Initial Management of Patellofemoral Syndrome
Begin with knee-targeted exercise therapy combined with patient education as the primary intervention, adding hip strengthening exercises and selecting from specific adjunctive treatments (prefabricated foot orthoses, manual therapy, taping, or movement retraining) based on individual patient presentation and response to initial assessment. 1, 2
Primary Treatment Foundation
Exercise Therapy (Core Intervention)
Quadriceps strengthening with the knee extended reduces patellofemoral pressure and forms the cornerstone of treatment, with high certainty evidence supporting short-term pain reduction. 2, 3
Progressive loading is essential for effective rehabilitation, with exercise parameters individualized based on symptom severity and irritability. 2
Combine knee exercises with hip-targeted exercises for superior outcomes, particularly hip abductor strengthening (side-lying leg raises, clamshells). 2, 4, 5
Add hip exercises specifically when patients demonstrate poor tolerance to loaded knee flexion activities. 2
Exercises should be performed twice daily until symptoms subside, then three times weekly for maintenance during athletic activity. 6
Patient Education (Mandatory Component)
Provide clear rationale for the specific intervention plan to build patient confidence and understanding. 2
Explain that pain does not necessarily correlate with tissue damage, which helps reduce fear-avoidance behaviors. 2, 4
Set realistic expectations about recovery timeframes, noting that over 50% of patients report persistent pain beyond 5 years without proper management. 1, 4
Emphasize activity modification and avoidance of activities that increase patellofemoral pressure (prolonged sitting with bent knees, ascending/descending stairs, squatting). 5, 3
Initial Assessment to Guide Treatment Selection
Subjective Evaluation
Assess pain levels and tolerance to determine exercise prescription intensity. 4
Evaluate fear of movement as this influences whether manual therapy or taping should be added initially. 2, 4
Determine patient expectations and self-efficacy regarding symptom management and recovery. 2, 4
Identify impact on daily life and recreational activities to prioritize functional goals. 4
Objective Evaluation
Test hip and knee strength to identify specific muscle weaknesses requiring targeted intervention. 4
Analyze movement patterns during functional activities to determine if movement retraining is needed. 4
Assess tissue tolerance to load to guide progressive exercise prescription. 4
Perform treatment direction tests for foot orthoses to identify favorable responders. 2
Adjunctive Interventions (Add Based on Specific Indications)
Prefabricated Foot Orthoses
- Prescribe when patients respond favorably to treatment direction tests, with benefits most evident in the short term. 2, 4, 5
Manual Therapy
Add when rehabilitation is hindered by elevated symptom severity or high fear of movement, including soft tissue mobilization of lateral retinacular structures and iliotibial band. 2, 4, 5
Manual therapy serves as a facilitator for exercise therapy rather than a standalone treatment. 4
Patellar Taping
Use when rehabilitation is hindered by symptom severity or fear of movement to provide immediate pain relief and gain patient trust. 2, 4, 5
Taping helps facilitate exercise participation but should not replace active interventions. 4
Movement/Running Retraining
- Consider for patients with task-specific biomechanical issues identified during movement analysis. 2, 4
Patellofemoral Braces
May provide subjective improvements in pain and disability, though objective evidence at physiologic stress levels is limited. 1
Braces incorporate elastic material with straps or buttresses to resist lateral patellar displacement. 1
More active patients may prefer braces with lateral hinges and adjustable patellar buttresses. 1
Pharmacologic Options
First-Line Medications
Acetaminophen up to 4,000 mg/day offers favorable safety profile for initial pain management. 2
Topical NSAIDs provide local anti-inflammatory effects with fewer systemic side effects compared to oral formulations. 2
Oral NSAIDs may reduce pain in the short term but do not improve outcomes after three months. 7
Cryotherapy
- Apply melting ice water through wet towel for 10-minute periods repeatedly for acute pain relief. 8
Treatment Algorithm
Week 0-6: Initial Phase
- Start all patients on knee-targeted exercise therapy (quadriceps strengthening with knee extended) plus education. 2, 3
- Add hip abductor strengthening exercises. 2, 4
- Consider acetaminophen or topical NSAIDs for pain control. 2
- Add taping if high symptom severity or fear of movement limits exercise participation. 2
- Add prefabricated foot orthoses if treatment direction tests are positive. 2
Week 6-8: Reassessment Phase
- If no improvement, reassess diagnosis and revisit assessment findings to ensure interventions align with initial reasoning. 2, 4
- Consider adding manual therapy if not already implemented. 2
- Evaluate for movement/running retraining needs if task-specific issues persist. 2
- Consider imaging (radiographs or MRI) only if diagnosis is uncertain after adequate conservative trial. 4
Beyond 8 Weeks: Advanced Management
Critical Pitfalls to Avoid
Do not focus solely on knee exercises without addressing hip strength, as this multimodal approach yields superior outcomes. 4, 5
Avoid over-reliance on passive treatments (manual therapy, taping, bracing) at the expense of active exercise therapy. 4, 5
Do not order imaging prematurely without adequate trial of conservative management (minimum 6-8 weeks). 4
Avoid complete immobilization for extended periods as this causes muscular atrophy. 8
Do not neglect patient education, as inadequate understanding contributes to the poor long-term prognosis seen in over 50% of patients. 4