Initial Therapy for Patellofemoral Pain Syndrome
Begin immediately with knee-targeted exercise therapy focused on progressive quadriceps strengthening combined with patient education—this is the primary treatment for all patients with patellofemoral pain syndrome. 1, 2
Primary Treatment Foundation
Knee-targeted exercise therapy must be prescribed first for every patient, focusing on progressive quadriceps strengthening using both open chain and closed chain movements. 2, 3 The quadriceps exercises should emphasize knee extension positions to reduce patellofemoral pressure. 2 Load, intensity, and frequency must be modified based on the patient's symptom severity and irritability. 1, 2
Add hip-targeted exercises immediately if the patient demonstrates poor tolerance to loaded knee flexion. 1, 2, 3 Hip-and-knee combined exercise therapy is superior to knee exercises alone and should be prioritized when patients cannot tolerate loaded knee flexion activities. 3
Essential Education Component
Patient education must accompany every intervention from the first visit. 1, 2 Specifically address these points:
- Pain does not correlate with tissue damage, particularly important for patients with symptoms lasting beyond 3 months. 2, 3
- Recovery requires several months of consistent conservative management. 3
- Load management strategies to build patellofemoral joint resilience. 3
- Reduce fear of movement and build confidence in the diagnosis. 2, 3
Initial Assessment to Guide Treatment Selection
Before prescribing interventions, objectively evaluate:
- Muscle strength using hand-held dynamometry or manual muscle testing for hip and knee strength. 3
- Movement patterns by observing single leg squat for biomechanical contributors. 1, 3
- Tissue tolerance to load through pain provocation tests. 1
- Structural factors such as patella alta or hypermobility. 1
- Contextual factors including fear avoidance during functional tasks. 1
Supporting Interventions (Add Based on Assessment)
Prefabricated foot orthoses should be prescribed only when patients respond favorably to treatment direction tests (have the patient squat with and without orthoses to assess immediate response). 1, 2, 3 Customize for comfort by modifying density and geometry. 3
Patellar taping should be applied when rehabilitation is hindered by elevated symptom severity and irritability. 2, 3 This provides immediate pain relief to gain patient trust. 4
Manual therapy targeting the lower quadrant can be considered as a supporting intervention to facilitate exercise therapy when rehabilitation is hindered by high fear of movement or elevated symptom severity. 2, 3
Movement/running retraining should be considered for runners with symptoms associated with specific biomechanical patterns, such as low cadence or narrow step width. 1, 2
Pharmacological Options
Acetaminophen up to 4,000 mg/day can be used as initial pharmacologic therapy due to its favorable safety profile. 2
Topical NSAIDs can be used as an alternative first-line therapy for local anti-inflammatory effects with fewer systemic side effects. 2
Treatment Timeline and Reassessment
Reassess after 6-8 weeks of consistent therapy. 3 If no improvement is observed, revisit the assessment findings to ensure interventions align with initial reasoning and consider whether the patient is engaging with the prescribed treatment. 1
Critical Interventions to Avoid
Do not use hyaluronic acid injection combined with exercise therapy, dry needling alone, lateral heel wedges, or NSAIDs as primary treatment due to lack of efficacy or potential harm. 3
Common Pitfalls
The most common error is failing to emphasize that exercise therapy and education are the foundation—all other interventions are supporting approaches only. 1 Another pitfall is neglecting to strengthen both quadriceps and hip muscles, which are essential for patellofemoral joint stability. 5 Finally, clinicians often underestimate the importance of patient education and self-management strategies in achieving long-term outcomes. 5, 6