What are the treatment options for patellofemoral osteoarthritis?

Treatment Options for Patellofemoral Osteoarthritis

Exercise therapy targeting both the knee and hip musculature, combined with patient education, forms the foundation of treatment for patellofemoral osteoarthritis, with patellofemoral bracing, topical NSAIDs, and intra-articular glucocorticoid injections serving as evidence-based adjuncts when symptoms persist. 1

Primary Treatment: Exercise Therapy

Knee-targeted exercise therapy is mandatory and should be initiated immediately. 1

• Begin with quadriceps strengthening using isometric contractions and straight-leg raises, particularly when loaded knee flexion provokes significant pain 1, 2
• Progress to closed-chain exercises (partial squats, step-ups, lunges) only after load tolerance improves 1, 2
• Add hip-targeted strengthening exercises (gluteals, abductors, external rotators) within 2-4 weeks, as combined hip-and-knee exercise therapy demonstrates superior outcomes compared to knee exercises alone 1, 2
• When poor tolerance to loaded knee flexion exists, emphasize hip exercises initially before advancing knee-focused work 1
• Exercise intensity, task selection, load, and frequency must be modified based on symptom severity and irritability 1

The effectiveness of exercise programs is enhanced when supervised or coupled with self-efficacy and self-management programs. 1

Essential Adjunct: Patient Education

Education should underpin every intervention and be adjusted to reflect individual patient needs. 1

• Challenge inaccurate beliefs about the condition and build confidence in the diagnosis 1
• Explain that pain does not correlate with structural damage, particularly when symptoms have persisted for extended durations 1
• Provide realistic expectations regarding recovery timeframes and the expected trajectory 1
• Teach load management principles to promote autonomy and reduce fear of movement 1

Weight Management

Weight loss is strongly recommended for patients with patellofemoral osteoarthritis who are overweight or obese (BMI ≥25 kg/m²). 1

• Weight reduction decreases patellofemoral joint loading and reduces the risk of symptomatic progression 1
• Combine weight loss efforts with exercise programs for optimal outcomes 1

Patellofemoral Bracing

Patellofemoral bracing receives a conditional recommendation from the American College of Rheumatology for patellofemoral knee osteoarthritis. 1

• Bracing can alleviate joint stress and reduce symptoms in individuals with patellofemoral osteoarthritis 3
• Consider bracing as an adjunct to exercise therapy, particularly when rehabilitation is hindered by elevated symptom severity 1, 3

Pharmacologic Management

Topical NSAIDs (First-Line Pharmacologic Option)

Topical NSAIDs are strongly recommended for knee osteoarthritis and represent the appropriate first pharmacologic choice for localized patellofemoral disease. 1

• Apply topical diclofenac sodium 2% solution twice daily to clean, dry skin over the affected knee 4
• Do not cover the knee with clothing until completely dry; avoid showering or bathing for at least 30 minutes after application 4
• Topical NSAIDs minimize systemic exposure compared to oral formulations 1

Oral NSAIDs

Oral NSAIDs are strongly recommended for knee osteoarthritis, particularly when polyarticular involvement exists or topical therapy proves insufficient. 1

• Use the lowest effective dose for the shortest duration necessary 1
• Monitor for cardiovascular, gastrointestinal, renal, and hepatic adverse effects 1, 4

Intra-Articular Glucocorticoid Injections

Intra-articular glucocorticoid injections for the knee receive a strong recommendation from the American College of Rheumatology. 1

• Reserve injections for moderate-to-severe pain unresponsive to exercise therapy and NSAIDs 1
• Injections provide faster short-term relief but do not improve long-term outcomes 5
• Be aware of potential tendon weakening with repeated injections 5

Conditional Pharmacologic Options

Acetaminophen, duloxetine, and tramadol receive conditional recommendations and may be considered when NSAIDs are contraindicated or ineffective. 1

• Acetaminophen can be used as first-line oral analgesia for regular dosing 5
• Duloxetine may benefit patients with concurrent central sensitization or mood disorders 1
• Tramadol should be reserved for refractory cases due to opioid-related risks 1

Topical Capsaicin

Topical capsaicin receives a conditional recommendation for knee osteoarthritis. 1

• Consider capsaicin when other topical agents are ineffective or not tolerated 1

Supporting Interventions Based on Individual Presentation

Prefabricated Foot Orthoses

Prescribe prefabricated foot orthoses when patients respond favorably to treatment direction tests. 1, 2

• Customize orthoses for comfort by modifying density and geometry 1
• Evidence supports short-term benefit; long-term use may not be necessary 1

Patellar Taping

Taping should be considered when rehabilitation is hindered by elevated symptom severity and irritability. 1, 2

