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.^[9]

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.^{[14, 15, 16, 17]}
Provide arch supports or orthotics to correct foot malalignments.

Syme et al found that both selective and general physiotherapy are valuable for rehabilitation of patients with patellofemoral pain syndrome.^[18]In a prospective, single-blind, randomized controlled trial, 8 weeks of physiotherapy—either physiotherapy that selectively emphasized retraining of the vastus medialis component of the quadriceps femoris muscle or physiotherapy that emphasized general strengthening of the quadriceps—proved superior to no treatment for pain reduction and improvement in subjective function and quality of life. The investigators suggest that selective physiotherapy may be appropriate early in rehabilitation, but clinicians should not lose focus on progressive rehabilitation.^[18]

Related Medscape Reference topics:

Lower Limb Orthotics and Therapeutic Footwear

Chronic Pain Syndrome

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 Medscape Reference topics:

Legg-Calve-Perthes Disease Imaging

Slipped Capital Femoral Epiphysis Surgery

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.^{[14, 19, 20]}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.

In the event that a lateral release does not alleviate symptoms and there is mal-positioning of the insertion of the patellar tendon on the tibial tuberosity, a patellar realignment procedure (tibial tubercle transfer) can be performed.^[21]There are three common procedures that move the tibial tubercle as well as modifications to them. The Elmslie-Trillat procedure moves the tibial tubercle medial, the Macquet procedure moves it lateral and the Fulkerson procedure is a combination of the previous two and moves the tibial tubercle both anterior and medial.^[22]

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.^[23]

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.^[24]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.^[25]

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.^[26]Hyaluronic acid may provide a scaffolding for rebuilding worn articular cartilage surfaces.

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.^{[27, 28]}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.

