What is the recommended physical therapy regimen for treating patellar maltracking?

Physical Therapy for Patellar Maltracking

Progressive quadriceps strengthening combined with iliotibial band stretching forms the foundation of physical therapy for patellar maltracking, with hip strengthening added when patients cannot tolerate loaded knee flexion. 1, 2, 3

Core Exercise Program

Quadriceps-Targeted Exercises (Primary Intervention)

• Prescribe progressive quadriceps strengthening using both open chain (leg extensions) and closed chain (squats, step-downs) exercises as the primary treatment. 1, 2
• Open chain exercises are most appropriate after 30 degrees of knee flexion, while closed chain exercises demonstrate improved patellar congruence at 0-20 degrees of knee flexion. 4
• Target a quadriceps strength-to-body-weight ratio of 61% in women and 86% in men, which correlates with pain resolution. 3
• Modify load, intensity, and frequency based on symptom severity and irritability—if the patient cannot tolerate loaded knee flexion initially, prioritize hip exercises first. 1, 2

Hip Strengthening (Add When Indicated)

• Add hip abductor and extensor strengthening when patients demonstrate poor tolerance to loaded knee flexion or when hip weakness is identified on examination. 1, 2
• Hip-and-knee combined exercise therapy demonstrates superior outcomes compared to knee exercises alone. 1, 2
• Assess hip strength using hand-held dynamometry or manual muscle testing before prescribing. 5, 2

Flexibility Component

• Include iliotibial band stretching as an essential component—improved ITB flexibility correlates significantly with pain resolution (p=0.0017). 3
• Add joint mobility exercises to the program. 3

Treatment Timeline and Progression

• Expect an average of 8 weeks of rehabilitation or 11 physical therapy visits for pain resolution in 84% of patients. 3
• Recovery requires several months of consistent conservative management. 2
• Reassess the diagnosis and consider imaging if no improvement occurs after 6-8 weeks of consistent therapy. 5, 2

Supporting Interventions (Adjuncts Only)

Patellar Taping

• Apply McConnell-style patellar taping when rehabilitation is hindered by elevated symptom severity, high irritability, or significant fear of movement. 1, 2
• Use taping as a temporary adjunct to facilitate exercise therapy, not as standalone treatment. 2

Prefabricated Foot Orthoses

• Prescribe prefabricated foot orthoses only when patients respond favorably to treatment direction tests (symptom improvement during functional tasks with orthoses in place). 1, 2
• Customize for comfort by modifying density and geometry. 1, 2

Manual Therapy

• Consider lower quadrant manual therapy when symptoms hinder exercise delivery or quality of life. 1, 2
• Use manual therapy as a supporting intervention to facilitate exercise therapy, not as primary treatment. 2

Movement Retraining

• Consider gait or running retraining when symptoms are associated with task-specific biomechanics (e.g., increasing step rate in runners with excessive stride length). 1, 2

Essential Patient Education (Underpin All Interventions)

• Educate patients that pain does not correlate with tissue damage, particularly in chronic presentations. 2
• Explain the expected recovery timeline of several months with consistent management. 2
• Teach load management strategies to build patellofemoral joint resilience. 2
• Address fear of movement and build confidence in the diagnosis. 2
• Provide rationale for each specific intervention prescribed. 1

Pre-Treatment Assessment Requirements

Before prescribing exercises, objectively evaluate: 2

• Hip and knee strength using hand-held dynamometry or manual muscle testing 5, 2
• Movement patterns through single leg squat observation 2
• Tissue tolerance to load via pain provocation tests 1
• Patellofemoral joint structure and function (patella alta, hypermobility) 1

Critical Pitfalls to Avoid

Do not use these interventions—they lack efficacy or cause harm: 2

• Hyaluronic acid injection combined with exercise therapy 2
• Dry needling as standalone treatment 2
• Lateral heel wedges 2
• NSAIDs as primary treatment 2

Objective Outcome: Improved Patellar Tracking

• Physical therapy successfully improves patellar tracking, with significant improvement in Merchant's congruence angle (p=0.0066) in patients who become pain-free. 3
• Vastus medialis oblique strengthening, iliotibial band stretching, and joint mobility exercises correct lateral patellar tracking in the majority of patients with lateral patellar compression syndrome. 3