eMedicine Specialties > Sports Medicine > Knee
Patellofemoral Joint Syndromes: Treatment & Medication
Updated: Jul 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Conservative treatment is successful in 80% of cases of patellofemoral joint syndromes. The goal of treatment is to control the symptoms. Underlying strength and flexibility deficits need to be addressed.
- Start by having the patient modify his/her activity level. Decrease activities that increase patellofemoral pressure (eg, jumping, squatting, kneeling). Gentle eccentric loading activities may be initiated.
- Apply ice for 10-15 minutes, 4-6 times per day, especially after activity.
- Increase muscle strength, especially of the VMO, with short-arc quadriceps sets, knee presses, isometric quadriceps sets, and straight-leg raises with the leg externally rotated. Biofeedback may aid in teaching recruitment of the VMO.
- Improve flexibility of the hamstrings, vastus lateralis, and iliotibial band. Stretch tight retinacular structures.
- Initiate proprioceptive exercises.
- Ultrasound or phonophoresis may decrease pain symptoms.
- A patellofemoral brace with a patella cutout and lateral stabilizer or McConnell taping/Kinesio Taping may improve neuromotor control of the patellofemoral joint by affecting the osseoligamentous structures through alteration of patellar tracking, improving proprioception, or a combination of these factors.9,10
- Provide arch supports or orthotics to correct foot malalignments.
Related eMedicine topics:
Lower Limb Orthotics
Virtual Reality Biofeedback in Chronic Pain and Psychiatry
Recreational Therapy
The patient should avoid any exacerbating activity (eg, deep knee bends, stair climbing, running, hiking). Initiate a home therapy program of flexibility, strengthening, and proprioceptive exercises. In addition, eccentric loading activities may be initiated.
Medical Issues/Complications
Give special consideration to young patients in whom conservative therapy fails. In such cases, entertain the possibility of referred pain from the hip (eg, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis).
Related eMedicine topics:
Legg-Calve-Perthes Disease
Slipped Capital Femoral Epiphysis
Surgical Intervention
Surgical intervention is not appropriate in the acute phase. Surgery should be reserved for those in whom a conservative course of treatment of 6 months' duration was unsuccessful.9,12,13 Other more specific causes of anterior knee pain should be excluded first. Lateral retinacular release with or without medial capsular reefing may benefit active young adult patients who have not been helped by 12 months of nonoperative treatment and who have patellar tilt and/or subluxation.
Other Treatment
Analgesics, which may reduce pain, do not possess anti-inflammatory properties. Acetaminophen may be helpful for moderate pain; tramadol hydrochloride (HCl) may abort severe pain.14
Nonsteroidal anti-inflammatory drugs (NSAIDs) can aid in pain reduction and reduce the inflammatory component, which can be associated with this condition. In the acute phase, administer NSAIDs on a scheduled basis at sufficient doses to confer the anti-inflammatory benefits. Narcotics are not appropriate for this condition. For severe pain, corticosteroid injections may be beneficial.
Dietary food supplements may prove beneficial in a select group of patients. Glucosamine/chondroitin sulfate and hyaluronic acid may have the potential to provide the substrates used in regenerating the articular cartilaginous surfaces.15 To date, however, no scientific proof has been presented that this occurs, despite anecdotal reports that some people who take these supplements have reported decreased pain, decreased swelling, and improved joint mobility.
Potential future treatment may include viscosupplementation with an intra-articular injection. However, this is not a US Federal Drug Administration (FDA) – indicated treatment thus far, and future research needs to be undertaken. Hyaluronic acid may provide a scaffolding for rebuilding worn articular cartilage surfaces.
Recovery Phase
Rehabilitation Program
Physical Therapy
If formal physical therapy was utilized in the acute phase, the patient should start to be weaned to a home therapy program. Activity may be advanced as tolerated in a slow, progressive manner. The patient should be sure to continue the following:
- Emphasize flexibility, strengthening, and proprioception exercises. Maintain eccentric loading activities.
- Use ice as needed for pain or inflammatory relief, especially following activity.
- Use a patellofemoral brace or McConnell taping as needed for activity.
- Use arch supports or orthotics, as needed.
Recreational Therapy
Advance activity as tolerated in a slow, progressive manner. One suggested approach may be to decrease the previous volume and intensity training by 50%, and then if symptoms do not return, to increase activity by 10% each week.
Surgical Intervention
Surgical intervention is usually not appropriate in the recovery phase. Surgery should be reserved for those in whom a 12-month trial of conservative therapy was unsuccessful.
Other Treatment (Injection, manipulation, etc.)
Analgesics (acetaminophen and tramadol HCl), as well as NSAIDs, should be continued for those with persistent pain; for those whose pain resolves, wean off these drugs. These medications may be continued on an as-needed basis for individuals with activity-related pain.
Intra-articular corticosteroid injections may be useful in recalcitrant cases. Corticosteroid injections should never be injected into the patellar tendon because of the predisposition for tendon rupture that is associated with this procedure.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Flexibility, strengthening, and proprioception programs should be continued indefinitely. Arch supports and orthotics should also be continued indefinitely. Braces and taping, as well as ice, may be weaned as progress permits.
Recreational Therapy
Activity may be progressed as tolerated.
Surgical Intervention
Surgery may be useful for patients who have been compliant and in whom a 12-month trial of conservative therapy was unsuccessful. Surgery may completely resolve the patient's symptomatology, partially resolve the symptomatology, or may not change the symptomatology; rarely is the symptomatology exacerbated iatrogenically. Surgery is more successful when a specific diagnosis has been established and when clear surgical goals can be defined.