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

Wieting JM, McKeag DB. Anterior knee pain and overuse. Sallis RE, Massimino F, eds. ACSM's Essentials of Sports Medicine. St. Louis, Mo: Mosby-Year Book; 1997. 421-32.
Scuderi GR, ed. The Patella. New York, NY: Springer-Verlag; 1995. xii-351.
Wertheimer C. Patellofemoral mechanics as a cause of anterior knee pain. Your Patient and Fitness. 1995. 9:19-23.
Eilert RE. Adolescent anterior knee pain. Pediatric Orthopedics. Philadelphia, Pa: Lippincott-Raven; 1991. 499-515.
Ruffin MT 5th, Kiningham RB. Anterior knee pain: the challenge of patellofemoral syndrome. Am Fam Physician. 1993 Jan. 47(1):185-94. [QxMD MEDLINE Link].
Pizzutillo PD. Osteochondroses. Sullivan JA, Grana WA, eds. The Pediatric Athlete. Park Ridge, Ill: American Academy of Orthopaedic Surgeons; 1990. 224.
Walsh WM. Knee injuries. Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. Philadelphia, Pa: Hanley & Belfus; 1990. 414-39.
Halabchi F, Mazaheri R, Seif-Barghi T. Patellofemoral pain syndrome and modifiable intrinsic risk factors; how to assess and address?. Asian J Sports Med. 2013 Jun. 4(2):85-100. [QxMD MEDLINE Link]. [Full Text].
Hrubes M, Nicola TL. Rehabilitation of the patellofemoral joint. Clin Sports Med. 2014 Jul. 33 (3):553-66. [QxMD MEDLINE Link].
Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral pain syndrome. Am Fam Physician. 2019 Jan 15. 99 (2):88-94. [QxMD MEDLINE Link].
Kaya D, Doral MN. Is there any relationship between Q-angle and lower extremity malalignment?. Acta Orthop Traumatol Turc. 2012. 46(6):416-9. [QxMD MEDLINE Link].
Hudson Z, Darthuy E. Iliotibial band tightness and patellofemoral pain syndrome: a case-control study. Man Ther. 2008 Feb 28. epub ahead of print. [QxMD MEDLINE Link].
Ferrari D, Kuriki HU, Silva CR, Alves N, Mícolis de Azevedo F. Diagnostic accuracy of the electromyography parameters associated with anterior knee pain in the diagnosis of patellofemoral pain syndrome. Arch Phys Med Rehabil. 2014 Aug. 95 (8):1521-6. [QxMD MEDLINE Link].
Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007 Jan 15. 75(2):194-202. [QxMD MEDLINE Link].
Cowan SM, Bennell KL, Hodges PW. Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome. Clin J Sport Med. 2002 Nov. 12(6):339-47. [QxMD MEDLINE Link].
Balachandar V, Barton C, Morrissey D. The efficacy of patellar taping in individuals with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2011 Dec. 45(15):A18. [QxMD MEDLINE Link].
Arazpour M, Notarki TT, Salimi A, Bani MA, Nabavi H, Hutchins SW. The effect of patellofemoral bracing on walking in individuals with patellofemoral pain syndrome. Prosthet Orthot Int. 2013 Feb 22. [QxMD MEDLINE Link].
Syme G, Rowe P, Martin D, Daly G. Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Man Ther. 2009 Jun. 14(3):252-63. [QxMD MEDLINE Link].
Earl JE, Vetter CS. Patellofemoral pain. Phys Med Rehabil Clin N Am. 2007 Aug. 18(3):439-58, viii. [QxMD MEDLINE Link].
LaBotz M. Patellofemoral syndrome: diagnostic pointers and individualized treatment. Phys Sportsmed. 2004 July. 32(7):22-9. [Full Text].
Reznik, Alan M. MD. Patella Realignment Tibial Tuberosity with Lateral Release. pdf document. Available at http://www.togct.com/downloads/reznik/Patella_Realignment.pdf. Accessed: 05/19/2014.
Shneider, David MD PC. The Patellofemoral Clinic. PatellaMD.com. Available at http://patellamd.com/16.html. Accessed: 05/19/2014.
Weil EK. Pain and pyrexia. Residents' Edition Prescribing Reference. 5th ed. New York, NY: Prescribing Reference, Inc; 1996. 164-8.
Kelly GS. The role of glucosamine sulfate and chondroitin sulfates in the treatment of degenerative joint disease. Altern Med Rev. 1998 Feb. 3(1):27-39. [QxMD MEDLINE Link]. [Full Text].
Kwoh CK, Roemer FW, Hannon MJ, Moore CE, Jakicic JM, Guermazi A, et al. Effect of oral glucosamine on joint structure in individuals with chronic knee pain: a randomized, placebo-controlled clinical trial. Arthritis Rheumatol. 2014 Apr. 66 (4):930-9. [QxMD MEDLINE Link].
Legré-Boyer V. Viscosupplementation: techniques, indications, results. Orthop Traumatol Surg Res. 2015 Feb. 101 (1 Suppl):S101-8. [QxMD MEDLINE Link].
Ott B, Cosby NL, Grindstaff TL, Hart JM. Hip and knee muscle function following aerobic exercise in individuals with patellofemoral pain syndrome. J Electromyogr Kinesiol. 2011 Aug. 21(4):631-7. [QxMD MEDLINE Link].
Ferber R, Kendall KD, Farr L. Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome. J Athl Train. 2011 Mar-Apr. 46(2):142-9. [QxMD MEDLINE Link]. [Full Text].
Islam K, Duke K, Mustafy T, Adeeb SM, Ronsky JL, El-Rich M. A geometric approach to study the contact mechanisms in the patellofemoral joint of normal versus patellofemoral pain syndrome subjects. Comput Methods Biomech Biomed Engin. 2013 Aug 19. [QxMD MEDLINE Link].
Freeman AJ, Jacobson NA, Fogg QA. Anatomical variations of the plantaris muscle and a potential role in patellofemoral pain syndrome. Clin Anat. 2008 Mar. 21(2):178-81. [QxMD MEDLINE Link].
Liebensteiner MC, Szubski C, Raschner C, et al. Frontal plane leg alignment and muscular activity during maximum eccentric contractions in individuals with and without patellofemoral pain syndrome. Knee. 2008 Jun. 15(3):180-6. [QxMD MEDLINE Link].
Vicenzino B, Collins N, Crossley K, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: a randomised clinical trial. BMC Musculoskelet Disord. 2008 Feb 27. 9(1):27. [QxMD MEDLINE Link]. [Full Text].