Treatment of Patellofemoral Pain Syndrome
Critical Clarification on Patellar Position
Patellofemoral pain syndrome typically involves LATERAL (not medial) patellar maltracking, and treatment is directed at correcting this lateral displacement. 1 The premise of the question contains an anatomical error—patellofemoral braces are specifically designed to resist lateral (not medial) displacement of the patella through application of a medially directed force. 1
Primary Treatment Approach
Individualized knee-targeted exercise therapy (with or without hip strengthening) forms the cornerstone of treatment and should be initiated immediately following assessment. 1
Core Exercise Program Components
Quadriceps strengthening with parameters modified based on symptom severity and irritability—prescribe knee-targeted exercises when quadriceps atrophy is present and the patient tolerates loaded knee flexion. 1
Hip-focused exercises should take priority initially when patients demonstrate poor tolerance to loaded knee flexion, as hip muscle dysfunction contributes to dynamic valgus and patellar maltracking. 1, 2
Stretching protocols must address lateral retinacular tightness, iliotibial band tightness, hamstrings, and gastrocnemius—these tight lateral structures contribute to abnormal patellar tracking. 3, 4
Exercise frequency: Perform twice daily until symptoms resolve, then continue three times weekly for maintenance during athletic activity. 3
Assessment-Driven Treatment Selection
The objective evaluation should identify specific impairments to guide intervention choices: 1
- Hip and knee strength deficits using hand-held dynamometry 1
- Movement pattern dysfunction through single-leg squat observation or treadmill running analysis 1
- Tissue load tolerance via pain provocation testing and effusion assessment 1
- Patellofemoral joint structure abnormalities including patella alta or hypermobility 1
Adjunctive Interventions
Patellar Bracing
Patellofemoral braces should be used as an adjunct to comprehensive rehabilitation, not as standalone treatment. 1
Braces work by applying a medially directed force to resist lateral patellar displacement. 1
Evidence for brace efficacy is mixed—patients report subjective improvements in pain and disability, but controlled studies show inconsistent objective benefits. 1
Off-the-shelf versions are adequate for most patients; more active individuals may benefit from braces with lateral hinges and adjustable patellar buttresses. 1
Foot Orthoses
Prefabricated foot orthoses should be prescribed when patients respond favorably to treatment direction tests (symptom improvement during functional tasks with orthoses in place). 1
Consider orthoses particularly for patients with foot pronation or pes planus contributing to malalignment. 5
Customize for comfort by modifying density and geometry. 1
Patellar Taping
Taping should be considered when elevated symptom severity, irritability, or high fear of movement hinders rehabilitation or quality of life. 1
- Short-term medially directed taping has evidence supporting its use. 2
Manual Therapy
Manual therapy is appropriate as an adjunct when symptoms significantly impair rehabilitation progress or quality of life. 1
- Diacutaneous fibrolysis applied to tight lateral structures can improve patellar position, reduce pain, and enhance function. 4
Movement Retraining
Movement or running retraining should be implemented when symptoms are linked to task-specific biomechanical faults (e.g., increasing step rate in runners with excessive stride length). 1
Education
Education must underpin all interventions, addressing: 1
- Rationale for the specific treatment plan
- Building confidence and understanding of the diagnosis
- Explaining that pain does not equal tissue damage
- Setting realistic recovery timeframes
- Promoting autonomy and reducing fear of movement
Pharmacologic Management
Short-term use of nonsteroidal anti-inflammatory drugs has limited evidence and should not be routine. 2
Reassessment Timeline
If favorable outcomes are not observed after a minimum of 6 weeks, revisit assessment findings to ensure interventions align with clinical reasoning and verify patient engagement. 1
Physical therapy demonstrates effectiveness in 60-80% of patients with patellofemoral pain syndrome when conservative treatment is properly implemented. 3
Surgical Consideration
Surgery (lateral retinacular release or lengthening) should only be considered after failure of a comprehensive rehabilitation program, with continuation of the exercise program required for surgical success. 2, 3