What is the initial management for post-patellar (behind the kneecap) knee pain?

Initial Management of Post-Patellar (Retropatellar) Knee Pain

Begin immediately with knee-targeted exercise therapy focused on progressive quadriceps strengthening, supported by patient education about pain mechanisms and load management. 1

Primary Treatment: Exercise Therapy

The cornerstone of management is knee-targeted exercise therapy, which demonstrates high certainty evidence for short-term pain reduction (SMD 1.16,95% CI 0.66,1.66) and moderate certainty evidence for functional improvement (SMD 1.19,95% CI 0.51,1.88). 1

Prescribe progressive quadriceps strengthening using both open and closed chain exercises, modifying parameters based on symptom severity and tissue irritability. 1

When to Add Hip Strengthening

• Add hip-and-knee combined exercise therapy when the patient cannot tolerate loaded knee flexion, as this allows tissue adaptation while maintaining therapeutic benefit. 2
• Hip strengthening should be prioritized if the patient demonstrates poor tolerance to loaded knee activities during initial assessment. 2

Exercise Dosing Considerations

• For in-season athletes or those requiring immediate pain relief, heavy loaded isometric contractions provide superior immediate pain reduction (up to 45 minutes post-intervention) compared to isotonic exercises, though both reduce pain at 4-week follow-up. 3
• Progress from isometric to isotonic loading as tissue tolerance improves. 3

Essential Education Component

Education must underpin all interventions and should address four key areas: 2

• The diagnosis and expected recovery timeline (typically several months of consistent management). 4
• Pain does not equal tissue damage - reassurance that activity-related pain can be managed through appropriate load modification. 2
• Load management strategies - how to modify task intensity, frequency, and volume based on pain response. 1
• Building confidence and reducing fear of movement to prevent kinesiophobia. 2

Supporting Interventions (Assessment-Driven)

Patellar Taping

• Apply McConnell-style patellar taping for short-term pain relief and improved function when immediate symptom reduction is needed. 4
• This can facilitate exercise tolerance during the initial treatment phase. 2

Prefabricated Foot Orthoses

• Prescribe only if the patient responds favorably to treatment direction tests (trial the orthosis during assessment to confirm symptom improvement). 2
• Customize for comfort by modifying density and geometry as needed. 2
• Note: Orthoses provide no additional benefit when combined with comprehensive exercise programs that already include taping and biofeedback. 1

Manual Therapy

• Lower quadrant manual therapy demonstrates primary efficacy and can be incorporated as an adjunct. 1
• Deep transverse friction massage is specifically effective for patellar tendon pain reduction if tendinopathy is present. 2

Critical Assessment Points

Before initiating treatment, evaluate: 2

• Tissue tolerance to load through pain provocation tests and presence of effusion
• Quadriceps and hip strength using hand-held dynamometry to guide exercise prescription
• Movement patterns during single leg squat to identify biomechanical contributors
• Structural factors such as patellar alta that may require specific alignment strategies

What NOT to Do

• Do not use lateral heel wedges - they have limited evidence and may worsen symptoms. 4
• Do not rely solely on NSAIDs - while they may provide short-term relief, they do not change long-term outcomes and exercise therapy is superior. 2
• Avoid hyaluronic acid injections - they demonstrate non-efficacy when compared to sham injections. 1
• Do not use dry needling - it shows no additional benefit when combined with exercise therapy and demonstrates non-efficacy compared to sham needling. 1

Expected Timeline and Reassessment

• Recovery typically requires several months of consistent conservative management. 4
• Reassess at minimum 6 weeks if favorable outcomes are not observed to determine if treatment modifications are needed. 2
• Over 50% of patients report persistent pain beyond 5 years despite treatment, emphasizing the importance of early, appropriate intervention. 1