Treatment for Patellofemoral Osteoarthritis with Chronic Knee Pain
Begin with a structured exercise therapy program targeting both hip and knee strengthening, combined with patient education about the condition—this is the cornerstone of treatment and should be implemented before considering any other interventions. 1
First-Line Treatment: Exercise Therapy
Quadriceps strengthening exercises are strongly recommended as they demonstrate significant improvements in pain (effect size 1.05) and functional outcomes in knee osteoarthritis, including patellofemoral disease. 1
Hip-and-knee-targeted exercise therapy should be prescribed together for optimal outcomes in patellofemoral osteoarthritis, as this combination addresses the biomechanical factors contributing to altered patellofemoral loading. 1, 2
Exercise programs should be continued for at least 3-6 months before determining treatment failure, as this duration is necessary to achieve meaningful improvements in pain and function. 3, 4
The exercise regimen should be adjusted based on tissue tolerance to load—if the patient has poor tolerance to loaded knee flexion (which appears likely given the inability to stand for true AP views), initially emphasize hip strengthening exercises and gradually progress to knee-focused exercises as tolerance improves. 1
Supporting Interventions
Patellofemoral Bracing
Patellofemoral braces are conditionally recommended for patients whose disease is causing sufficient impact on ambulation, joint stability, or pain to warrant assistive device use. 1
The recommendation is conditional due to variability in trial results and patient tolerance issues—optimal management requires clinician familiarity with various brace types and expertise in proper fitting. 1
Kinesiotaping
- Kinesiotaping is conditionally recommended as it permits range of motion while providing support, though evidence quality is limited by inability to blind participants. 1
Cognitive Behavioral Therapy
- CBT is conditionally recommended for all knee osteoarthritis patients, as it addresses pain perception, coping strategies, and may improve outcomes related to mood, sleep, and fear avoidance behaviors. 1
Assistive Devices
- Cane use is strongly recommended if the disease is causing sufficient impact on ambulation or pain—this patient's inability to stand for radiographs suggests significant functional limitation that may warrant cane use. 1
Education Component
Patient education must be integrated throughout treatment, focusing on understanding that patellofemoral osteoarthritis represents a continuum of disease that often begins with patellofemoral pain in younger years. 5, 6
Education should emphasize that pain does not equal damage, particularly important given the chronic nature of symptoms, and should build confidence in the diagnosis and recovery process. 1
Set realistic expectations: patellofemoral osteoarthritis is highly prevalent (69% of people with chronic patellofemoral pain show radiographic OA), and even individuals under 50 years commonly demonstrate radiographic changes. 6
Interventions to Avoid
Modified shoes and wedged insoles are conditionally recommended AGAINST in knee osteoarthritis, as available evidence does not demonstrate clear efficacy. 1
Arthroscopic surgery is NOT indicated for degenerative patellofemoral changes, even in the presence of mechanical symptoms, as high-quality evidence shows no meaningful benefit over conservative treatment. 3, 2
When Conservative Treatment Fails
If inadequate response after 3 months of appropriate conservative management, intra-articular corticosteroid injection may be considered as a temporizing measure. 3, 7
Joint replacement surgery should only be considered for end-stage disease with inability to cope with pain after exhausting all appropriate conservative options—this patient's radiographs show maintained joint spacing, indicating this is not yet appropriate. 1, 2
Critical Pitfalls to Avoid
Do not rush to imaging-based interventions—the small osteophytes and hypertrophic changes are common age-related findings that do not dictate treatment decisions. 3
Do not assume the patient's inability to stand indicates need for surgery—this functional limitation is precisely what exercise therapy and supportive interventions are designed to address. 1, 4
Do not neglect the hip musculature—weakness and imbalance between vastus medialis and vastus lateralis must be corrected, and hip muscle strengthening is essential for optimal patellofemoral joint loading. 1, 4
Ensure at least 3 months of structured conservative treatment before considering the treatment a failure—anterior knee pain typically requires this duration for meaningful improvement. 4