What is the recommended treatment for a patient with patellofemoral pain syndrome?

Treatment of Patellofemoral Pain Syndrome

Knee-targeted exercise therapy combined with patient education should be the primary treatment for all patients with patellofemoral pain syndrome, with additional supporting interventions (prefabricated foot orthoses, manual therapy, taping, or movement retraining) added based on individual patient presentation and response to treatment. 1

Primary Treatment Foundation

Exercise Therapy (Core Intervention)

• Knee-targeted quadriceps strengthening exercises must be prescribed for all patients, focusing on exercises with the knee extended to reduce patellofemoral pressure 2, 3
• Add hip-targeted exercises when patients demonstrate poor tolerance to loaded knee flexion or when initial knee exercises provoke excessive symptoms 1, 2
• Combining hip and knee exercises provides superior pain reduction compared to knee exercises alone, with clinically important differences (mean difference -2.20 on 0-10 pain scale) 4
• Progressive loading is essential—modify task, load, intensity, and frequency based on pain response and symptom irritability 2, 5
• Exercise therapy has high certainty evidence for short-term pain reduction and moderate certainty evidence for functional improvement 2, 5

Patient Education (Essential Component)

• Education must underpin all interventions and be adjusted to reflect individual patient needs 1, 2
• Provide clear rationale for the specific intervention plan being delivered 1, 2
• Build confidence and understanding that pain does not necessarily correlate with tissue damage 1, 2
• Set realistic expectations about recovery timeframes, noting that over 50% of patients report persistent pain beyond 5 years despite treatment 1, 2
• Promote autonomy and reduce fear of movement 1

Initial Assessment Requirements

Before selecting treatments, conduct a thorough evaluation that identifies:

• Subjective factors: pain levels during specific activities, fear of movement, patient expectations for recovery, self-efficacy relating to symptoms, and perceived patellofemoral joint resilience 1, 2
• Objective impairments: hip and knee strength (using hand-held dynamometry), movement patterns during functional tasks (single leg squat, treadmill running), tissue tolerance to load (pain provocation tests), and patellofemoral joint structure/function (patella alta, hypermobility) 1
• Functional manifestations: observe how subjective features manifest during functional tasks, particularly fear avoidance behaviors 1, 5

Supporting Interventions (Add as Needed)

Prefabricated Foot Orthoses

• Prescribe when patients respond favorably to treatment direction tests (symptom improvement during functional tasks with orthoses in place) 1, 2
• Customize for comfort by modifying density and geometry 1
• Evidence supports their use as an adjunctive treatment alongside exercise therapy 1, 5

Manual Therapy

• Consider when rehabilitation or quality of life is hindered by elevated symptom severity and irritability, or when high fear of movement is present 1, 2
• Target the patellofemoral joint and surrounding soft tissues to improve mobility and reduce pain 3
• Use as a short-term adjunct to facilitate exercise therapy participation 5

Patellar Taping

• Apply when rehabilitation is hindered by elevated symptom severity or high fear of movement 1, 2
• May provide short-term pain relief and improved function 5, 6
• Evidence is insufficient to support routine use, but can be valuable for specific presentations 6

Movement/Running Retraining

• Consider when symptoms are reasoned to be associated with task-specific biomechanics (e.g., excessive stride length in runners) 1, 2
• Increasing step rate in runners with excessive stride length is one specific intervention 1
• Particularly beneficial for active patients to reduce patellofemoral joint stress 3

Pharmacologic Management

First-Line Options

• Acetaminophen (up to 4,000 mg/day) can be used as initial pharmacologic therapy due to favorable safety profile 2, 5, 3
• Topical NSAIDs serve as an alternative first-line therapy, providing local anti-inflammatory effects with fewer systemic side effects compared to oral NSAIDs 2, 5, 3
• A short course of oral nonsteroidal anti-inflammatory drugs may be considered 6

Treatment Algorithm

1. Initial Assessment Phase: Evaluate pain levels, fear of movement, expectations, self-efficacy, perceived joint resilience, hip/knee strength, movement patterns, and tissue tolerance 1, 2, 5

2. Primary Treatment (All Patients): Begin knee-targeted exercise therapy combined with education 1, 2

3. Modify Based on Tolerance:

   • If poor tolerance to loaded knee flexion → add hip-targeted exercises 1, 2
   • If quadriceps atrophy with good tolerance to loaded knee flexion → emphasize knee-targeted exercises 1

4. Add Supporting Interventions Based on Presentation:

   • Favorable response to treatment direction tests → add prefabricated foot orthoses 1, 2, 5
   • High symptom severity or fear of movement → add manual therapy and/or taping 1, 2
   • Task-specific biomechanical issues → add movement/running retraining 1, 2

5. Reassessment (Minimum 6 Weeks): If favorable outcomes are not observed, revisit assessment findings to ensure interventions align with initial reasoning and review patient engagement 1, 2

Common Pitfalls to Avoid

• Failing to address modifiable risk factors such as muscle weakness (quadriceps, hip musculature) and biomechanical issues 3, 7
• Neglecting to strengthen both quadriceps and hip muscles, which are essential for patellofemoral joint stability 3
• Overlooking the importance of patient education and self-management strategies, which should underpin all interventions 1, 3
• Prescribing supporting interventions without first establishing exercise therapy and education as the foundation 1
• Failing to individualize exercise parameters based on symptom severity and irritability 1, 2
• Not reassessing after an adequate trial period (minimum 6 weeks) to determine if treatment modifications are needed 1, 2

Evidence Quality and Prognosis

The 2024 British Journal of Sports Medicine best practice guide synthesized data from 65 high-quality randomized controlled trials involving 3,796 participants, combined with interviews from 12 patients and 19 clinical experts 1. This represents the highest quality and most recent evidence available. However, clinicians should be aware that PFPS has a poor prognosis, with over 50% of patients reporting persistent pain more than 5 years post-diagnosis despite treatment 1, 2. Patients with PFPS are six times more likely to be anxious or depressed and have poorer health-related quality of life than asymptomatic peers 1, 2.