Approach
The first stage in the management of patellofemoral pain syndrome is symptom control: e.g., activity modification, NSAIDs, ice or cold application, and patellar taping or patellar bracing. Once the pain is under control, patients should be classified according to the type of mechanism contributing to their patellofemoral pain, and treatment decisions should be focused appropriately.[5]
Symptom control
The treatment programme should focus on relative rest and activity modification (i.e., lower levels of activity, particularly of those exerting compressive force). During the acute phase, ice or other methods of cold application may be used for 10 to 15 minutes, 2 to 3 times daily, to further reduce symptoms. Heat is generally not recommended.[23] There is limited evidence for the effectiveness of NSAIDs for short-term pain reduction.
Correcting abnormal patellar posture using the McConnell taping technique may help to align the patella within the trochlea (or in some way decrease patellofemoral contact stresses) for those patients unable to perform strengthening exercises due to pain.[54] Taping the patella may reduce symptoms, increase quadriceps activity, and permit increased loading of the knee joint; although, evidence regarding the efficacy of patellar taping from trials reporting clinically relevant outcomes is insufficient and of low quality, and further trials measuring the long-term effects of such taping are required.[55][56][57] There is limited evidence of sufficient quality to determine whether taping is an effective treatment in addition to physiotherapy alone.[58]
Patients may report decreased pain from wearing a properly fitted dynamic patellar stabilisation brace. Kinematic imaging studies have shown a mechanical effect of knee braces on reducing patellar tracking abnormalities.[62] Improvement may be related to increasing contact area (through compression), dispersing joint reaction forces over a greater surface, and decreasing joint stress.[63] Studies have shown inconsistent results in evaluating the efficacy of the patellofemoral brace; however, use of a brace is recommended if a long-term solution is needed. It is likely that a subgroup of patients, such as those with increased patellar displacement, will respond favourably to brace therapy.[64][65][66][67]
Treatment of specific mechanical problem
Once the specific mechanical problem has been identified, treatment should focus on exercises aimed at restabilising the patella.
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Abnormal patellofemoral joint mechanics
For patients with abnormal patellofemoral joint mechanics and quadriceps muscle weakness or imbalance, an open or closed kinetic chain exercise programme is initiated, with addition of taping or a brace if pain limits the patient's ability to perform these exercises.[58] Open-chain exercises include knee extension exercises, and closed-chain exercises include lunges, wall slides, and leg press machine exercises. Closed-chain exercises are preferred by many practitioners because they better replicate the demands of athletic activity by requiring co-contraction of muscle groups and loading of the joint in functional positions.
For patients with abnormal patellofemoral tracking/alignment and tightness of soft tissue structures, adhesions between the iliotibial band and the overlying fascia may be reduced with deep longitudinal massage. Passive stretches may also be applied to the lateral patellar retinacular structures through a sustained medial glide of the patella.
For patients with abnormal patellofemoral tracking/alignment and decreased patellar mobility, mobilisation techniques can be beneficial.[78] These techniques aim to passively mobilise the patella and increase range of motion, especially in the medial direction. This therapy should be performed with care to prevent excessive patellofemoral joint compression. Mobilisation techniques should be employed when the knee is either in extension or slightly flexed (no more than 20°).
Altered lower-extremity alignment and/or motion
Lower kinetic chain problems should be managed by orthotics; strengthening of hip extensors, abductors, and external rotators; and normalisation of gait mechanics.
Orthotics may be indicated in patients with subtalar joint pronation in order to reduce the dynamic Q angle. Orthotics should extend to the sulcus or web space of the toes for control of forefoot instability in athletes. The addition of orthoses and foot targeted exercises was more effective than knee targeted exercises alone in one study.[83]
Hip internal rotation should be treated with weight-bearing exercises to the hip extensors, abductors, and external rotators. Young women with patellofemoral pain are more likely to demonstrate external rotation and weakness in hip abduction than age-matched non-symptomatic women.[21][49][84]
Gait deviations should also be addressed using real-time video feedback while running on a treadmill. Further research is needed to better address kinematic gait characteristics associated with patellofemoral pain syndrome, although some studies suggest that a midfoot to forefoot strike pattern may convey less stress to the patellofemoral joint than a heelstrike running gait.[85]
Overuse
Patients likely to have overuse as the aetiology of their patellofemoral pain syndrome (e.g., athletes) should have their training programme evaluated for obvious errors, including increasing exercise intensity too quickly, inadequate time for recovery, and excessive hill work.[5] Runners should reduce mileage to a level that does not provoke pain (while running or the day after running). Alternative activities such as cycling, swimming, or the use of an elliptical trainer or anti-gravity treadmill can be used to maintain fitness while treatment is ongoing.[23]
Rehabilitation
A comprehensive rehabilitation programme should form part of the treatment approach. Symptoms in some patients will return when rehabilitation is terminated or when they return to their previous activity level. In this case, a comprehensive home exercise programme is necessary. Exercise therapy reduces pain, and improves function and symptoms in the short to long term.[86]
Surgery
Surgery for patellofemoral pain syndrome is used when patients have persistent symptoms despite rehabilitation, provided they have structural alignment abnormalities that are potentially correctable by surgery.
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