What is the treatment for a runner with knee pain and a positive patellar tilt test, who also has overpronation, in addition to physician therapy?

Treatment for Runner with Knee Pain, Positive Patellar Tilt, and Overpronation

For a runner with patellofemoral pain, positive patellar tilt test, and overpronation, prescribe knee-targeted exercise therapy as the foundation, add prefabricated foot orthoses if they pass a treatment direction test (immediate symptom improvement with trial orthoses during squatting), and support with patellar taping if symptoms are severe enough to hinder rehabilitation. 1

Primary Treatment: Knee-Targeted Exercise Therapy

Knee-targeted exercise therapy is the cornerstone intervention with high certainty evidence for pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19). 2

• Prescribe progressive quadriceps strengthening using both open and closed chain exercises 2
• Train quadriceps and surrounding muscle groups 2-3 days per week at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets 3
• Allow at least 48 hours rest between training sessions for the same muscle group 3
• Rest 2-3 minutes between sets for optimal strength gains 3
• Gradually increase resistance, repetitions, or frequency as strength improves 3

If the patient cannot tolerate loaded knee flexion initially, add hip strengthening exercises to allow tissue adaptation while maintaining therapeutic benefit. 2

Addressing Overpronation: Prefabricated Foot Orthoses

Prefabricated foot orthoses demonstrate primary efficacy and should be prescribed, but only after confirming favorable response to treatment direction testing. 1

Treatment Direction Test Protocol:

• Have the patient perform squats without orthoses and note pain level 1
• Repeat squats with trial prefabricated orthoses in place 1
• Prescribe orthoses only if immediate symptom improvement occurs during this test 1
• Customize for comfort by modifying density and geometry 1, 2

Evidence indicates prefabricated foot orthoses are most beneficial in the short term; they help change function but are not necessarily needed long-term. 1 This addresses the overpronation biomechanical factor while avoiding the pitfall of prescribing orthoses to patients who won't benefit. 4

Supporting Intervention: Patellar Taping

Use medially directed patellar taping when elevated symptom severity and irritability hinder rehabilitation progress. 1, 3, 2

• Taping provides short-term relief for the positive patellar tilt by improving patellar alignment 3, 2
• Consider timing based on training season demands 1
• If favorable outcomes are not observed after a realistic trial period (minimum 6 weeks), reassess the intervention strategy 2

Essential Education Component

Education must underpin all interventions and address specific concerns about patellofemoral pain. 2

Critical educational points to cover:

• Pain does not equal tissue damage, particularly important given hypersensitivity patterns in patellofemoral pain 3, 2
• Expected recovery timeline of several months with consistent conservative management 2
• Load management strategies to balance training volume with tissue capacity 5
• Building confidence and reducing fear of movement 2

Complementary Stretching Program

• Perform quadriceps and hamstring stretching 2-3 days per week 3
• Hold static stretches for 10-30 seconds, with 60 seconds total stretching time per exercise 3
• Repeat each stretch 2-4 times 3
• Stretch after warming muscles through light aerobic activity 3
• Daily stretching provides greatest gains 3

Running Retraining Considerations

Movement/running retraining can be considered when symptoms align with specific assessment findings. 1

• Increasing cadence may benefit runners with low cadence 1
• Increasing step width is another evidence-supported modification 1
• These modifications address biomechanical loading patterns that may contribute to symptoms in runners with overpronation 5

Critical Pitfalls to Avoid

• Do not use lateral heel wedges as they have limited evidence and may worsen symptoms 2
• Avoid relying solely on NSAIDs; while they provide short-term pain relief, they do not change long-term outcomes and exercise therapy is superior 2
• Do not prescribe foot orthoses without performing treatment direction testing first 1
• Avoid complete immobilization as this causes muscular atrophy and deconditioning 3

Assessment Parameters to Monitor

• Assess tissue tolerance to load through pain provocation tests during squatting 2
• Evaluate quadriceps and hip strength using hand-held dynamometry to guide exercise progression 2
• Observe single leg squat movement patterns to identify ongoing biomechanical contributors 2
• Monitor patellar alignment and tilt throughout treatment 2

Expected Timeline and Reassessment

• Recovery typically requires several months of consistent conservative management 2
• Approximately 80% of patients with patellofemoral conditions recover completely within 3-6 months with appropriate conservative treatment 3
• Reassess at minimum 6 weeks if favorable outcomes are not observed, revisiting assessment findings and ensuring interventions align with symptom severity 1, 2