What is the recommended treatment for a young female patient presenting with knee pain, possibly due to patellofemoral pain syndrome or ligament sprain?

Treatment of Young Female Knee Pain

Young females with knee pain should receive knee-targeted exercise therapy combined with hip strengthening exercises as the foundation of treatment, supported by patient education about the benign nature of patellofemoral pain syndrome. 1

Initial Clinical Assessment

When evaluating a young female with knee pain, focus on these specific findings:

• Document weight-bearing ability by having the patient take at least 4 steps, as this directly influences management decisions 2
• Assess knee flexion to 90 degrees to determine functional limitation 2
• Palpate for joint effusion, which may indicate inflammatory processes or structural damage 2
• Evaluate pain patterns: gradual onset diffuse retropatellar or peripatellar pain that worsens with squatting, stair climbing, and prolonged sitting is characteristic of patellofemoral pain syndrome 1, 3
• Perform squatting test, as pain with squatting is the most sensitive physical examination finding for patellofemoral pain syndrome 3

Imaging Strategy

Plain radiographs are NOT initially necessary for typical patellofemoral pain syndrome in young females unless specific red flags are present. 3

Obtain radiographs (AP, lateral, Merchant/sunrise, and tunnel views) only if: 2

• Pain has persisted for more than 6 weeks despite conservative treatment
• Joint effusion is present on examination
• Acute trauma with suspected fracture
• Atypical presentation requiring exclusion of other diagnoses

Reserve MRI for: 4, 2

• Persistent symptoms after 6-8 weeks of adequate conservative treatment
• Consideration of surgical intervention
• Normal radiographs with ongoing symptoms requiring evaluation of meniscal pathology, cartilage lesions, or bone marrow edema

Primary Treatment Protocol

Exercise Therapy (Foundation of Treatment)

Knee-targeted exercises combined with hip strengthening should be prescribed immediately: 1

• Quadriceps strengthening focusing on progressive resistance training 5, 6
• Hip abductor strengthening including side-lying leg raises and clamshells 1
• Add hip strengthening specifically when patients demonstrate poor tolerance to loaded knee flexion 2
• Progress exercises based on tissue tolerance, incorporating eccentric strengthening as pain allows 2
• Include balance, agility, and coordination exercises to improve performance-based function 2

Common pitfall to avoid: Focusing only on knee exercises without addressing hip strength leads to suboptimal outcomes 1

Patient Education (Essential Component)

Education must underpin all interventions: 1

• Explain that pain does not necessarily correlate with tissue damage to reduce fear and anxiety 1
• Set realistic expectations: recovery typically requires 6-8 weeks of consistent therapy 1
• Address the psychological component: young females with patellofemoral pain are six times more likely to experience anxiety or depression 1
• Teach the "pacing principle" of "small amounts often" linked to daily activities to establish routine 2

Adjunctive Interventions

Patellar taping and manual therapy can facilitate exercise therapy when rehabilitation is hindered by high symptom severity, irritability, or fear of movement 1, 2

Prefabricated foot orthoses may be beneficial when patients respond favorably to treatment direction tests, with customization for comfort providing the most benefit in the short term 1, 2

Soft tissue mobilization of lateral retinacular structures and iliotibial band can be used as a manual therapy technique 1

Pharmacological Management

NSAIDs should be used for short-term symptom relief only, not as primary treatment: 3

• Short course of oral NSAIDs (typically 7-14 days) for pain control during initial exercise therapy 3
• Topical NSAIDs or capsaicin can be considered as alternatives with excellent safety profiles 2
• Avoid long-term NSAID use as it does not address the underlying biomechanical issues 3

Reassessment and Escalation

If no improvement after 6-8 weeks of consistent therapy: 1

• Reassess diagnosis and consider imaging if not yet obtained 1, 2
• Rule out other pathologies including meniscal tears, cartilage lesions, or osteochondritis dissecans 4
• Consider MRI to evaluate medial patellofemoral ligament integrity, cartilage injury extent, and loose bodies 4

Surgery is considered only as a last resort after failure of comprehensive conservative management 3

Critical Pitfalls to Avoid

• Over-reliance on passive treatments without adequate exercise therapy leads to poor long-term outcomes 1
• Overemphasis on imaging without adequate trial of conservative management wastes resources and may lead to unnecessary interventions 1
• Inadequate education about the condition results in poor adherence and persistent symptoms, with over 50% of patients reporting pain more than 5 years post-diagnosis 1
• Failure to address hip weakness significantly reduces treatment effectiveness in young females 1, 2