What is the treatment for runner's knee (patellofemoral pain syndrome)?

Treatment for Runner's Knee (Patellofemoral Pain Syndrome)

Exercise therapy targeting the knee and hip muscles, combined with education, should be the primary treatment for runner's knee, with prefabricated foot orthoses and patellar taping as supporting interventions when needed. 1

Core Treatment: Exercise Therapy

Knee-Targeted Exercises (Foundation)

• Quadriceps strengthening exercises must be prescribed as the foundation of treatment, with strong evidence showing clinically important pain reduction (1.46 points on 0-10 scale) and functional improvement (12.21 points on AKPS scale) compared to no treatment 2, 3
• Exercises should focus on increasing quadriceps strength and preserving normal knee mobility 1
• Both closed kinetic chain exercises (foot in contact with surface, like squats) and open kinetic chain exercises (foot free, like leg extensions) are equally effective—choose based on patient tolerance 4, 2

Hip-and-Knee Combined Exercises (Enhanced Approach)

• Adding hip strengthening to knee exercises provides superior pain reduction (additional 2.20 points on 0-10 scale) compared to knee exercises alone, particularly targeting hip abductors 2, 3
• Hip-and-knee combination should be prioritized in patients with poor tolerance to loaded knee flexion or those showing hip weakness on examination 1
• The evidence for combined hip-knee exercises is stronger than knee exercises alone for short-term pain outcomes 2

Essential Supporting Component: Education

• Education must underpin all interventions, adjusted to the patient's specific needs and beliefs 1
• Address misconceptions that pain equals tissue damage, especially in chronic cases (symptoms >3 months) 1
• Explain the recovery timeline, load management principles, and promote patient autonomy to reduce fear-avoidance behaviors 1
• Build confidence in the diagnosis and expected outcomes based on symptom severity, irritability, and patient goals 1

Supporting Interventions (Evidence-Based Adjuncts)

Prefabricated Foot Orthoses

• Prescribe prefabricated (not custom) foot orthoses for patients who respond favorably to treatment direction tests (e.g., improved pain with squat test while wearing orthoses) 1
• Customize for comfort by modifying density and geometry 1
• Most beneficial in the short term; long-term use may not be necessary 1
• This addresses a knowledge translation gap, as many clinicians lack confidence prescribing orthoses despite strong evidence 1

Patellar Taping

• Use patellar taping when elevated symptom severity and irritability hinder rehabilitation progress 1
• Taping provides subjective improvement in pain and stability, though objective effects may diminish at higher stress levels 1
• Reassess after a realistic trial period if favorable outcomes are not observed 1

Movement/Running Retraining

• Consider gait retraining for runners with assessment findings that align with the intervention (e.g., low cadence, excessive hip adduction) 1
• Specific interventions include increasing step cadence or step width 1
• Address core and proximal strength to optimize lower extremity biomechanics 5

Treatment Phases and Progression

Initial Phase (1-2 weeks)

• Relative rest from aggravating activities (not complete immobilization, which causes muscle atrophy) 5, 6
• Ice application through wet towel for 10-minute periods for short-term pain relief 5
• Gentle stretching of hamstrings and adductors 5
• Begin education about diagnosis and load management 1

Intermediate Phase (2-6 weeks)

• Progressive strengthening exercises (knee-targeted or hip-and-knee combined based on assessment) 5, 3
• Continue stretching program 5
• Add prefabricated foot orthoses if treatment direction tests are positive 1
• Consider patellar taping if symptoms hinder exercise progression 1

Advanced Phase (6+ weeks)

• Sport-specific or activity-specific exercises 5
• Running retraining if applicable 1, 5
• Gradual return to normal activities as tolerated 5
• Maintenance program to prevent recurrence 5

Critical Pitfalls to Avoid

• Never prescribe complete immobilization—this leads to muscle atrophy and deconditioning 5
• Avoid corticosteroid injections—they may provide faster short-term relief but don't improve long-term outcomes and potentially weaken tendon structure 5
• Surgery should be avoided in all patients with PFPS—there is no evidence supporting surgical intervention for this condition 3
• Do not rely solely on passive modalities (ultrasound, electrical stimulation)—active exercise therapy is superior 5
• Ensure exercises match symptom severity and irritability; overly aggressive loading can worsen symptoms 1

Assessment-Driven Decision Making

Key examination findings that guide treatment selection: 1

• Muscle strength deficits (hip abductors, quadriceps) → prioritize strengthening
• Movement pattern abnormalities during single-leg squat → consider movement retraining
• Poor tissue tolerance to load (pain provocation, effusion) → modify exercise intensity/frequency
• Structural factors (patella alta, hypermobility) → may benefit from taping or orthoses
• Fear-avoidance behaviors (antalgic gait, task hesitance) → emphasize education and graded exposure

The treatment algorithm should be guided by symptom severity, irritability, patient goals, and specific physical impairments identified during assessment, not by a one-size-fits-all protocol. 1