Surgical intervention includes arthroscopy for articular cartilage shaving, with or without lateral release of the retinaculum. Surgery may also include proximal or distal realignment. Open surgical procedures include patellar tendon transfer, or rarely, patellectomy.
Other Treatment
Analgesics (acetaminophen and tramadol HCl) and NSAIDs may be beneficial on an as-needed basis. Dietary supplements may be helpful on an individual basis. Corticosteroid injections may be beneficial for recalcitrant cases.
Medication
Analgesics may provide pain relief (acetaminophen for moderate pain, tramadol HCl for severe pain). NSAIDs may alleviate the pain, as well as reduce the inflammatory component. Narcotic medication is not indicated for this condition.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or who have sustained injuries.
Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)
Provides pain relief. May be a first-line drug therapy, especially in those with contraindications to NSAID use. May use on a prn basis.
Adult
325-650 mg PO q4-6h prn pain
Pediatric
<6 years: Not established
6-12 years: 325 mg, 1/2-1 tab PO 3-4 times/d prn pain
>12 years: Administer as in adults
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity.
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity can occur in patients with chronic alcoholism with various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate a serious illness.
Tramadol HCl (Ultram)
Inhibits ascending pain pathways, altering the perception of and response to pain. Also inhibits reuptake of norepinephrine and serotonin.
Indicated for moderate to moderately severe pain. This drug is generally not a first-line DOC, but it is a reasonable second-line DOC in those who do not have opioid dependency.
Adult
50-100 mg PO q4-6h; maximum of 400 mg/d; adjust dose in those with a decreased creatinine clearance or who have cirrhosis to 50-100 mg PO q12h
For those aged >75 years, the maximum dosage is 300 mg/d
Pediatric
Not established
Decreases carbamazepine effects significantly; cimetidine increases toxicity, risk of serotonin syndrome with coadministration of antidepressants
Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 d; use of SSRIs, TCAs, opioids, acute alcohol intoxication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in the presence of respiratory depression, increased intracranial pressure, head trauma, seizures, opioid dependency; not recommended in nursing mothers; can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in the presence of liver disease, myxedema, hypothyroidism, hypoadrenalism; development of tolerance or dependency with extended use may occur
Nonsteroidal Anti-inflammatory Drug (nsaid), Cox-2 Selective
COX-2 selective drugs are:
- Indicated for the relief of the signs and symptoms of osteoarthritis, rheumatoid arthritis in adults, and ankylosing spondylitis
- Indicated for the management of acute pain in adults
- Indicated for the treatment of primary dysmenorrhea
- Indicated to reduce the number of adenomatous colorectal polyps in familial adenomatous polyposis
Celecoxib (Celebrex)
A 4-[5-(4-methylphenyl)-3-(triflouromethyl)-1H-pyrazol-1-yl) benzenesulfonamide and a diaryl-substituted pyrazole. Primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus incidence of GI toxicity, such as endoscopic peptic ulcers, bleeding ulcers, perforations, and obstructions, may be decreased when compared to nonselective NSAIDs. Seek lowest dose for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
CYP450 2C9 substrate; coadministration with fluconazole may cause an increase in celecoxib plasma concentrations because of inhibition of the celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity; treatment of perioperative pain in the setting of coronary artery bypass graft surgery (CABG)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in patients with compromised cardiac function, hypertension, conditions predisposing to fluid retention; caution in the presence of severe heart failure and hyponatremia because circulatory hemodynamics may deteriorate; NSAIDs may mask the usual signs of infection; caution in the presence of existing controlled infections; evaluate therapy when symptoms or laboratory results suggest liver dysfunction
Nonsteroidal Anti-inflammatory Drug (NSAID), Oral
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Many NSAIDs are currently on the market. In general, the mechanism of action of these agents is the same. No evidence exists that one NSAID is more efficacious than another; however, individual response may differ.
Flurbiprofen (Ansaid)
May inhibit the cyclooxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ibuprofen (Ibuprin, Advil, Motrin)
First-line DOC for the reduction of pain and inflammation. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
10 mg/kg PO q6-8h; not to exceed 40 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Actron, Orudis, Oruvail)
For relief of mild to moderate pain and inflammation.
Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Naprelan, Naprosyn, Anaprox)
For the relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
2.5-5 mg/kg/dose PO; not to exceed 15 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Dietary Supplements
Dietary supplements may provide nutrients that may play a role in the formation of cartilage.
Glucosamine
Dietary supplement derived from crab shells. Hypothesized to provide the structural building blocks that are used in regenerating articular cartilage.
Adult
1500 mg/d for a minimum of 6-8 wk; must be taken regularly
Pediatric
Not established
None reported
Documented hypersensitivity to shellfish (glucosamine is derived from crab shells)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Shellfish allergies
Chondroitin sulfate
Dietary supplement derived from bovine trachea. Hypothesized to provide the structural building blocks that are used to regenerate articular cartilage.
Adult
1200 mg/d for minimum of 6-8 wk; must be taken regularly
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
None reported
More on Patellofemoral Joint Syndromes |
| Overview: Patellofemoral Joint Syndromes |
| Differential Diagnoses & Workup: Patellofemoral Joint Syndromes |
 Treatment & Medication: Patellofemoral Joint Syndromes |
| Follow-up: Patellofemoral Joint Syndromes |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
anterior knee pain, chondromalacia patella, patellalgia, patellar compression syndrome, patellofemoral dysfunction, patellofemoral pain syndrome, PFPS, peripatellar knee pain, retropatellar knee pain, global or generalized knee pain, joint line pain, posterior knee pain, patellar maltracking syndrome, miserable malalignment syndrome
