What is the appropriate management for a patient diagnosed with left knee patellofemoral syndrome?

Understanding Your Orthopedic Surgeon's Diagnosis

Your orthopedic surgeon has diagnosed you with patellofemoral pain syndrome (pain behind/around the kneecap) complicated by several anatomical factors: your kneecap moves more than normal (mild hypermobility), the fat pad beneath your kneecap is inflamed, and you have extra tissue folds (medial plica and ligamentum mucosum) that may be contributing to irritation.

What These Terms Mean

• Patellofemoral syndrome: Pain originating from where your kneecap (patella) meets your thighbone (femur), typically worsening with stairs, squatting, running, or prolonged sitting with bent knees 1
• Mild hypermobility: Your kneecap has excessive movement, which can lead to abnormal tracking and increased stress on surrounding tissues 2
• Fat pad irritation: The cushioning tissue (Hoffa's fat pad) beneath your kneecap is inflamed, contributing to anterior knee pain 3
• Medial plica/ligamentum mucosum: These are remnant tissue folds from fetal development that can become irritated and cause pain when they thicken or catch during knee movement 3

Evidence-Based Treatment Approach

First-Line Treatment: Exercise Therapy (Start Immediately)

Begin with knee-targeted quadriceps strengthening combined with hip muscle exercises, as this combination provides superior pain reduction compared to knee exercises alone. 4

Phase 1 (Weeks 1-4): Pain Control and Muscle Balance

• Focus on correcting the imbalance between your inner quadriceps (vastus medialis) and outer quadriceps (vastus lateralis) before progressing to heavier strengthening 3
• Perform exercises at 50-60% of your maximum capacity, 3 days per week 2
• Hip strengthening (particularly gluteus medius) combined with quadriceps work reduces pain by an average of 2.20 points on a 0-10 scale in the short term—a clinically meaningful improvement 4
• Expect pain reduction of approximately 1.46 points (0-10 scale) and functional improvement of 12 points (0-100 scale) within 3 months 5

Phase 2 (Weeks 5-12): Progressive Loading

• Advance to closed kinetic chain exercises (exercises where your foot stays planted, like squats and leg presses) as these are better tolerated with patellofemoral pain 4
• Increase exercise intensity based on symptom irritability—if your knee is highly irritable, emphasize hip exercises over loaded knee flexion 4
• Continue for at least 3 months before considering other options, as this is the minimum duration needed to assess effectiveness 3

Supporting Interventions (Add Based on Your Response)

Prefabricated Foot Orthoses (Insoles)

• Use these if you respond favorably to a simple test: try squatting with and without the insoles—if symptoms improve with them, continue use 4
• Most beneficial in the short term (first 3-6 months) while you build strength 4
• The American College of Rheumatology conditionally recommends patellofemoral braces if your symptoms significantly impact walking, joint stability, or pain 4

Patellar Taping

• Consider taping if your pain severity is hindering your ability to perform rehabilitation exercises 4
• Discontinue if you don't see favorable outcomes after a realistic trial period 4

Education Component (Essential Throughout)

• Understand that your pain does not equal tissue damage, especially important given your anatomical variants (plica, fat pad irritation) 4
• Pain with activity is expected during rehabilitation and doesn't indicate harm 4
• Recovery typically takes 3-6 months with consistent exercise therapy 3, 5

What to Avoid

Do NOT pursue surgery for patellofemoral pain syndrome—there is no indication for surgical intervention 1. The plica and ligamentum mucosum findings are common anatomical variants that rarely require surgical removal unless conservative treatment fails after 3-6 months 3.

Expected Outcomes

• Short-term (3 months): Clinically meaningful pain reduction during activities and improved function with exercise therapy 5
• Long-term (12 months): An additional 88 per 1000 patients achieve full recovery compared to no treatment 5
• Over 2/3 of patients successfully return to full function with rehabilitation protocols 2

Red Flags Requiring Re-evaluation

• No improvement after 3 months of consistent exercise therapy 3
• Development of true mechanical locking (knee gets stuck and cannot move, different from catching sensations) 1
• Progressive worsening despite appropriate conservative management 3