Treatment of patellofemoral pain is similar to the treatment of

knee pain in general. Most cases can be treated without

surgery. Nonsurgical options include:
Nonsteroidal anti-inflammatory drugs (NSAIDs). Drugs like
aspirin, naproxen, and ibuprofen reduce both pain and
swelling.
Treatment

There is no set protocol for treating PFPS. Treatment will

depend on each individual’s unique case and presentation.
Based on experience and training, different therapists may
also have certain techniques they use so treatment can vary
between therapists. Currently, research shows a few strategies
that can be effective treatment for many cases of PFPS and
therefore we have been incorporating these interventions into
our treatment plans for individuals diagnosed with PFPS in
the clinic.

1. Hip abductor strengthening 2,7

Strengthening exercises for the hip abductors in order to help
combat PFPS is found to be supported by a number of recent
research articles. Our hip abductors are muscles that are used
to bring the leg away from the midline, for example if you
were to take a step out to the side. The notable hip abductors
include gluteus medius and gluteus minimus (Figure 3). These
muscles also help to keep our leg in proper alignment and
prevent us from forming a “dynamic Q angle”. A dynamic Q
angle is when your leg forms a Q angle that is larger than
when you are standing still on two feet. This can occur
because of muscle weakness and is often seen in movements
such as single leg squats (refer to Figure 4). Again, this
incorrect alignment of the leg can cause the patella to track
incorrectly and can lead to PFPS. It is very common for these
muscles to be weak, even in those who do not have symptoms
of PFPS, therefore this is an important part of the treatment
plan of many patients but especially those who exhibit pain in
their knees. As indicated by the research, strengthening of the
hip abductors may also be indicated in the prevention of PFPS
in patients that are at risk for the condition such as young
female athletes.

Figure 3. Gluteus medius and gluteus minimus in relation to

their surrounding structures. These two muscles help to
abduct our hips.
Figure 4. Single leg squat. The figure on the left shows a
single leg squat performed with proper form. The image on
the right shows what can happen when a single leg squat is
completed with weak hip abductors. In the image on the right,
the knee falls inwards which means the leg is no longer
straight. When the leg is not straight, it is difficult for the
patella to move in a straight line up and down the leg as the
knee bends and straightens.

2) Strengthening muscles around the knee 7

Overall, research shows that addressing the entire lower limb

to be important in the rehabilitation of PFPS. In other words,
treatment should focus on more than just the knee. Greater
improvements in pain relief and knee function are shown
when strengthening programs are applied to both knee and hip
muscles.

The quadriceps are the muscles that attach to the patella and
straighten our legs. If these muscles are not all adequately
strong and working together, the patella may not track
properly when the quadriceps contract. However,
strengthening the quadriceps in isolation can increase force
and pressure in the structures related to PFPS (patella and
femur) which might further cause irritation. Exercises such as
mini squats are more favourable since they help strengthen the
quadriceps while also strengthening other muscles that
support the hips and knees. The key with mini squats is to
ensure proper form and alignment of the legs while
completing the exercise otherwise the exercise could bring on
symptoms in the knees.

Figure 5. Mini squat for strengthening of entire lower

extremity including the quadriceps. A resistance band is often
used to help cue the proper alignment of the legs (preventing
an active Q angle).

3) Stretching 2,7
Another way PFPS is commonly managed is by stretching. If
certain muscles are tight, they can have a direct effect in
causing PFPS by pulling the patella out of alignment as it
glides. Another way tight muscles have an effect on the
patella is if they cause the overall alignment of the leg to be
altered, leading to active Q angles or compensations with
movement that put stress on certain areas of the legs more
than other areas.

A therapist may choose to stretch any tight muscles manually

and/or show stretches to be completed at home. The following
muscles have been found to be commonly tight in those who
experience PFPS:

 Hamstrings
 Iliopsoas (hip flexors)
 Tensor fascia lata
 Gastrocnemius
If one or more are tight they should be addressed as a part of
the treatment plan.

4) Other Treatment 7

Due to the huge variety in patient presentation and therapist

style, I will not be able to touch on everything regarding PFPS
in this blog. Based on experience, therapists may add other
forms of exercises and treatment such as manual therapy.
Other factors that seem to play less of a role in PFPS
intervention, though may still be addressed and treated
include:

 foot over pronation

 generalized joint laxity
 patellar hypermobility
 limb length discrepancy.
Adjuncts to treatment 1,8

Physiotherapy should include education on the condition as

well as exercises and/or manual work as a part of the
treatment plan for any condition. Additionally, there are a few
extra measures we can take at an appointment to assist the
process or manage symptoms:

