Management of Patellofemoral Osteoarthritis
Begin with progressive quadriceps strengthening exercises combined with patient education as the primary treatment for all patients with patellofemoral osteoarthritis, regardless of age or severity. This approach has high-certainty evidence for short-term pain reduction and moderate-certainty evidence for functional improvement. 1, 2
Initial Conservative Management (First-Line for All Patients)
Exercise Therapy Foundation
Initiate knee-targeted exercise therapy immediately, focusing on progressive quadriceps strengthening using both open-chain (straight-leg raises, knee extensions) and closed-chain movements (partial squats, step-ups). This is the cornerstone intervention with the strongest evidence base. 1, 3
Begin quadriceps strengthening in knee extension (isometric contractions, straight-leg raises) to reduce patellofemoral joint pressure during the initial phase. This positioning minimizes stress on the damaged cartilage while building strength. 2
Add hip-abductor and external-rotator strengthening once the patient demonstrates improved load tolerance. Combined hip-and-knee strengthening is superior to knee-only programs, particularly when patients cannot tolerate loaded knee flexion. 1, 2
Tailor load, intensity, and frequency based on the patient's symptom severity and irritability. Progressive loading is essential—adjust according to pain response during and after activity. 1, 3
Referral to a physiotherapist is a mainstay of treatment. Supervised programs show significant improvements in pain (effect size 1.05) and functional indices compared to control groups. 4
Patient Education (Deliver at Every Visit)
Explain that pain does not necessarily reflect ongoing tissue damage. This reduces fear-avoidance behaviors that limit rehabilitation participation. 1, 2
Set realistic expectations: more than 50% of patients report persistent symptoms beyond five years. Emphasize the need for several months of consistent conservative care and long-term commitment to exercise. 1, 2
Introduce load-management strategies and address fear of movement during functional tasks. High fear may necessitate additional manual therapy or taping to facilitate exercise adherence. 1, 3
Assessment to Guide Additional Interventions
Evaluate hip and knee muscle strength objectively using hand-held dynamometry or manual testing. Strength deficits determine the focus and progression of the exercise program. 1
Observe single-leg squat performance to identify maladaptive movement patterns (e.g., knee valgus, hip adduction). This biomechanical screening informs targeted corrective exercises. 1
Conduct pain-provocation tests to assess tissue tolerance to load. Results guide appropriate progression of loading intensity. 1
Screen for structural contributors including patella alta, trochlear dysplasia, and generalized joint hypermobility. These factors modify exercise selection and may indicate need for adjunct interventions. 1, 5, 6
Supporting Physical Interventions (Add Based on Assessment)
Apply patellar taping when rehabilitation is hindered by elevated symptom severity or high fear of movement. Taping provides immediate short-term pain relief and improved function (moderate-certainty evidence). 2, 3
Prescribe prefabricated foot orthoses only when a directional test (e.g., squat with versus without orthoses) shows an immediate positive response. Customize density and geometry to prioritize patient comfort. 1, 2, 3
Consider a patellofemoral brace conditionally when the condition markedly impairs ambulation, joint stability, or pain. This recommendation is conditional because results vary and patient tolerance can be limited; proper fitting expertise improves effectiveness and reduces brace migration. 2, 3
Implement movement or running retraining for patients whose symptoms are linked to specific gait patterns (e.g., low cadence, narrow step width). Retraining aims to modify biomechanical stress on the patellofemoral joint. 1
Pharmacologic Management
Use topical NSAIDs as first-line pharmacologic therapy for local anti-inflammatory effect with fewer systemic side effects. Apply diclofenac sodium topical solution 40 mg (2 pump actuations) to each painful knee twice daily on clean, dry skin; avoid showering for 30 minutes after application. 2, 3, 7
Acetaminophen (up to 4,000 mg/day) may be used as initial systemic analgesic because of its favorable safety profile. This is an alternative first-line option. 2, 3
Oral NSAIDs or tramadol are recommended when topical agents are insufficient for symptom control. These provide additional relief but carry greater systemic risk. 2
Weight Reduction
- Advise weight loss in overweight or obese patients. While supported by relatively weak evidence in knee OA generally, a large cohort study showed that weight loss reduced the risk of developing symptomatic knee OA in women. 4
Interventions NOT Recommended
Do not prescribe glucosamine or chondroitin supplementation—there is no clinically significant benefit compared with placebo. Strong evidence against use. 2
Strongly discourage intra-articular hyaluronic acid injections due to lack of efficacy. Strong evidence against use. 2
Do not recommend acupuncture because of lack of effectiveness. Evidence regarding corticosteroid injections remains inconclusive. 2
Reassessment and Escalation
Reassess after 6–8 weeks of consistent therapy. If no clinically meaningful improvement is observed, revisit the initial assessment findings, verify that interventions align with identified impairments, and confirm patient engagement with the prescribed program. 1, 2
If conservative management fails after adequate trial (typically 6+ months), consider surgical options based on age, activity level, and disease severity. 8, 9, 6
Surgical Management (When Conservative Treatment Fails)
Younger, Active Patients (<50 years or active >50 years)
Arthroscopic assessment of patellofemoral articular cartilage can address mechanical symptoms and evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. This is the initial surgical step. 6
Tibial tubercle osteotomy (TTO) should be considered in patients less than 50 years of age or active patients >50 years old who fail arthroscopic treatment. This addresses malalignment and unloads damaged cartilage. 6
Patellar thinning osteotomy offers good clinical and radiological results in selected patients with isolated patellofemoral osteoarthritis. At mean 9.1-year follow-up, all patients except one were satisfied; this presents an alternative method of managing patellofemoral OA. 10
Patellofemoral arthroplasty (PFA) should be considered in younger patients with severe isolated patellofemoral OA refractory to the above treatments. If implanted correctly, PFA can lead to good results and delay the need for total knee replacement. 9, 6
Older Patients or Severe Disease
Total knee replacement is usually the preferred option in older patients with isolated patellofemoral osteoarthritis due to predictable good outcomes and lower revision rate. 9
In selected cases, particularly with severely thinned patella, retropatellar resurfacing should not be done during total knee replacement. 9
Joint replacement must be considered for refractory pain associated with disability and radiological deterioration. Six studies focused on patellofemoral joint resurfacing or replacement, and all reported improvements in pain and/or function compared with baseline. 4
Common Pitfalls to Avoid
Failing to emphasize that exercise therapy and patient education constitute the foundational treatment—all other modalities are adjunctive. This oversight reduces outcomes. 1, 2
Neglecting to incorporate both quadriceps and hip strengthening, which are essential for patellofemoral joint stability. Hip weakness contributes to dynamic malalignment. 1, 2
Using patellofemoral braces without proper fitting expertise, which limits effectiveness and patient tolerance. Off-the-shelf models are often sufficient when properly fitted. 2, 3
Setting unrealistic expectations for rapid recovery—emphasize that conservative management requires months of consistent effort. 1, 2
Treating patellofemoral OA identically to tibiofemoral OA—it is a unique entity with distinct epidemiology, biomechanics, and risk factors requiring targeted treatment. 6