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

Treatment for Runner's Knee (Patellofemoral Pain Syndrome)

Knee-targeted exercise therapy focusing on quadriceps strengthening combined with hip strengthening exercises should be the primary treatment, supported by patient education and delivered through a structured physiotherapy program. 1

First-Line Treatment: Exercise Therapy

Core Exercise Components

• Quadriceps strengthening exercises are mandatory and form the foundation of treatment, with progressive resistance training targeting the quadriceps muscle group 1

• Hip-and-knee-targeted exercise therapy should be prescribed together when patients demonstrate poor tolerance to loaded knee flexion or show hip abductor/extensor weakness on examination 1

• Hip strengthening specifically targeting hip abductors and extensors is critical, as bilateral muscle deficits exist even in unilateral presentations and hip weakness is a consistent predictor of patellofemoral pain 2

• Exercise prescription must be modified based on symptom severity and irritability, with greater emphasis on hip exercises when knee-loaded activities provoke excessive pain 1

Exercise Delivery Principles

• Active exercise therapy takes priority over passive modalities because active interventions promote self-management and demonstrate superior effectiveness 3

• Task, load, intensity, and frequency should be progressively adjusted as the patient's tolerance improves 1

• Both limbs should be treated even in unilateral presentations because bilateral muscle deficits exist regardless of which knee is symptomatic 2

Essential Supporting Intervention: Education

Education must underpin all interventions and be adjusted to each patient's specific needs, including challenging inaccurate beliefs about their diagnosis, explaining that pain does not equal tissue damage (especially in chronic cases), managing load expectations, promoting autonomy, and reducing fear of movement 1

Evidence-Based Adjunctive Therapies

Prefabricated Foot Orthoses

• Prescribe prefabricated foot orthoses to patients who respond favorably to treatment direction tests (e.g., improved pain with squatting while wearing orthoses during assessment) 1

• Customize orthoses for comfort by modifying density and geometry rather than ordering expensive custom versions 1

• Orthoses provide primary benefit in the short term (weeks to months) and may not be needed long-term once strength and biomechanics improve 1

Patellar Taping

• Use taping for patients where rehabilitation is hindered by elevated symptom severity and irritability, particularly during high-demand periods like competitive seasons 1

• Discontinue taping if favorable outcomes are not observed after a realistic trial period and reassess the underlying impairments being targeted 1

Patellofemoral Braces

• Consider patellofemoral braces as an adjunctive option, as patients report subjective improvements in pain and disability with brace wear, though objective evidence is mixed 1

• Select off-the-shelf neoprene braces with lateral buttresses for most patients, reserving more expensive custom options only for unusual limb contours 1

Movement and Running Retraining

• Implement running retraining when assessment findings align with modifiable biomechanical factors, such as low cadence or narrow step width in runners 1

• Specific interventions include increasing cadence or increasing step width based on individual running mechanics 1

Treatment Algorithm by Phase

Initial Phase (Weeks 1-2)

• Begin knee-targeted quadriceps strengthening exercises at intensity tolerated by symptom severity 1

• Initiate patient education addressing diagnosis, pain mechanisms, and recovery expectations 1

• Assess hip strength bilaterally and add hip-targeted exercises if weakness is identified 1, 2

• Apply patellar taping if symptoms are highly irritable and limiting exercise participation 1

• Trial prefabricated foot orthoses using treatment direction tests during the initial assessment 1

Intermediate Phase (Weeks 2-6)

• Progress exercise intensity, load, and complexity as tissue tolerance improves 1

• Continue hip and knee strengthening with emphasis on functional movement patterns 1

• Implement running retraining if applicable, focusing on cadence or step width modifications 1

• Wean off taping as symptoms improve and exercise tolerance increases 1

Advanced Phase (Weeks 6+)

• Introduce sport-specific or activity-specific exercises relevant to the patient's goals 3

• Progress to full return to running or desired activities as tolerated 3

• Establish maintenance program to prevent recurrence 3

Critical Pitfalls to Avoid

• Never prescribe complete rest or immobilization, as this leads to muscle atrophy and deconditioning; instead, modify activities to avoid pain while maintaining movement 3

• Avoid corticosteroid injections, as they provide only short-term relief without improving long-term outcomes and may weaken tendon structures 3

• Do not rely on passive modalities alone (ultrasound, electrical stimulation) without active exercise therapy 3

• Surgery should be avoided in all patients with patellofemoral pain syndrome, as it is not effective for this condition 4

Interventions Lacking Clear Guidance

Lower quadrant manual therapy, vastus medialis oblique biofeedback, and perineural dextrose injections showed some efficacy in research but lack clear implementation guidance from clinical experts and patients, making their routine use difficult to recommend 1