What are the treatment options for anterior knee pain that worsens when going up and down stairs?

Treatment of Anterior Knee Pain Worsening with Stairs

Quadriceps strengthening exercises are the cornerstone of treatment and should be initiated immediately for all patients with anterior knee pain that worsens with stair climbing, as this pattern strongly suggests patellofemoral dysfunction. 1

Initial Conservative Management

Exercise Therapy (Primary Treatment)

Strengthening exercises provide the foundation for long-term improvement in pain and function. 1, 2

• Start with isometric quadriceps exercises that provoke no pain, beginning in the first week of treatment 3
• Progress to sustained isometric exercises for both quadriceps and proximal hip girdle muscles (gluteus medius and maximus) 1
• Add eccentric exercises once the quadriceps is reactivated, provided the knee does not react with effusion or increased pain 3
• Include aerobic conditioning and range of motion/stretching exercises in the treatment plan 1
• Follow the principle of "small amounts often" by linking exercise regimens to daily activities to promote adherence 1
• Start within the patient's capability and build intensity over several months rather than aggressive early progression 1

Patellofemoral Bracing

For patients with lateral patellar subluxation or maltracking, patellofemoral braces provide symptomatic relief by resisting lateral displacement and maintaining patellar alignment. 1

• Most patients report significant subjective improvements in pain and disability with brace wear 3, 1
• Off-the-shelf braces are adequate for most patients without requiring customization 1
• More active persons may prefer a patellofemoral brace with a lateral hinge and adjustable patellar buttress 3
• Proper fitting is essential: measure leg circumference 3 inches above and below mid-patella, align patella in center of cutout, and secure straps with moderate tension 3

Patellar Taping

Medial patellar taping provides short-term pain relief and functional improvement and should be used for acute symptom management while building strength through exercise. 1

• Taping shows statistically significant pain reduction immediately and within 4 days of application 1
• This is a Grade B recommendation for temporary relief during the strengthening phase 1

Pharmacologic Management

Acetaminophen (paracetamol) is the first-line oral analgesic to try first and, if successful, the preferred long-term oral analgesic. 3, 1

• Use up to 4,000 mg/day as needed for pain control 1
• Topical NSAIDs have clinical efficacy and are safe as an alternative or adjunct 3, 1
• Oral NSAIDs should be considered only if unresponsive to acetaminophen, with appropriate gastroprotection in high-risk patients 3, 1

Adjunctive Interventions

Weight Management (If Applicable)

For overweight patients, weight loss education should be incorporated as it reduces knee osteoarthritis risk and improves symptoms. 1

• Include regular self-monitoring with monthly weight recording 1
• Increase physical activity while following a structured meal plan 1
• Reduce saturated fat and sugar intake 1

Footwear and Orthotics

Appropriate footwear is essential for all patients with anterior knee pain. 1

• Comfortable shoes are recommended for all patients 1
• Prefabricated foot orthoses may benefit select patients with patellofemoral pain who respond favorably to treatment direction tests 1
• Avoid lateral wedged insoles as they lack evidence and may worsen symptoms 1

Assistive Devices

Walking aids should be considered to reduce pain and increase participation in patients with significant functional limitation. 1

• Use a walking stick on the contralateral side for unilateral knee pain 1
• Consider walking frames or wheeled walkers for bilateral involvement 1

Treatment Duration and Expectations

Continue rehabilitation for 9-12 months depending on the patient's functional goals, as evidence shows no benefit to shorter programs. 3

• 87% of patients describe improved symptoms immediately after a physical therapy program 4
• 68% report sustained improvement at mean 16-month follow-up 4
• 57% substantially increase their activity level from baseline 4

Common Pitfalls to Avoid

The evidence for patellofemoral braces is mixed - while patients consistently report subjective improvements, objective effects may be limited, and many efficacy claims lack rigorous evidence. 3 However, given their safety profile, low cost, and high patient satisfaction, they remain a reasonable adjunct to exercise therapy.

Avoid relying on bracing alone - lower extremity muscle strengthening, flexibility improvements, and technique refinement are more important than bracing in treating anterior knee pain. 3

Do not rush load progression - the knee should not react with effusion or increased pain when advancing exercises. 3