What is the recommended treatment for a patient with patellofemoral pain syndrome presenting with anterior knee pain worsened by deep knee flexion, stair climbing, and prolonged sitting, and a body mass index over 25 kg/m²?

Treatment for Patellofemoral Pain Syndrome with BMI >25 kg/m²

Initiate knee-targeted exercise therapy with progressive quadriceps strengthening as the primary treatment, combined with prefabricated foot orthoses if the patient demonstrates immediate symptom improvement during treatment direction testing, and add hip strengthening exercises if the patient cannot tolerate loaded knee flexion. 1

Primary Intervention: Knee-Targeted Exercise Therapy

Prescribe progressive quadriceps strengthening exercises as the cornerstone of treatment, using both open and closed chain exercises. 1 This intervention has high certainty evidence for short-term pain reduction (SMD 1.16,95% CI 0.66,1.66) and moderate certainty evidence for short-term functional improvement (SMD 1.19,95% CI 0.51,1.88). 1

Exercise Parameters

• Train 2-3 days per week at 60-70% of one-repetition maximum 2
• Perform 8-12 repetitions across 2-4 sets 2
• Rest 2-3 minutes between sets 2
• Allow at least 48 hours rest between training sessions for the same muscle group 2
• Modify exercise parameters based on symptom severity and irritability 1, 3

When to Add Hip Strengthening

Add hip flexor, abductor, and external rotator strengthening exercises if the patient demonstrates poor tolerance to loaded knee flexion. 1, 3 This allows tissue adaptation while maintaining therapeutic benefit. 3 Hip-and-knee combined exercise therapy should be prioritized in patients who cannot tolerate initial quadriceps loading. 3

Supporting Intervention: Prefabricated Foot Orthoses

Prescribe prefabricated foot orthoses only after confirming favorable response through treatment direction testing. 1, 4 This is particularly important given the patient's BMI >25 kg/m², as excess weight increases patellofemoral joint stress. 5

Treatment Direction Testing Protocol

• Have the patient perform squats or stair climbing without orthoses and note pain level 4
• Repeat the same activity with trial prefabricated orthoses in place 4
• Prescribe orthoses only if immediate symptom improvement occurs during this test 4
• Customize orthoses for comfort by modifying density and geometry 1

The 2024 British Journal of Sports Medicine guideline identifies prefabricated foot orthoses as demonstrating primary efficacy when combined with hip-and-knee-targeted exercise therapy, vastus medialis oblique biofeedback, soft tissue stretching, and patellar taping. 1 However, orthoses are most beneficial in the short term and may not be needed long-term. 4

Adjunctive Interventions for Symptom Management

Patellar Taping

Use medially directed patellar taping when elevated symptom severity and irritability hinder rehabilitation progress. 1, 4 Taping provides short-term pain relief and can facilitate exercise therapy adherence. 1 The 2024 guideline notes that taping was advocated by both patients and clinical experts despite being inadequately tested in meta-analysis. 1

NSAIDs for Short-Term Pain Relief

Consider a short course of oral or topical NSAIDs for acute pain management, but recognize they do not change long-term outcomes. 6, 7 Topical NSAIDs are preferable as they eliminate gastrointestinal hemorrhage risk. 2 Exercise therapy remains superior to pharmacologic management alone. 3

Manual Therapy

Consider lower quadrant manual therapy as it demonstrates moderate certainty evidence for short-term functional improvement (SMD 2.30,95% CI 1.60,3.00). 1 Deep transverse friction massage may provide additional pain relief. 1, 2

Essential Education Component

Education must underpin all interventions and address specific patient concerns. 1, 3, 2 Key educational points include:

• Pain does not equal tissue damage, particularly important for patients with fear of movement 1, 3, 4
• Expected recovery timeline of several months with consistent conservative management 3, 4
• Load management strategies to avoid symptom aggravation 3
• Building confidence and reducing fear of movement 1, 3
• The condition represents biomechanical dysfunction rather than structural damage in most cases 5, 7

Weight Management Consideration

Address the patient's BMI >25 kg/m² as a modifiable risk factor, as excess weight increases patellofemoral joint stress and contributes to symptom persistence. 5, 7 Weight reduction should be incorporated into the overall treatment plan to reduce joint loading. 7

Activity Modification

Implement relative rest by reducing activities that reproduce pain, particularly deep knee flexion, stair climbing, and prolonged sitting. 1, 6 However, avoid complete immobilization as this causes muscular atrophy and deconditioning. 2

Critical Pitfalls to Avoid

• Do not use lateral heel wedges as they have limited evidence and may worsen symptoms. 3, 4
• Do not rely solely on NSAIDs for treatment, as they provide short-term relief but do not change long-term outcomes. 3, 4
• Do not prescribe prefabricated foot orthoses without first performing treatment direction testing to confirm benefit. 1, 4
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment. 2, 6
• Avoid complete rest or immobilization, which leads to deconditioning. 2

Assessment-Driven Decision Making

Before initiating treatment, perform targeted assessment to guide intervention selection: 1, 3

• Assess quadriceps and hip strength using hand-held dynamometry to determine exercise prescription 3
• Evaluate tissue tolerance to load through pain provocation tests (e.g., squatting, single leg squat) 3, 6
• Observe movement patterns during functional tasks to identify biomechanical contributors 3
• Examine footwear quality and fit 7, 8
• Assess for patellar hypermobility or limited patellar mobility 7

Expected Timeline and Reassessment

Recovery typically requires several months of consistent conservative management, with approximately 80% of patients recovering completely within 3-6 months with appropriate conservative treatment. 2, 4 Reassess at minimum 6 weeks if favorable outcomes are not observed, revisiting assessment findings and ensuring interventions align with symptom severity. 3, 4

When Imaging is Indicated

Routine knee radiography is not indicated for young, active patients with classic overuse-related patellofemoral pain and no red-flag findings. 4 However, obtain plain radiographs if: 7

• History of trauma or prior knee surgery 7
• Presence of knee effusion 7
• Patient age >50 years (to rule out osteoarthritis) 7
• Pain does not improve with conservative treatment 6, 7

Surgery as Last Resort

Consider surgery only after failure of a comprehensive 3-6 month rehabilitation program. 2, 6, 7 Surgery is considered a last resort for patellofemoral pain syndrome. 6