Patellofemoral Pain Syndrome

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Clinically Relevant Anatomy

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Mechanism of Injury / Pathological Process

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Clinical Presentation

Patient's usually present with compliant of anterior knee pain that is aggravated by activities that increase patellofemoral compressive forces such as: ascending/descending stairs, sitting with knees bent, kneeling, and squatting.

Diagnostic Procedures

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Outcome Measures

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Lower Extremity Functional Scale (http://academic.regis.edu/clinicaleducation/pdf's/Knee_Pain_LEFS.pdf)

Management / Interventions

Common interventions for the treatment of PFPS are listed below:

• Manual Therapy
• Exercise (open vs. closed chain)
• Quadriceps strengthening
• Patellar Taping
• Orthotics
• Proximal Muscle strengthening
• Modalities

What treatments LACK support by current evidence?

• No significant difference was noted in open vs. closed chain exercises with respect to exercise type.
• Further evidence is needed to investigate the long term effects of patella taping, the mechanism of action and direction of force (medial, neutral, lateral).  Clinical evidence for the success of this intervention is still unclear due to an insufficient amount of high level evidence, inconsistency of tape application techniques, in ability to identify the precise mechanism of aciton, and variance in measurements of specific outcome variables.
• No date is available regarding massage, thermotherapy, TENS, electrical stimulation, and biofeedback for treatment of PFPS.

What treatments are SUPPORTED by the best available evidence?

• Tyler et al noted the role of hip muscle function in the treatment of PFPS.  A 93% success rate occurred with hip flexor strenght improvements and normalization of Ober (IT band/tensor fascia latae) and Thomas (hip flexor) tests.
• A case report by Mascal et al documented weakness of hip abductors, extensors and external rotators in testing of 2 patients with PFPS.  Treatment consisted of recruitment and endurance training of the hip, pelvis, and trunk musculature which resulted in a significant reduction in pain, improved LS kinematics during dynamic testing and ability to return to original level of function.
• Whittingham et al investigated the effectiveness of daily patella taping and exercise on pain and function in individuals with PFPS.  Results suggest that patella taping may be useful in conjunction with strengthening exercise to enhance speed of recovery.
• 2 articles were reviewed in regards to the effect of foot orthoses on PFPS.  Both studies suggest that the use of orthotics in patient's who present with excessive pronation resulted in improved pain/stiffness (note: multiple interventions were used in these studies, including orthosis).  Patients with patellofemoral pain may benefit from the use of foot orthosis if the patient demonstrates the following: excessive foot pronation and/or a LE alignment profile that includes excessive lower extremity internal rotation during weight bearing and increased Q-angle.  Additional studies are needed to assess the treatment efficacy of foot orthosis for patients with PFPS.

Take Home Message:Focus on identifying the root cause of the problem and always consider proximal and distal influences (regional interdependence).  Based on the available evidence, exercise and manual therapy seem to be the most benefical in the managment of anterior knee pain.  Addressing the strength and ROM deficits at the hip and pelvis has also shown to be effective in management of anterior knee pain.

Differential Diagnosis

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Key Evidence

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Resources

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Case Studies

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References

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