• Apply patellar taping for immediate short-term pain relief while strengthening exercises progress 2, 3
• If favorable outcomes are not observed after a realistic trial period, reassess the underlying pathomechanics 1

Movement/Running Retraining

Movement or running retraining can be considered when symptoms are reasoned to be associated with specific biomechanical patterns. 1

• Interventions such as increasing cadence or step width may benefit runners with patellofemoral osteoarthritis 1
• Align retraining strategies with assessment findings that support the intervention 1

Mind-Body and Behavioral Interventions

Tai chi is strongly recommended, while yoga and cognitive behavioral therapy (CBT) receive conditional recommendations. 1

• Tai chi provides benefits for pain, function, and quality of life 1
• Yoga and CBT may help patients with concurrent anxiety, depression, or fear-avoidance behaviors 1

Additional Conditional Interventions

Acupuncture, thermal modalities (heat/cold), and radiofrequency ablation receive conditional recommendations. 1

• Acupuncture may provide modest symptom relief in select patients 1
• Cryotherapy with melting ice water applied for 10-minute intervals can provide acute pain relief 5
• Radiofrequency ablation may be considered for refractory pain when other interventions have failed 1

Interventions NOT Recommended

Do not prescribe glucosamine, chondroitin, or intra-articular hyaluronic acid for patellofemoral osteoarthritis. 2, 5, 6

• Glucosamine and chondroitin show no clinically significant benefit compared to placebo 2, 5
• Intra-articular hyaluronic acid is strongly discouraged due to lack of efficacy 2, 5

Arthroscopic surgery is strongly contraindicated for degenerative patellofemoral osteoarthritis. 5, 7

• Surgery shows no benefit over conservative management for degenerative disease 5, 7
• Reserve surgical consultation only for end-stage disease with inability to cope with pain after exhausting all appropriate conservative options 7

Structured Treatment Algorithm

Phase 1: Initial Assessment (Weeks 1-2)

• Evaluate tolerance to loaded knee flexion using functional tests (single-leg squat, step-down) 1, 2
• Identify quadriceps and/or hip muscle weakness through objective strength assessment 1, 2
• Assess for pathomechanical factors such as patellar malalignment, trochlear dysplasia, or lower limb alignment abnormalities 6, 8
• Determine symptom severity, irritability, and impact on daily activities to guide treatment intensity 1

Phase 2: Immediate Intervention (Weeks 1-4)

• Initiate quadriceps strengthening in extension (isometric contractions, straight-leg raises) 1, 2
• Begin patient education addressing pain neuroscience, load management, and realistic recovery expectations 1
• Apply patellar taping if symptoms are severe and hindering rehabilitation 1, 2
• Prescribe topical NSAIDs for localized pain control 1, 4
• Recommend weight loss if BMI ≥25 kg/m² 1

Phase 3: Progression (Weeks 4-12)

• Add hip strengthening exercises (abductors, external rotators, gluteals) 1, 2
• Progress to closed-chain exercises (partial squats, step-ups, lunges) as load tolerance improves 1, 2
• Consider prefabricated foot orthoses if treatment direction tests are favorable 1, 2
• Escalate to oral NSAIDs if topical therapy is insufficient 1
• Consider intra-articular glucocorticoid injection for moderate-to-severe pain unresponsive to above measures 1

Phase 4: Maintenance (After 12 Weeks)

• Maintain a home exercise program to prevent symptom recurrence 2, 5
• Gradually reintegrate sports or work activities according to tolerance 2, 5
• Continue weight management and self-management strategies 1

Refractory Cases

• If disabling symptoms persist after 3-6 months of appropriate conservative therapy, consider surgical consultation for end-stage disease 5, 7
• Surgical options may include tibial tubercle osteotomy in younger patients (<50 years) or patellofemoral arthroplasty in severe cases refractory to all conservative measures 6

Common Pitfalls to Avoid

• Do not prescribe knee exercises alone without hip strengthening, as combined therapy is superior 1, 2
• Avoid complete immobilization or prolonged rest, which leads to muscle atrophy and worsens outcomes 5, 7
• Do not initiate oral NSAIDs before trying topical NSAIDs, as this exposes patients to unnecessary systemic side effects 1, 5
• Do not advance exercise intensity too quickly; progress only when load tolerance improves to avoid symptom exacerbation 1, 2
• Do not refer for arthroscopic surgery for degenerative patellofemoral osteoarthritis, as it provides no benefit over conservative management 5, 7
• Avoid prescribing glucosamine, chondroitin, or hyaluronic acid injections, as they lack evidence of efficacy 2, 5