Patellofemoral Pain Management

Patellofemoral pain (PFP) is a common knee condition, especially in physically active individuals, characterized by pain around the kneecap.

PFP is characterized by recurrent or chronic symptoms, with up to 70-90% of individuals experiencing recurring pain.

While short-term outcomes of PFP treatment are often positive, long-term success remains limited, highlighting the complexity of PFP and the need for a deeper understanding of its causes.

PFP is multifactorial, meaning it involves multiple contributing factors, making it challenging to treat.

The National Athletic Trainers' Association (NATA) uses the Strength of Recommendation (SOR) Taxonomy to categorize the strength of recommendations based on the quality of supporting evidence.

Recommendations with an A grade are considered most strongly supported by high-quality evidence and should be implemented in clinical practice.

Recommendations with a B or C grade have less supporting evidence and should be discussed and considered by the sports medicine team.

Hip adduction and internal rotation during dynamic activities, such as running and landing, are strong risk factors for PFP.

Increased impulse and moments of knee abduction during running and landing are risk factors for PFP.

Novice runners who develop PFP often generate greater vertical peak forces at the lateral heel and metatarsals during running.

While reduced isometric hip-abductor, external-rotator, and hip-extensor strength were initially considered risk factors, research shows they are more likely to occur after PFP develops, possibly due to inactivity.

Quadriceps weakness is a confirmed risk factor for PFP.

Delayed activation of the vastus medialis obliquus (VMO) muscle relative to the vastus lateralis (VL) muscle is a risk factor for PFP.

Static measures like the Q-angle, foot posture index, and lower leg-heel alignment are not predictors of PFP development.

Individuals with quadriceps tightness and decreased vertical jump performance are more likely to develop PFP.

A 10-cm visual analog scale (VAS) is used to assess pain changes during rehabilitation, with a change of 2 cm or more considered clinically meaningful.

Patient-reported outcome measures, like the Anterior Knee Pain Scale (AKPS) and the Lower Extremity Functional Scale (LEFS), are used to assess functional improvement in PFP treatment.

Multimodal treatment plans, incorporating gluteal and quadriceps strengthening, patient education, activity modification, and other interventions, are recommended for PFP management.

An initial 3-week program of isolated gluteal strengthening exercises is recommended before starting quadriceps strengthening.

Interventions addressing trunk muscle control and capacity are essential for PFP management.

To minimize patellofemoral joint stress, non-weight-bearing quadriceps exercises should be done between 45° and 90° of knee flexion, and weight-bearing exercises between 0° and 45°.

Patellar taping can be beneficial if it allows pain-free exercise, though its long-term effects are still being studied.

Movement-retraining programs with real-time visual or auditory feedback can improve altered lower extremity gait mechanics, addressing excessive hip adduction and internal rotation.

Foot orthoses, used in conjunction with other treatment strategies, can provide some benefit for PFP.

Electrotherapy like ultrasound and low-level laser therapy offer limited effectiveness in PFP management.

Surgical intervention should be considered only for patients with evident lateral patellar compression or instability who haven't responded to extensive rehabilitation.

Lateral retinacular release or lengthening can benefit PFP cases with excessive lateral patellar tilting but no instability or severe cartilage damage.

Patellofemoral joint realignment procedures, like the Fulkerson osteotomy, are used to address PFP with patellar instability.

Quadriceps strengthening exercises, historically a mainstay in PFP treatment, should be performed in a pain-free manner, minimizing patellofemoral joint stress.

Weight-bearing quadriceps exercises, simulating functional activities, are preferred as they activate multiple muscle groups simultaneously, promoting muscle synergy.

Isolated hip and trunk strengthening exercises, targeting the hip abductors and external rotators, are recommended to improve hip kinematics and reduce patellofemoral joint stress.

Movement retraining, focusing on correct hip and knee mechanics during dynamic activities, can significantly reduce pain and improve function.

Patellar bracing, while not always superior to exercise alone, can be considered for patients who cannot exercise regularly.

Foot orthoses, while not essential for everyone with PFP, can be helpful for individuals with excessive foot pronation during gait.

Neuromuscular electrical stimulation (NMES) shows minimal benefit over exercise alone in PFP management and is not recommended as a primary treatment strategy.

Arthroscopic lavage and debridement, a minimally invasive surgical procedure, are not more effective than conservative treatment for PFP.