What is the most likely diagnosis and initial management for a 36‑year‑old healthy man with a six‑month history of activity‑related compressive patellofemoral tendon pain, limp, and occasional popping, without obesity or systemic symptoms?

Patellofemoral Pain Syndrome: Diagnosis and Management

Most Likely Diagnosis

This 36-year-old man has patellofemoral pain syndrome (PFPS), characterized by his six-month history of activity-related anterior knee pain, popping sensation, and limp without acute trauma. 1

The clinical presentation is classic for PFPS:

• Gradual onset of diffuse retropatellar/peripatellar pain rather than sudden onset 1
• Activity-related compression-type pain during loaded knee flexion activities 2, 1
• Popping sensation consistent with patellar maltracking 3
• Age under 40 years in a physically active individual (lifetime prevalence ~25% in this demographic) 4
• Anterior knee pain during squatting is 91% sensitive for PFPS 4

Initial Management Algorithm

Step 1: Immediate Foundation (Start Today)

Begin progressive quadriceps strengthening exercises as the primary treatment—this has the highest quality evidence with high certainty for short-term pain reduction. 2

• Prescribe both open chain exercises (leg extensions) and closed chain movements (squats, step-downs) 2
• Modify load, intensity, and frequency based on his current symptom severity and irritability 2
• If he cannot tolerate loaded knee flexion initially, start with hip strengthening first (hip abductors, external rotators) then progress to combined hip-and-knee exercises 2, 1

Step 2: Essential Patient Education (Critical Component)

Educate him that pain does not correlate with tissue damage, especially in chronic presentations like his six-month history. 2

Specifically address:

• Expected recovery timeline of several months with consistent conservative management 2
• Load management strategies to build patellofemoral joint resilience 2
• Reduce fear of movement and build confidence in the diagnosis 2
• He is six times more likely to experience anxiety or depression with PFPS, so monitor psychological factors 1

Step 3: Combined Hip-and-Knee Exercise Protocol

Hip-and-knee combined exercise therapy is superior to knee exercises alone and should be prioritized. 2

Specific exercises include:

• Hip abductor strengthening: side-lying leg raises, clamshells 1
• Hip external rotator strengthening 1
• Progressive quadriceps strengthening with both eccentric and concentric loading 2
• Assess his single leg squat for biomechanical contributors before prescribing specific movement patterns 2

Step 4: Adjunctive Interventions (If Needed)

Consider patellar taping only if his elevated symptom severity and irritability are hindering rehabilitation. 2

• Prefabricated foot orthoses may be beneficial if he responds favorably to treatment direction tests 2, 1
• Lower quadrant manual therapy (soft tissue mobilization of lateral retinacular structures and iliotibial band) can facilitate exercise therapy 2, 1
• These are supporting interventions only—exercise therapy remains the foundation 2

Critical Pitfalls to Avoid

Do not use hyaluronic acid injection combined with exercise therapy, dry needling alone, lateral heel wedges, or NSAIDs as primary treatment—these lack efficacy or cause potential harm. 2

Additional pitfalls:

• Do not focus only on knee exercises without addressing hip strength 1
• Do not over-rely on passive treatments or imaging without adequate conservative trial 1
• Do not expect rapid improvement—over 50% of patients report persistent pain more than 5 years post-diagnosis if they fail to persist with exercise therapy 1

Reassessment Timeline

If no improvement after 6-8 weeks of consistent therapy, reassess the diagnosis and consider imaging (radiographs or MRI) to rule out other pathologies. 1

• Use hand-held dynamometry or manual muscle testing to objectively evaluate hip and knee strength at reassessment 2
• Evaluate for quadriceps weakness, soft-tissue tightness, and abnormal biomechanics as contributing factors 5, 6

Prognosis Considerations

Failure to persist with exercise therapy and inadequate education lead to poor prognosis. 1

• His six-month chronicity requires emphasis on the several-month recovery timeline 2
• Surgical referral is rarely indicated and should only be considered after exhausting conservative management for 3-6 months minimum 5