 Taping
o K-tape used to hold patella in place so it moves in proper

alignment with activity

o Allows for a bit more mobility than a brace

o Helps confirm diagnosis if it reduces symptoms

o Can be done a number of different ways depending on

patient preference or activity requirements

 Acupuncture
o Pain modulation

o Help manage tightness in surrounding muscles

 Modalities
o Heat, ice, TENS, etc. can all help with short term pain

modulation
 Swimming vs running
o Alternative way to maintain fitness

o Less weight bearing through the knee

Physiotherapists use something called “outcome measures” to

measure an effect that a treatment is having and to determine
if that effect is positive or negative. Research shows that there
are two specific outcome measures that could be used to help
determine the effects of treatment over time.
 Anterior Knee Pain Scale: a highly reliable scale with a
specific focus on symptoms and activities associated with
anterior knee pain
 Visual Analogue Scale (VAS): for patient self-report of
pain or symptoms
o VAS consists of rating pain or symptoms on a scale of 0-

10 to help describe symptoms from a minimum (no

symptoms at all) to a maximum (worst imaginable
symptoms)
o A change of at least 1.1 in rating depicts that a

significant difference has been made

Prognosis 12

 Patients may gradually return to sport or activity over a

period of 4-6 weeks
o Increase activity as symptoms are decreased

 Exercises should be continued at home to prevent

regression or return of symptoms
 Unfortunately, about 40% of patients with patellofemoral
pain syndrome may have long-term symptoms (>12
months)

Exercise. Regular exercise can decrease stiffness and

strengthen the muscles that support your knee. Patients
who have patellofemoral arthritis should try to avoid
activities that put stress on the front of the knee, such as
squatting. If you regularly do high-impact exercise,
switching to low-impact activities will put less stress on
your knee. Walking and swimming are good low-impact
options.
Activity modification. In many cases, avoiding activities
that bring on symptoms — such as climbing stairs — will
help relieve pain.
Weight loss. If you are overweight, losing just a few
pounds can make a big difference in the amount of stress
you place on your knee. Losing weight can also make it
easier to move and maintain independence.
Physical therapy. Specific exercises can improve range-of-
motion in your knee. Exercises to strengthen the
quadriceps muscles will help relieve pressure on the
kneecap when you straighten your leg. If an exercise
causes pain, stop the exercise and talk to your doctor or
physical therapist.
Cortisone (steroid) injections. Cortisone is a powerful anti-
inflammatory medicine that can be injected directly into
your knee.
Viscosupplementation. In this procedure, a substance is
injected into the joint to improve the quality of the joint
fluid. The effectiveness of viscosupplementation in
treating arthritis is unclear and continues to be studied by
researchers.
Surgical Treatment
Surgery is an option when nonsurgical treatment has
failed. Several types of surgical procedures are available.
Chondroplasty. This procedure is done with arthroscopy
— inserting thin surgical instruments into small incisions
around your knee. During a chondroplasty, your surgeon
trims and smooths roughened arthritic joint surfaces.
Chondroplasty is an option in cases of mild to moderate
cartilage wear.
Realignment. The soft tissues on either side of the kneecap
are tightened or released to change the position of the
kneecap in the trochlear groove.
Cartilage grafting. Normal healthy cartilage tissue may be
taken from another part of the knee or from a tissue bank
to fill a hole in the articular cartilage. This procedure is
typically considered only for younger patients who have
small areas of cartilage damage.
Tibial tuberosity transfer. This procedure can help relieve
pain in patients with arthritis in specific portions of the
patella. The patellar tendon below the kneecap attaches to
a bump on the front of the knee called the tibial
tuberosity. Shifting the bump in any direction will change
the position of the kneecap. After the procedure, the
patella should move more smoothly in the trochlear
groove, reducing pressure on the arthritic areas and
relieving pain.
Patellofemoral replacement. During this "partial" knee
replacement, damaged bone and cartilage surfaces are
removed and replaced with metal and polyethylene
(plastic) components. A thin metal shield is used to
resurface the trochlear groove at the end of the femur. A
plastic “button” or cover is used to resurface the backside
of the patella. These components are typically held to the
bone with cement.

(Left) X-ray taken from above the knee. The patella and
the trochlear groove of the femur have become deformed
due to arthritis. There is bone rubbing on bone. (Right)
The same knee after patellofemoral replacement. The
patellar implant on the underside of the kneecap does not
show in an x-ray.
Patellofemoral replacement surgery cannot be carried out
if there is arthritis involving other parts of the knee. If this
is the case, your doctor may recommend a total knee
replacement.
Total knee replacement. In a total knee replacement, all
the cartilage surfaces of the knee are resurfaced. The end
of the femur and the top of the tibia are capped with a
metal prosthesis. A plastic spacer is placed in between
these components to create a smooth gliding
surface. Additionally, the patella itself is usually
resurfaced with a plastic “button.