have poor tolerance to loaded knee flexion 1
   • Addresses biomechanical contributors to patellofemoral pain 3

3. Patient Education

   • Should underpin all interventions and be adjusted to reflect individual needs 1
   • Provide rationale for specific intervention plans 1
   • Build confidence and understanding of the diagnosis 1
   • Explain that pain does not necessarily correlate with tissue damage 1
   • Set realistic expectations about recovery timeframes 1

Supporting Interventions

1. Prefabricated Foot Orthoses

   • Prescribe when patients respond favorably to treatment direction tests (symptom improvement during functional tasks with orthoses in place) 1
   • Customize for comfort by modifying density and geometry 1
   • Particularly beneficial for patients with foot alignment issues contributing to knee pain 3

2. Manual Therapy

   • Consider when rehabilitation is hindered by elevated symptom severity or high fear of movement 1
   • Targets the patellofemoral joint and surrounding soft tissues to improve mobility and reduce pain 3
   • Includes soft tissue stretching of lateral patellar structures 4

3. Taping Techniques

   • Useful when rehabilitation is hindered by symptom severity or fear of movement 1
   • McConnell-style patellar taping can be effective as part of a comprehensive approach 1
   • Provides immediate pain relief to gain patient trust 4

4. Movement/Running Retraining

   • Consider when symptoms are associated with task-specific biomechanics 1
   • Example: increasing step rate in runners with excessive stride length 1
   • Reduces patellofemoral joint stress in active patients 3

Pharmacological Management

• Acetaminophen (up to 4,000 mg/day) as initial pharmacologic therapy due to favorable safety profile 3
• Topical NSAIDs as an alternative first-line therapy for local anti-inflammatory effects with fewer systemic side effects 3
• Limited evidence supports routine use of oral NSAIDs 2

Treatment Algorithm

1. Initial Assessment

   • Evaluate pain levels, fear of movement, expectations, self-efficacy, and perceived joint resilience 1
   • Conduct objective evaluation of functional manifestations and key impairments 1

2. Primary Treatment

   • Begin with knee-targeted exercise therapy and education for all patients 1
   • Add hip-targeted exercises if patient shows poor tolerance to loaded knee flexion 1

3. Adjunctive Treatments

   • Add prefabricated foot orthoses if favorable response to treatment direction tests 1
   • Implement manual therapy and/or taping for patients with high symptom severity or fear of movement 1
   • Consider movement/running retraining for patients with task-specific biomechanical issues 1

4. Follow-up and Progression

   • Reassess after minimum 6 weeks of treatment 1
   • If outcomes are unfavorable, revisit assessment findings to ensure interventions align with initial reasoning 1
   • Review patient engagement and adherence to prescribed program 1

Common Pitfalls to Avoid

• Failing to address modifiable risk factors such as obesity, muscle weakness, and biomechanical issues 3
• Neglecting to strengthen both quadriceps and hip muscles, which are essential for patellofemoral joint stability 3
• Overlooking the importance of patient education and self-management strategies 3
• Rushing to imaging studies before beginning treatment - for many patients with clinical diagnosis of PFPS, imaging is not necessary 2
• Considering surgery before exhausting comprehensive rehabilitation options - surgery should only be considered after failure of a complete rehabilitation program 2