What is the recommended evaluation and management of patellofemoral pain in a healthy young to middle‑aged adult who is physically active and has no red‑flag features?

Patellofemoral Pain: Evaluation and Management

Primary Treatment Recommendation

Begin knee-targeted quadriceps strengthening exercises combined with patient education immediately—this is the foundation of treatment for all physically active adults with patellofemoral pain. 1, 2

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Initial Evaluation: Key Clinical Features to Assess

History

• Pain characteristics: Gradual onset diffuse retropatellar or peripatellar pain worsening with squatting, stair descent, prolonged sitting, and running 1, 3, 4
• Symptom duration and impact: Over 50% have persistent pain beyond 5 years, making early aggressive conservative management critical 1, 2
• Psychosocial screening: Patients are six times more likely to have anxiety or depression—assess fear of movement, self-efficacy, and expectations 1, 5
• Activity level and goals: Determine what activities the patient wants to return to, as this guides exercise progression 1, 2

Physical Examination

• Pain provocation with bilateral squatting: 91% sensitive and 50% specific for patellofemoral pain 3, 6
• Hip and knee strength testing: Use hand-held dynamometry or manual muscle testing to identify weakness in hip abductors, hip extensors, and quadriceps 1, 2, 6
• Single-leg squat assessment: Observe for dynamic valgus (knee collapsing inward), which indicates hip muscle weakness and contributes to lateral patellar maltracking 1, 2, 7
• Structural factors: Check for patella alta, generalized joint hypermobility, and foot posture abnormalities (pes planus) 1, 2
• Movement quality during functional tasks: Assess gait, running mechanics if applicable, and tolerance to loaded knee flexion 1, 2

Imaging

• Radiographs are NOT routinely indicated for diagnosis of patellofemoral pain 3, 4
• Consider plain radiographs only if: Conservative treatment fails after 6–8 weeks, or if you need to exclude osteoarthritis, fracture, or osteochondritis dissecans 5, 4

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Treatment Algorithm

Step 1: Universal Foundation (All Patients)

Knee-targeted exercise therapy 1, 2, 8

• Quadriceps strengthening using both open-chain (leg extensions) and closed-chain (squats, step-ups) exercises 1, 2
• Progressive loading: Start with exercises the patient can tolerate and gradually increase resistance and volume over weeks 1, 2
• Adjust intensity based on symptom irritability: If pain is severe or the patient cannot tolerate loaded knee flexion, begin with isometric quadriceps contractions or straight leg raises 2, 9

Patient education (delivered at every visit) 1, 2, 5

• Explain that pain does not equal tissue damage and does not predict long-term joint harm 1, 2
• Set realistic expectations: Conservative treatment requires several months of consistent effort 1, 2
• Teach load management strategies to avoid symptom flares while maintaining activity 1, 2
• Address fear-avoidance beliefs to improve adherence 1, 5

Step 2: Add Hip-Targeted Exercises (Based on Assessment)

Immediately add hip strengthening if the patient has poor tolerance to loaded knee flexion or demonstrates hip weakness on examination 1, 2, 6

• Hip abductor exercises: Side-lying leg raises, clamshells, resistance band hip abduction 5, 6, 7
• Hip extensor exercises: Bridges, single-leg deadlifts 6, 7
• Evidence shows combined hip-and-knee programs are superior to knee-only programs for reducing pain in the short and long term 1, 2, 8

Step 3: Supporting Interventions (Tailored to Individual Presentation)

Prefabricated foot orthoses 1, 2, 5

• Prescribe only if a directional test (e.g., squat with versus without orthoses) shows immediate symptom improvement 1, 2
• Most beneficial in the short term; prioritize patient comfort over customization 2, 5

Patellar taping or bracing 1, 2, 5, 4

• Use when high symptom severity or fear of movement hinders exercise participation 1, 2
• Provides short-term pain relief to facilitate exercise therapy 2, 4

Manual therapy 1, 2, 5

• Soft tissue mobilization of lateral retinacular structures and iliotibial band 5
• Reserve for patients with elevated symptom irritability or fear-avoidance that limits exercise adherence 1, 2

Movement or running retraining 1, 2

• Implement for runners with task-specific biomechanical issues (e.g., low cadence, narrow step width, excessive dynamic valgus) 1, 2, 7
• Focus on correcting gait patterns that increase patellofemoral joint stress 1, 7

Pharmacologic adjuncts 2

• Acetaminophen up to 4,000 mg/day for short-term pain relief due to favorable safety profile 2
• Topical NSAIDs as an alternative first-line option for local anti-inflammatory effects with fewer systemic side effects 2, 4, 7

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Reassessment and Progression

• Reassess after 6–8 weeks of consistent therapy 2, 5
• If no clinically meaningful improvement: Revisit the initial assessment to confirm interventions align with identified impairments, verify patient adherence to the prescribed program, and consider imaging to exclude other pathology 2, 5
• Return to sport/activity: Progress from basic strength and cardiovascular fitness to sport-specific high-level tasks (running, cutting, jumping) once the patient can safely tolerate high loads 1

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Critical Pitfalls to Avoid

• Prescribing knee exercises alone without addressing hip strength: Hip abductor and extensor weakness is a consistent predictor of patellofemoral pain and must be targeted 1, 2, 5, 6
• Over-reliance on passive modalities (taping, manual therapy, orthoses) without emphasizing exercise therapy and education as the primary treatment 1, 2, 5
• Ordering imaging prematurely: Radiographs do not aid diagnosis and should be reserved for cases that fail conservative management 5, 3, 4
• Failing to address psychosocial factors: Anxiety, depression, and fear-avoidance significantly impact outcomes and must be screened and managed 1, 5
• Inadequate exercise dosage or progression: Rehabilitation requires months of progressive loading; underdosing or stopping too early leads to persistent symptoms 1, 2
• Considering surgery: There is no indication for surgical intervention in patellofemoral pain syndrome 3, 4