What is the recommended treatment for patellofemoral syndrome in young, active females experiencing knee pain during activities like climbing stairs, squatting, or jumping?

Patellofemoral Pain Syndrome Treatment

For young, active females with patellofemoral pain syndrome, initiate knee-targeted exercise therapy combined with hip strengthening exercises and patient education as the primary treatment, with prefabricated foot orthoses added when patients respond favorably to treatment direction tests. 1

Initial Assessment

Before starting treatment, evaluate the following specific features:

• Pain characteristics: Severity during activities like stair climbing, squatting, and jumping 1
• Fear of movement: Degree of avoidance behaviors (e.g., "I avoid squatting because I am afraid it will hurt") 1
• Self-efficacy: Confidence levels with functional tasks (e.g., "I don't have the confidence to climb stairs anymore") 1
• Functional tolerance: Observe single leg squat for knee valgus angle (PFP patients demonstrate significantly greater valgus angles of 16.8° vs 8.4° in controls during single leg squatting) 2
• Hip and knee strength: Use hand-held dynamometry to quantify weakness 1
• Tissue tolerance to load: Pain provocation tests and presence of effusion 1

Primary Treatment Protocol

Exercise Therapy (Foundation of Treatment)

Knee-targeted exercises should be prescribed first, with the following specifications:

• Focus on progressive quadriceps strengthening with the knee extended to reduce patellofemoral pressure 3
• Include both open and closed kinetic chain exercises 4
• Modify task, load, intensity, and frequency based on pain response 4
• Progressive loading is essential for effective rehabilitation 3, 4

Hip-targeted exercises must be added when:

• Patient demonstrates poor tolerance to loaded knee flexion 1, 3
• Hip weakness is identified on examination (common contributing factor in young females) 5
• Include hip abductor exercises such as side-lying leg raises and clamshells 5

Evidence for combined hip and knee exercises: Pooled data from three studies showed hip plus knee exercises reduced pain during activity by 2.20 points more than knee exercises alone (95% CI -3.80 to -0.60), which includes a clinically important effect 1

Patient Education (Underpins All Interventions)

Provide specific education on:

• Pain does not correlate with tissue damage: PFPS is caused by imbalances in forces controlling patellar tracking, not progressive joint destruction 5
• Expected recovery timeframes: Over 50% of patients report persistent pain beyond 5 years when they fail to persist with exercise therapy 5
• Rationale for exercise prescription: Build confidence and reduce fear of movement 3
• Autonomy and self-management: Promote independence in symptom control 1

Supporting Interventions (Add Based on Specific Indications)

Prefabricated Foot Orthoses

• Prescribe when patients respond favorably to treatment direction tests (symptom improvement during a functional task with orthoses in situ) 1, 3
• Customize for comfort by modifying density and geometry 1
• Note: Despite primary efficacy evidence, there is a knowledge translation gap with clinicians lacking confidence in prescribing them 1

Patellar Taping

• Use when rehabilitation is hindered by elevated symptom severity or high fear of movement 1, 4
• Provides short-term relief of pain and improved function 4

Manual Therapy

• Consider when rehabilitation is hindered by elevated symptom severity or high fear of movement 3
• Lower quadrant manual therapy demonstrated efficacy in meta-analysis 1
• Caveat: Recent PFP consensus does not support isolated manual therapy, conflicting with earlier findings 1

Movement/Running Retraining

• Implement for patients with task-specific biomechanical issues 3
• Particularly relevant given that PFP patients demonstrate significantly greater knee valgus during landing tasks (21.7° vs 13.5° in controls) 2

Pharmacologic Management (Adjunctive Only)

• Acetaminophen (up to 4,000 mg/day) as initial pharmacologic therapy due to favorable safety profile 3, 4
• Topical NSAIDs as alternative first-line therapy for local anti-inflammatory effects with fewer systemic side effects 3, 4

Treatment Algorithm

1. Week 0: Begin knee-targeted exercise therapy + education for all patients 1, 3
2. Week 0-2: Add hip-targeted exercises if poor tolerance to loaded knee flexion is present 1, 3
3. Week 0-2: Add prefabricated foot orthoses if favorable response to treatment direction tests 1, 3
4. Week 2-4: Implement taping and/or manual therapy for patients with high symptom severity or fear of movement 1, 4
5. Week 4-6: Consider movement/running retraining for patients with task-specific biomechanical issues 3
6. Week 6-8: Reassess if no improvement; revisit assessment findings to ensure interventions align with initial reasoning 3

Common Pitfalls to Avoid

• Focusing only on knee exercises without addressing hip strength is a frequent error that leads to treatment failure 5
• Over-reliance on passive treatments (taping, manual therapy) without emphasizing active exercise therapy leads to poor long-term outcomes 5
• Inadequate patient education about the benign nature of the condition and importance of exercise persistence contributes to the high rate of chronic symptoms (>50% with persistent pain at 5 years) 1, 5
• Ordering excessive imaging is not indicated unless symptoms fail to improve with appropriate conservative management 5

Prognosis

The evidence shows high certainty for short-term pain reduction and moderate certainty for functional improvement with exercise therapy 4. However, the condition has a poor prognosis overall, with over 50% of people reporting persistent pain more than 5 years post-diagnosis despite receiving treatment 1. PFP is thought to be a precursor to patellofemoral osteoarthritis, making adherence to exercise therapy essential 1.