Diagnosis and Treatment of Patellofemoral Pain Syndrome
Knee-targeted exercise therapy combined with education should be the primary treatment for patellofemoral pain syndrome, with additional interventions tailored to the patient's specific presentation. 1
Diagnosis
- Patellofemoral pain syndrome (PFPS) typically presents as gradual onset diffuse retropatellar and/or peripatellar pain during activities such as squatting, stair climbing, and running 1
- Poor prognosis is common, with over 50% of patients reporting persistent pain more than 5 years after diagnosis despite treatment 1
- PFPS is associated with increased anxiety, depression, reduced physical activity, and poorer health-related quality of life 1
Treatment Algorithm
Primary Interventions (High Priority)
- Knee-targeted exercise therapy should be the foundation of treatment for all patients with PFPS, with high certainty evidence supporting its use for short-term pain reduction 2, 1
- Focus on strengthening quadriceps muscles, particularly with the knee extended to reduce patellofemoral pressure 1
- Combine with patient education about the condition, explaining that pain does not necessarily correlate with tissue damage, and setting realistic expectations about recovery timeframes 1
Supporting Interventions (Based on Individual Assessment)
- Hip-targeted exercise therapy should be added, particularly for patients with poor tolerance to loaded knee flexion 2, 1
- Prefabricated foot orthoses can be beneficial when combined with hip-and-knee-targeted exercise therapy, especially for patients who respond favorably to treatment direction tests 2, 1
- Manual therapy targeting the lower quadrant shows moderate certainty evidence for short-term function improvement and can be considered when rehabilitation is hindered by elevated symptom severity or high fear of movement 2, 1
- Patellar taping can be useful when rehabilitation is hindered by symptom severity or fear of movement 2, 1
- Movement/running retraining should be considered for patients with task-specific biomechanical issues 1
Pharmacological Management
- Acetaminophen (up to 4,000 mg/day) can be used as initial pharmacologic therapy due to its favorable safety profile 1
- Topical NSAIDs can be used as an alternative first-line therapy for local anti-inflammatory effects with fewer systemic side effects 1
Assessment Focus Points
- Evaluate pain levels, fear of movement, expectations, self-efficacy, and perceived joint resilience during initial assessment 1
- Conduct objective evaluation of functional manifestations and key impairments that influence symptoms to guide treatment selection 2
- Pay particular attention to understanding the person's background and establishing why they have sought care 2
Treatment Efficacy Evidence
- High certainty evidence supports knee-targeted exercise therapy for short-term pain reduction (SMD 1.16,95% CI 0.66,1.66) 2
- Moderate certainty evidence supports knee-targeted exercise therapy for short-term function improvement (SMD 1.19,95% CI 0.51,1.88) 2
- Moderate certainty evidence supports lower quadrant manual therapy for short-term function improvement (SMD 2.30,95% CI 1.60,3.00) 2
- Evidence supports the efficacy of prefabricated foot orthoses when combined with hip-and-knee-targeted exercise therapy 2
- Evidence supports dry needling and vibration therapy when combined with hip-and-knee-targeted exercise therapy 2
Common Pitfalls to Avoid
- Failing to progressively load exercises, which is essential for effective rehabilitation 1
- Neglecting to strengthen both quadriceps and hip muscles, which are essential for patellofemoral joint stability 1, 3
- Overlooking the importance of patient education and self-management strategies 1, 3
- Using dry needling alone (without exercise therapy), as evidence shows non-efficacy compared to sham needling 2
- Using hyaluronic acid injection combined with hip-and-knee-targeted exercise therapy, as evidence shows non-efficacy compared to sham saline injection with exercise therapy 2