What is the best treatment approach for a young to middle-aged adult with patellofemoral pain syndrome?

Treatment of Patellofemoral Pain Syndrome

Begin with knee-targeted exercise therapy focused on progressive quadriceps strengthening with the knee extended, combined with patient education—this is the foundation of treatment with high certainty evidence for short-term pain reduction. 1, 2

Primary Treatment Approach

Knee-Targeted Exercise Therapy

• Prescribe quadriceps strengthening exercises with the knee extended to reduce patellofemoral pressure. 2, 3
• Include both open and closed chain exercises—evidence shows they are equally effective. 4, 5
• Modify task, load, intensity, and frequency based on the patient's pain response and symptom irritability. 1, 2
• Progressive loading is essential for effective rehabilitation. 2
• Continue for a minimum of 6 weeks before reassessing outcomes. 2

Add Hip-Targeted Exercises When:

• The patient demonstrates poor tolerance to loaded knee flexion. 1, 2
• Combined hip and knee exercises show superior pain reduction compared to knee exercises alone (mean difference -2.20 for pain during activity). 5
• Hip muscle strengthening has shown clinically significant effects with pain reduction of -65.0 points in some studies. 6

Patient Education (Underpins All Interventions)

• Explain that pain does not necessarily correlate with tissue damage, particularly in patients with persistent symptoms. 1, 2
• Provide rationale for the specific intervention plan to build confidence and understanding. 2
• Set realistic expectations: over 50% of patients report persistent pain more than 5 years post-diagnosis despite treatment. 2
• Address fear of movement and build self-efficacy through education. 1, 2
• Discuss load management strategies and expected recovery timeframes. 1

Supporting Interventions (Add Based on Specific Presentations)

Prefabricated Foot Orthoses

• Prescribe when patients respond favorably to treatment direction tests (e.g., improved squat mechanics with orthoses in place). 1, 2
• Customize for comfort by modifying density and geometry. 1
• Evidence supports short-term benefit; may not be necessary long-term. 1

Patellar Taping

• Use when rehabilitation is hindered by elevated symptom severity or high fear of movement. 1, 2, 7
• Provides short-term relief of pain and improved function. 7
• Reassess after a realistic trial period; if no favorable outcomes, revisit assessment findings. 1

Manual Therapy

• Consider when rehabilitation is hindered by elevated symptom severity or high fear of movement. 2, 7
• Use as an adjunct to exercise therapy, not as standalone treatment. 2

Movement/Running Retraining

• Implement for patients with task-specific biomechanical issues identified on assessment (e.g., low cadence runners, narrow step width). 1, 2
• Interventions include increasing cadence or step width during running. 1

Pharmacologic Management

First-Line Options

• Acetaminophen up to 4,000 mg/day as initial pharmacologic therapy due to favorable safety profile. 2, 7
• Topical NSAIDs as alternative first-line therapy for local anti-inflammatory effects with fewer systemic side effects. 2, 7

Bracing

• Patellofemoral braces are conditionally recommended for patients with significant impact on ambulation, joint stability, or pain. 7
• Progressive resistance bracing has shown significant reductions in symptoms. 8

Treatment Algorithm

Initial Assessment:

• Evaluate pain levels during activities (squatting, stairs, running). 2
• Assess fear of movement, self-efficacy, and perceived joint resilience. 2, 7
• Objectively evaluate muscle strength (hip and knee), movement patterns (single leg squat), and tissue tolerance to load. 1

Treatment Sequence:

1. Start all patients on knee-targeted exercise therapy + education. 1, 2
2. Add hip exercises if poor tolerance to loaded knee flexion. 1, 2
3. Add prefabricated foot orthoses if favorable response to treatment direction tests. 1, 2
4. Add taping and/or manual therapy if high symptom severity or fear of movement. 1, 2
5. Add movement retraining if task-specific biomechanical issues present. 1, 2
6. Consider acetaminophen or topical NSAIDs for symptom management. 2, 7

Reassessment at 6 Weeks:

• If outcomes are unfavorable, revisit assessment findings to ensure interventions align with initial clinical reasoning. 2
• Verify patient engagement with the exercise program. 1
• Adjust exercise parameters, load, or supporting interventions as needed. 1, 2

Important Caveats

• The prognosis is guarded—more than 50% of patients report persistent pain beyond 5 years despite treatment. 2
• PFPS is associated with increased anxiety, depression, reduced physical activity, and poorer health-related quality of life. 2
• Most studies are underpowered, and over 80% of trials do not show clinically significant benefit. 6
• There is no evidence that a single treatment modality works for all patients—individualization based on objective findings is critical. 6
• Avoid relying on imaging alone; always combine with symptoms and clinical signs. 1