Patellofemoral pain syndrome (PFPS) is one of the most common issues when dealing with moderately active patients with general complaints of knee pain. Diagnosis and treatment of PFPS can be difficult at times, as it can be clouded by other comorbidities, unclear imaging findings, and patient beliefs regarding the need for injections or surgical intervention for their knee pain. The Journal of Orthopedic Sports Physical Therapy came out with a renewed set of Clinical Practice Guidelines, found here, that we can use for the classification and treatment of PFPS.
Retro- or peri-patellar pain during squatting, as well as other functional activities that load the PFJ in a flexed position, should be used as diagnostic tests for PFPS. Patellofemoral pain can also be further classified into one of four categories per the guidelines as follows.
- Overuse/overload without other impairment: when a patient presents with a history of dramatically increased volume or intensity of PFJ loading at a rate that surpasses the patient’s ability to recover and adapt appropriately
- Muscle performance deficits: when a patient presents with strength deficits in the hip and quadriceps, likely leading to impaired femoral control and mechanics during PFJ loading activities
- Movement coordination deficits: when a patient presents with excessive or poorly controlled knee valgus during dynamic activities, not necessarily due to lower extremity weakness; this category of patient is likely to respond positively to movement re-education interventions and assessment of kinematics
- Mobility impairments: when a patient presents with higher than normal foot mobility and/or deficits in flexibility of their hamstrings, quadriceps, gastrocnemius, soleus, lateral retinaculum, or iliotibial band
With respect to interventions, guidelines suggest a combination of hip and knee targeted exercises for functional improvement in the short, medium, and long term. Hip-targeted exercise therapy for the posterolateral hip musculature can be the focus of early stages of treatment until unloading of the PFJ results in decreased pain with quadriceps contraction. Once this is achieved, movement toward closed and open chain quadriceps strengthening to include resisted squats and resisted knee extension should occur. Other treatment modalities, including patellar taping, manual therapy, and biophysical agents such as ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, and therapeutic laser can be used in combination with exercise intervention, but should not be used in isolation. The overall recommendation for combined interventions in your treatment is a good reminder to always go back to the toolbox for additional tools and a varied approach.