What is the most appropriate next step in management for a 37‑year‑old woman with left knee pain worsened by descending stairs and squatting, recent 10 K training, bilateral over‑pronation, and no red‑flag findings?

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Management of Patellofemoral Pain in a Runner with Overpronation

The next best step is physical therapy focused on knee-targeted exercise therapy, specifically progressive quadriceps strengthening, combined with prefabricated foot orthoses after confirming favorable response through treatment direction testing. 1

Primary Treatment: Knee-Targeted Exercise Therapy

Physical therapy with knee-targeted exercise therapy forms the foundation of treatment for this patient's patellofemoral pain syndrome. 1

  • Progressive quadriceps strengthening should be prescribed using both open and closed chain exercises, training 2-3 days per week at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets, with at least 48 hours rest between training sessions for the same muscle group and 2-3 minutes rest between sets. 1

  • This approach has high certainty evidence for pain reduction (SMD 1.16) and moderate certainty evidence for functional improvement (SMD 1.19). 1

  • Recovery typically requires several months of consistent conservative management, with approximately 80% of patients recovering completely within 3-6 months with appropriate conservative treatment. 1

Addressing the Biomechanical Component: Foot Orthoses

Given the bilateral overpronation observed on gait examination, prefabricated foot orthoses should be prescribed, but only after confirming favorable response through treatment direction testing. 1

  • Treatment direction testing involves having the patient perform squats without orthoses and noting pain level, then repeating squats with trial prefabricated orthoses in place, and prescribing orthoses only if immediate symptom improvement occurs during this test. 1

  • Prefabricated foot orthoses demonstrate primary efficacy and are most beneficial in the short term, helping to change function but not necessarily needed long-term. 1

  • Critical pitfall to avoid: Lateral wedge insoles should not be used as they have limited evidence and may worsen symptoms. 1

Adjunctive Interventions

Patellar taping can be used when elevated symptom severity and irritability hinder rehabilitation progress, providing short-term relief by improving patellar alignment with medially directed taping. 1

NSAIDs (oral or topical) may be considered for short-term pain relief, but they do not change long-term outcomes and exercise therapy is superior. 1, 2 If used, ibuprofen 400 mg every 4-6 hours as necessary can provide pain relief, though doses greater than 400 mg were no more effective in controlled trials. 2

Essential Patient Education

Education must underpin all interventions and address the following specific concerns: 1

  • Pain does not equal tissue damage in patellofemoral pain syndrome. 1
  • Expected recovery timeline is several months with consistent conservative management. 1
  • The condition responds well to exercise therapy when performed consistently. 1

Why Not the Other Options?

X-ray of the knee is not indicated as the next step because this patient has no red-flag findings and presents with a classic overuse injury pattern in a young, active individual. 3 Imaging would be appropriate only if symptoms are not explained by clinical findings or if there is suspicion for structural pathology. 3

Intra-articular corticosteroid injection is not appropriate as first-line treatment for patellofemoral pain in this young runner. 3 While corticosteroid injections have a role in knee osteoarthritis, this patient's presentation is consistent with patellofemoral pain syndrome from training overload and biomechanical factors, which respond best to exercise therapy and biomechanical correction. 1

Ibuprofen alone addresses only symptom relief without addressing the underlying biomechanical and strength deficits driving the condition. 1 While NSAIDs can provide short-term pain relief, they do not change long-term outcomes and are inferior to exercise therapy. 1

Reassessment Strategy

If favorable outcomes are not observed at minimum 6 weeks, reassess findings and ensure interventions align with symptom severity, revisiting the assessment and potentially adjusting the exercise prescription or considering additional interventions. 1

References

1
Guideline

Treatment for Runner with Knee Pain, Positive Patellar Tilt, and Overpronation

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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