What is the best course of treatment for a middle-aged patient with knee pain after running a marathon, who has a positive patellar tilt test and bilateral overpronation, and experiences pain with running?

Treatment Approach for Patellofemoral Pain with Overpronation in a Middle-Aged Runner

For this middle-aged runner with post-marathon knee pain, positive patellar tilt test, and bilateral overpronation, you should implement a comprehensive physical therapy program consisting of individualized knee-targeted exercise therapy (with hip strengthening), prefabricated foot orthoses to address the overpronation, patient education, and a structured gradual return-to-running protocol. 1, 2

Primary Treatment Components

Exercise Therapy Foundation

Knee-targeted exercise therapy combined with hip strengthening forms the cornerstone of treatment for patellofemoral pain syndrome (PFPS). 1, 2 The British Journal of Sports Medicine emphasizes that exercise parameters should be modified based on symptom severity and irritability 1:

• Prescribe quadriceps strengthening at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets, performed 2-3 days per week with at least 48 hours rest between sessions 3
• Include hip abductor exercises (side-lying leg raises, clamshells) as hip weakness is a common contributing factor 2
• If the patient demonstrates poor tolerance to loaded knee flexion initially, emphasize hip exercises first before progressing to more aggressive knee-targeted work 1

Addressing Overpronation

Prefabricated foot orthoses should be prescribed immediately, as both the positive patellar tilt test and bilateral overpronation indicate biomechanical dysfunction contributing to abnormal patellar tracking. 1

• Prescribe orthoses when patients respond favorably to treatment direction tests (symptom improvement during functional tasks with orthoses in place) 1
• Customize for comfort by modifying density and geometry 1
• The American Academy of Family Physicians notes that anatomic misalignment including excessive foot pronation should be treated with shoe orthotics 1

Patient Education

Education must underpin all interventions to build confidence and reduce fear of movement. 1, 3, 2

• Explain that pain does not correlate with tissue damage and that PFPS represents imbalances in patellar tracking forces, not progressive joint destruction 1, 2
• Set realistic expectations: approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 3
• Emphasize that over 50% of patients report persistent pain beyond 5 years when they fail to persist with exercise therapy or over-rely on passive treatments 2

Adjunctive Treatments

Patellar Taping

Consider medially directed patellar taping for short-term symptom relief, particularly given the positive patellar tilt test indicating lateral patellar tracking dysfunction. 1, 3

• Use taping when rehabilitation is hindered by elevated symptom severity and irritability 1
• Movement/running retraining and taping are advocated by both patients and clinical experts despite limited formal testing 1

Pain Management

For acute pain relief during the initial treatment phase: 1, 3

• NSAIDs (topical preferred) provide short-term pain relief but do not affect long-term outcomes 1, 3
• Cryotherapy through a wet towel for 10-minute periods provides effective acute relief 1, 3

Structured Return-to-Running Protocol

This patient must follow a graduated return-to-running progression, as attempting to resume marathon training prematurely will perpetuate the injury. 1

Initial Phase: Rest and Walking Progression

• Complete rest from running until achieving 10-14 consecutive days of pain-free walking 4
• Progress to 30-45 minutes of continuous pain-free walking before any return to running 4

Walk-Run Progression

Begin with a walk-run program consisting of short running intervals: 1

• Start with 30-60 second running increments at 30-50% of usual pace, interspersed with 60 seconds of walking recovery 1, 4
• Perform on alternate days only initially to allow bone and tissue mechanosensitivity to recover (98% returns after 24 hours rest) 1
• Progress running increments by 1-2 minutes per progression 1

Progression Guidelines

Pain must guide all progressions: 1

• If pain occurs during or after running, rest until symptoms resolve, then resume at a lower level 1
• The patient should be pain-free both during and following each session before advancing 1
• Progress distance before speed—build to 50% of pre-injury distance before introducing any speed work 1, 4
• Increase distance by approximately 10% per progression, though recognize individual tolerance may vary 1, 4

Surface Considerations

• Start on level surfaces (treadmill or running track) and avoid hills initially, as they increase patellofemoral joint stress 1
• Avoid hard or uneven surfaces during early return-to-running phases 1

Biomechanical Assessment and Correction

Address lower extremity biomechanics throughout treatment: 1

• Assess hip and knee strength using hand-held dynamometry 1
• Observe movement patterns during single leg squat and treadmill running 1
• Consider gait retraining to reduce stride length and increase cadence, which reduces vertical loading rates 1
• Research demonstrates that quadriceps and hamstring dysfunction is significant in runners who overpronate 5

Critical Pitfalls to Avoid

Common errors that lead to treatment failure: 1, 3, 2

• Focusing only on knee exercises without addressing hip strength leads to poor outcomes 2
• Over-reliance on passive treatments (taping, manual therapy) without emphasizing active exercise therapy results in chronic symptoms 2
• Allowing the patient to resume running too quickly before adequate strength recovery (aim for 75-80% strength symmetry between limbs) 4
• Progressing running speed before distance is established 1, 4

Reassessment Timeline

If no improvement occurs after 6-8 weeks of consistent therapy: 2

• Reassess the diagnosis and consider radiographs to rule out osteoarthritis, osteophytes, or loose bodies 2
• Review patient engagement with the exercise program and address barriers to adherence 1
• Ensure interventions align with initial clinical reasoning and assessment findings 1

Expected Outcomes

With appropriate conservative treatment including exercise therapy, orthoses, education, and gradual return-to-running: 3, 2

• Approximately 80% of patients recover completely within 3-6 months 3
• Success depends critically on patient persistence with exercise therapy and avoiding premature return to full running volume 2