What is the recommended treatment for pain located above the knee cap?

Treatment for Pain Above the Knee Cap (Suprapatellar Pain)

For pain located above the knee cap, initiate a multimodal conservative treatment program centered on quadriceps strengthening exercises performed with the knee in extension, combined with hip strengthening, activity modification, and topical NSAIDs for pain relief. 1, 2

Immediate First-Line Management

Pain Relief Strategies

• Apply topical NSAIDs (such as diclofenac) as the initial pharmacologic intervention, which provides superior safety profiles compared to oral medications, particularly in older adults 1, 3
• Use patellar taping techniques to provide immediate pain reduction and gain patient trust, which is critical for treatment adherence 2, 4
• Consider acetaminophen (up to 4,000 mg/day) as an alternative if NSAIDs are contraindicated 1, 5
• Oral NSAIDs (ibuprofen or naproxen) should be reserved for cases where topical agents and acetaminophen prove insufficient 1, 3

Activity Modification

• Immediately reduce or eliminate activities that increase patellofemoral pressure, including prolonged sitting, stair climbing, squatting, and jumping 1, 6, 7
• Educate the patient that activity modification is essential and non-negotiable for successful outcomes 2

Core Exercise Therapy Program

Quadriceps Strengthening (Primary Focus)

• Prescribe quadriceps strengthening exercises performed exclusively with the knee in full extension to minimize patellofemoral joint stress 1, 6
• Ensure at least 12 supervised physical therapy sessions, as this demonstrates significantly greater efficacy (effect size 0.46) compared to fewer sessions (effect size 0.28, p=0.03) 3

Hip Strengthening (Essential Component)

• Include gluteal muscle strengthening exercises, which possess the strongest evidence base for patellofemoral pain management 2, 4
• Target hip abductors and external rotators specifically, as weakness in these muscle groups contributes to altered movement patterns 4

Core Strengthening

• Incorporate core stabilization exercises as part of the comprehensive program 4

Complementary Interventions

Orthotic Devices

• Prescribe foot orthoses in combination with the exercise program, as this combination demonstrates superior outcomes compared to exercise alone 2, 4
• Consider patellar bracing with soft braces (nonelastic, nonadhesive material), though ensure concurrent exercise to prevent muscle atrophy 1

Manual Therapy

• Apply patellofemoral and tibiofemoral joint mobilizations as adjunctive treatment 2, 4
• Use deep transverse friction massage to reduce pain 1

Additional Modalities

• Consider acupuncture, which has supporting evidence for patellofemoral pain 2
• Neuromuscular training and gait retraining may be beneficial for movement pattern correction 4

Weight Management (If Applicable)

• For patients with BMI ≥25, prescribe weight loss with a goal of 5-7.5% body weight reduction, which demonstrates significant pain reduction in knee conditions 1, 3

Treatment Progression and Monitoring

Progression Criteria

• Base progression on objective measures including effusion status, soreness rules, and systematic increases in loading 4
• Emphasize function over symptoms, using graded exposure principles for chronic presentations 4

Expected Timeline

• Most patients with patellofemoral pain respond to conservative treatment within 4-6 weeks 6, 7
• Continue supervised exercise therapy for the full 12-session minimum before considering treatment failure 3

Critical Pitfalls to Avoid

• Do not bypass topical NSAIDs in favor of oral NSAIDs, as topical agents have superior safety profiles and strong evidence 1, 3
• Do not perform quadriceps strengthening with the knee flexed, as this increases patellofemoral joint stress and may exacerbate symptoms 1, 6
• Do not consider surgery for patellofemoral pain, as there is no indication for surgical intervention in this condition 7, 2
• Do not accept "physical therapy trials" without documented supervised sessions ≥12, as inadequate dosing shows significantly inferior outcomes 3
• Do not prescribe bracing without concurrent exercise, as this leads to muscle atrophy and functional loss 1

When to Consider Advanced Evaluation

• If pain persists despite 12+ supervised physical therapy sessions with documented compliance to the multimodal program 3
• If mechanical symptoms (locking, catching) suggest alternative diagnoses such as meniscal pathology 7
• If history suggests acute traumatic patellar dislocation with possible osteochondral fracture 8