What are the best exercises for patella femoral syndrome?

Best Exercises for Patellofemoral Pain Syndrome

Progressive quadriceps strengthening using both open and closed chain exercises is the primary treatment for patellofemoral pain syndrome, with hip strengthening added when patients cannot tolerate loaded knee flexion. 1, 2

Primary Exercise Foundation: Knee-Targeted Quadriceps Strengthening

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). 2, 3

Specific Exercise Prescription

• Prescribe both open chain exercises (foot not in contact with surface) and closed chain exercises (foot in contact with surface) for quadriceps strengthening. 1, 2
• Both exercise types are equally effective—there is strong evidence showing no significant difference in pain reduction or functional improvement between open and closed chain approaches. 1, 4
• Closed chain exercises may be better tolerated initially by patients with higher symptom severity. 5
• Modify load, intensity, and frequency based on symptom severity and irritability—patients with high irritability require lower loads and slower progression. 1, 2

Examples of Effective Exercises

• Closed chain exercises: squats, step-ups, leg press, single-leg squats 5
• Open chain exercises: seated knee extensions, straight leg raises 4, 5
• Progress exercises over several months as tissue tolerance improves. 2

When to Add Hip Strengthening

Add hip-and-knee combined exercise therapy when patients demonstrate poor tolerance to loaded knee flexion—this approach is superior to knee exercises alone in these cases. 1, 2

Hip Exercise Specifics

• Target hip abductors and lateral rotators specifically. 6, 7
• Hip strengthening combined with quadriceps exercises provides significantly greater pain relief than quadriceps exercises alone. 6
• Both closed chain exercises focusing on hip and knee together, and isolated hip strengthening exercises, improve hip muscle torque equally. 6
• The advantage of adding isolated hip strengthening is greater pain reduction, not just strength gains. 6

Assessment to Guide Hip Exercise Addition

• Evaluate hip and knee strength using hand-held dynamometry or manual muscle testing before prescribing. 1, 2
• Observe single leg squat for biomechanical contributors—excessive hip adduction or internal rotation indicates need for hip strengthening. 1, 2
• Assess tissue tolerance to load through pain provocation tests—if loaded knee flexion significantly increases pain, prioritize hip strengthening initially. 2, 8

Essential Education Component

Education must accompany every exercise intervention and address specific misconceptions. 1, 2

• Educate that pain does not correlate with tissue damage, particularly in chronic presentations—this reduces fear of movement. 2
• Set realistic expectations: recovery requires several months of consistent conservative management. 2
• Teach load management strategies to build patellofemoral joint resilience progressively. 2

Supporting Interventions to Enhance Exercise Tolerance

Patellar Taping

• Apply patellar taping when rehabilitation is hindered by elevated symptom severity and irritability—this allows patients to perform exercises they otherwise could not tolerate. 1, 2, 8
• Reassess after a realistic period; if no favorable outcomes, revisit assessment findings. 1

Prefabricated Foot Orthoses

• Prescribe prefabricated foot orthoses only when patients respond favorably to treatment direction tests. 2, 8
• Customize for comfort by modifying density and geometry. 2, 8

Manual Therapy

• Consider lower quadrant manual therapy as a supporting intervention to facilitate exercise therapy—it demonstrates efficacy but should not replace exercise. 1, 2

Exercise Progression Algorithm

1. Start with progressive quadriceps strengthening (both open and closed chain) in all patients. 2, 3
2. If patient cannot tolerate loaded knee flexion: prioritize hip strengthening initially, then progress to combined hip-and-knee exercises as tolerance improves. 2, 8
3. If patient tolerates loaded knee flexion but has biomechanical deficits (hip adduction/internal rotation on single leg squat): add isolated hip strengthening exercises for greater pain relief. 6
4. Modify parameters based on symptom irritability: high irritability requires lower loads, slower progression, and potentially taping support. 1, 2

Critical Pitfalls to Avoid

• Do not use lateral heel wedges—they have limited evidence and may worsen symptoms. 2, 8
• Do not rely on NSAIDs as primary treatment—they do not change long-term outcomes and exercise therapy is superior. 2, 8
• Do not use hyaluronic acid injection combined with exercise therapy or dry needling alone—these lack efficacy. 2

Expected Timeline and Reassessment

• Expect recovery to require several months of consistent conservative management. 2, 8
• Reassess at minimum 6 weeks if favorable outcomes are not observed—revisit assessment findings and ensure interventions align with symptom severity. 1, 2, 8
• If no improvement after 6-8 weeks of consistent therapy, reassess diagnosis and consider imaging. 2