What is the treatment for patellofemoral (kneecap) syndrome?

Treatment of Patellofemoral Pain Syndrome

Knee-targeted exercise therapy focusing on progressive quadriceps strengthening is the primary treatment for patellofemoral pain syndrome, with hip strengthening added when patients cannot tolerate loaded knee flexion, and all interventions must be underpinned by patient education. 1

Core Treatment Foundation

Primary Intervention: Exercise Therapy

Quadriceps strengthening demonstrates the highest quality evidence with high certainty for short-term pain reduction (SMD 1.16) and moderate certainty for functional improvement (SMD 1.19). 1

• Prescribe progressive quadriceps exercises using both open chain (leg extensions) and closed chain (squats, step-downs) movements 1
• Modify load, intensity, and frequency based on symptom severity and irritability 1
• Continue exercises twice daily until symptoms resolve, then three times weekly for maintenance during sports participation 2

Hip-and-knee combined exercise therapy is superior to knee exercises alone and should be prioritized when patients demonstrate poor tolerance to loaded knee flexion. 1

• Target hip abductors and extensors specifically, as weakness in these muscle groups is a consistent predictor of patellofemoral pain 3, 4
• Use progressive resistance exercises for hip strengthening 4
• Address bilateral muscle deficits even in unilateral presentations 4

Essential Component: Patient Education

Education must accompany every intervention and should specifically address: 1

• Pain does not correlate with tissue damage, particularly in chronic presentations 1
• Expected recovery timeline of several months with consistent conservative management 5
• Load management strategies to build patellofemoral joint resilience 1
• Reducing fear of movement and building confidence in the diagnosis 1

Supporting Interventions (Add Based on Individual Assessment)

Prefabricated Foot Orthoses

Use only when patients respond favorably to treatment direction tests (observe pain response during squatting with and without orthoses). 1

• Customize for comfort by modifying density and geometry 1
• Evidence supports short-term benefit; long-term use may not be necessary 1
• Most effective when combined with exercise therapy 1

Patellar Taping (McConnell-Style)

Apply taping when rehabilitation is hindered by elevated symptom severity and irritability. 1

• Discontinue if favorable outcomes are not observed after a realistic trial period 1
• Taping combined with exercise therapy, vastus medialis oblique biofeedback, and soft tissue stretching shows efficacy 1

Manual Therapy

Lower quadrant manual therapy demonstrates moderate certainty evidence for short-term functional improvement (SMD 2.30). 1

• Consider as a supporting intervention to facilitate exercise therapy 1
• Use when tissue tolerance to load is limited 5

Movement/Running Retraining

Consider in runners with symptoms associated with specific biomechanical patterns. 1

• Increase cadence in runners presenting with low cadence 1
• Increase step width when assessment findings align with this intervention 1

Assessment-Driven Treatment Selection

Before prescribing interventions, objectively evaluate: 1, 5

• Muscle strength: Hip and knee strength using hand-held dynamometry or manual muscle testing 3, 5
• Movement patterns: Observe single leg squat for biomechanical contributors 5
• Tissue tolerance: Pain provocation tests and presence of effusion 5
• Structural factors: Patellar alta, hypermobility, or patella tilt/subluxation on imaging 3, 5

Critical Pitfalls to Avoid

Do not use these interventions as they lack efficacy or demonstrate harm:

• Hyaluronic acid injection combined with exercise therapy (non-efficacious compared to sham) 1
• Dry needling alone (non-efficacious compared to sham) 1
• Lateral heel wedges (limited evidence, may worsen symptoms) 5
• NSAIDs as primary treatment (do not change long-term outcomes; exercise therapy is superior) 5

Do not add these interventions to exercise therapy as they provide no additional benefit:

• Prefabricated foot orthoses when combined with comprehensive multimodal therapy 1
• Dry needling when combined with hip-and-knee exercise therapy 1
• Vibration therapy when combined with hip-and-knee exercise therapy 1

Treatment Timeline and Reassessment

• Expect recovery to require several months of consistent conservative management 5
• Reassess diagnosis and consider imaging if no improvement after 6-8 weeks of consistent therapy 3
• Rule out coexisting pathology: patellar tendinopathy, osteochondral defects, meniscal pathology, or intra-articular pathology 3

Special Considerations

For patients with patellar tendinopathy (enthesopathy) coexisting with patellofemoral pain:

• Add deep transverse friction massage specifically for patellar tendon pain 5
• Consider corticosteroid iontophoresis for the enthesopathy component 5
• Continue knee-targeted exercise therapy as the foundation 5

For patients unable to tolerate loaded knee flexion:

• Prioritize hip strengthening initially to allow tissue adaptation 1
• Progress to combined hip-and-knee exercises as tolerance improves 1