Patellofemoral Pain Syndrome and Weight-Bearing Activities
Weight-bearing activities should be initiated immediately without restriction in patients with patellofemoral pain syndrome, as early unrestricted weight-bearing combined with knee-targeted exercise therapy forms the foundation of evidence-based management. 1
Immediate Weight-Bearing Protocol
Full weight-bearing should begin immediately without immobilization or bracing, as evidence demonstrates that early weight-bearing significantly reduces patellofemoral pain (from 35% to 8%) without compromising knee function, range of motion, or joint stability at 1-year follow-up. 1
Patients can safely perform all weight-bearing activities including squatting, stair climbing, and running as tolerated, with pain used as a guide rather than a contraindication. 1
The key principle is that pain during weight-bearing activities does not equal tissue damage, and patients should be educated that experiencing some discomfort during functional activities is expected and safe during the rehabilitation process. 1, 2
Core Treatment: Knee-Targeted Exercise Therapy
Progressive quadriceps strengthening must be prescribed as the primary intervention, with high certainty evidence showing substantial pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19). 1, 2
Specific Exercise Parameters:
Closed kinetic chain exercises (leg press, squats, step-downs) should be initiated at 3 weeks and can improve subjective knee function and functional outcomes without compromising stability. 1
Training frequency: 2-3 days per week at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets. 2
Rest periods: Allow at least 48 hours between training sessions for the same muscle group, with 2-3 minutes rest between sets for optimal strength gains. 2
Open kinetic chain exercises (seated knee extension) can be safely added at 4 weeks post-diagnosis, progressing from 90° to 40° of knee flexion initially, then advancing range as tolerated. 1
Hip Strengthening Integration:
Hip abductor and extensor strengthening should be added based on objective weakness identified during assessment, as hip weakness is a consistent predictor of patellofemoral pain syndrome. 3, 4
Specific exercises include side-lying leg raises and clamshells targeting hip abductors. 4
Supporting Interventions for High Symptom Severity
When Weight-Bearing Activities Are Highly Irritable:
Medially directed patellar taping should be applied when elevated symptom severity and irritability hinder rehabilitation progress, providing short-term relief by improving patellar alignment during weight-bearing tasks. 1, 2
- Taping is used as a facilitator to enable exercise therapy, not as a standalone treatment. 1
Foot Orthoses for Overpronation:
Prefabricated foot orthoses should only be prescribed after confirming favorable response during treatment direction testing—have the patient perform squats noting pain level, then repeat with trial orthoses in place, prescribing only if immediate symptom improvement occurs. 2
- Orthoses are most beneficial short-term for changing function during weight-bearing activities but are not necessarily needed long-term. 2
Manual Therapy:
Lower quadrant manual therapy demonstrates moderate certainty evidence for short-term function improvement (SMD 2.30,95% CI 1.60,3.00) and can be used when fear of movement or high irritability limits weight-bearing exercise participation. 1
- Soft tissue mobilization of lateral retinacular structures and iliotibial band can facilitate return to weight-bearing activities. 4
Critical Pitfalls to Avoid
Do not restrict weight-bearing or prescribe non-weight-bearing periods, as this delays recovery and increases patellofemoral pain without providing any protective benefit. 1
Avoid relying on NSAIDs as primary treatment—they provide only short-term pain relief without changing long-term outcomes, and exercise therapy is superior. 2
Do not use lateral heel wedges, as they have limited evidence and may worsen symptoms during weight-bearing activities. 2
Never focus solely on knee exercises without addressing hip strength when objective weakness is identified, as this represents incomplete treatment. 4
Avoid overemphasis on imaging before adequate trial of conservative management (minimum 6-8 weeks of consistent therapy). 3, 4
Education Component (Essential)
Education must underpin all interventions and specifically address:
The diagnosis and pathophysiology of patellofemoral pain syndrome. 1, 2
Pain during weight-bearing does not correlate with tissue damage—experiencing discomfort during squats, stairs, or running is expected and safe. 1, 2
Expected recovery timeline of several months (typically 3-6 months) with consistent conservative management, with approximately 80% of patients recovering completely. 2
Goal setting relative to their specific functional limitations in daily activities and sports participation. 1
Reassessment Timeline
If no improvement after 6-8 weeks of consistent conservative therapy, reassess the diagnosis and consider imaging (anteroposterior, lateral, and axial radiographs) to rule out other pathologies such as osteochondral defects, meniscal pathology, or patellar tendinopathy. 3, 4
Minimum reassessment at 6 weeks if favorable outcomes are not observed, revisiting assessment findings and ensuring interventions align with symptom severity. 2
Objective Assessment Priorities
During evaluation, pay particular attention to:
Hip abductor and extensor strength using hand-held dynamometry or manual muscle testing, as weakness is a consistent predictor. 3
Movement patterns during weight-bearing tasks (single leg squat observation) to identify biomechanical contributors. 1
Tissue tolerance to load through pain provocation tests during functional weight-bearing activities. 1
Psychological comorbidities, as patients with patellofemoral pain are six times more likely to experience anxiety or depression, which can affect engagement in weight-bearing rehabilitation. 3, 4