Patellofemoral pain is usually diagnosed by exclusion of all other causes of knee pain (Gilchrist 2004; Brukner & Khan, 2007).  With multifactorial causes and influences, the most consistent risk factors are lower knee extension strength and being female (Lankhorst et al. 2012).

Patient reported symptoms: insidious onset of pain which can be difficult to localise but is usually on the anterior or anteromedial aspect of the knee; crepitus, snapping or clicking of the patella, and intermittent swelling (Gilchrist, 2004; Brukner et al., 2007). Symptoms are commonly aggravated by activities that load the patellofemoral joint such as squatting, jumping, walking or running especially downhill, stair climbing, sitting for long periods of time or rising from prolonged sitting (Harrison, 1998; Gilchrist, 2004). Giving way due to muscle inhibition is a common compliant (Brukner et al., 2007).

Clinical signs: effusion, full but painful active and passive movement, pain on patellar compression (Gilchrist, 2004), and reproduction of symptoms on double or single leg squat, incline squat, or palpation (Brukner et al., 2007).

For example:

• Patellar compression (Gilchrist, 2004) (Video link)
  
  
  Can also be known as Clarke’s sign and patellofemoral grind test. The patient is positioned in longsitting with their knee fully extended and quadriceps relaxed. The clinician places the web space of their hand on the superior aspect of the patella. A caudad movement is applied. The patient is asked to contract their quadriceps. A positive result is reproduction of symptoms
• Double or single leg squat, incline squat (Brukner et al., 2007)
  Looking for reproduction of symptoms
• Patella glides and position
• Palpation
  Looking for reproduction of symptoms

• Life style advice
• Weight and pain management
• Biomechanics
• Acute - PEACE and LOVE, early rehab, progressive conditioning
• Long recovery periods, responding - 3-6 months
• Surgery rare

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status. Clinical reasoning should inform treatment based on subjective and objective findings. Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Active exercise

Eccentric Quadriceps exercises produce better functional outcomes compared to standard quadriceps strengthening exercises (Crossley et al., 2001).

A six week regimen of quadriceps muscle retraining, patellofemoral joint mobilisation, patellar taping and daily home exercises significantly reduces patellofemoral pain compared to placebo in the short term (Crossley et al., 2002).

Exercise therapy evidence limited for pain reduction and conflicting for functional as far as functional improvement.  Strong evidence that open and closed Kinetic chain exercises are equally effective (Heintjes et al., 2003).

Growing evidence to support the effectiveness of gluteal strengthening when treating PFPS (Barton et al., 2013).

Analgesics/NSAIDs, walking aid, weight management, physiotherapy referral if failure to improve after 6 weeks. Advice to stay active, continue low impact activities (NHS Scotland 2011).

Non evidence based strategies

Patellar Taping: poor quality trials with conflicting results (Callaghan & Selfe, 2012).

Acupuncture: very limited evidence of poor quality (Jensen et al 1999).

Orthoses: no significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses (Collins et al, 2012; Crossley et al., 2009).

Ultrasound: ultrasound therapy was not shown to have a clinically important effect on pain relief for people with patellofemoral pain syndrome (Brosseau et al., 2001).

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other

Escalation

Criteria to refer on:

• Instability and recurrent subluxation
  • 1st time dislocation requires conservative management for at least 3 months. If no improvement and the dislocations are recurrent with ongoing instability, then the patients can be considered for investigation/surgery if they wish. 
• Surgery for PF pain is rare and further intervention is often not required.

Adebajo AO, Dickson DJ. Collected reports on the rheumatic diseases. 2005;Series 4 (revised). Click here to access full text version (link correct as at 20.8.15)

Brukner P, Khan K. Clinical sports medicine. 3rd ed. ed. Australia: McGraw-Hill; 2007.

Harrison E, Magee D, Quinney H. Development of a clinical tool and patient questionnaire for evaluation of patellofemoral pain syndrome patients. Clin J Sport Med 1996 Jul;6(3):163-170.

Heintjes Edith M, Berger M, Bierma-Zeinstra Sita MA, Bernsen Roos MD, Verhaar Jan AN, Koes Bart W. Pharmacotherapy for patellofemoral pain syndrome. 2004(3).

BARTON, C.J., LACK, S., MALLIARAS, P. and MORRISSEY, D., 2013. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. British journal of sports medicine, 47(4), pp. 207-214. Link here (link correct as at 21/8/15)

COLLINS, N.J., BISSET, L.M., CROSSLEY, K.M. and VICENZINO, B., 2012. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Sports medicine (Auckland, N.Z.), 42(1), pp. 31-49.

CROSSLEY, K.M., MARINO, G.P., MACILQUHAM, M.D., SCHACHE, A.G. and HINMAN, R.S., 2009. Can patellar tape reduce the patellar malalignment and pain associated with patellofemoral osteoarthritis? Arthritis and Rheumatism, 61(12), pp. 1719-1725. Link here (link correct as at 21/8/15)

CALLAGHAN, M.J. and SELFE, J., 2012. Patellar taping for patellofemoral pain syndrome in adults. The Cochrane database of systematic reviews, 4, pp. CD006717. Link here (link correct as at 21/8/15)

CROSSLEY, K., BENNELL, K., GREEN, S. and MCCONNELL, J., 2001. A systematic review of physical interventions for patellofemoral pain syndrome. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 11(2), pp. 103-110. Link here (link correct as at 21/8/15)

CROSSLEY, K., BENNELL, K., GREEN, S., COWAN, S. and MCCONNELL, J., 2002. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. The American Journal of Sports Medicine, 30(6), pp. 857-865. Link here (link correct as at 21/8/15)

CROSSLEY, K.M., MARINO, G.P., MACILQUHAM, M.D., SCHACHE, A.G. and HINMAN, R.S., 2009. Can patellar tape reduce the patellar malalignment and pain associated with patellofemoral osteoarthritis? Arthritis and Rheumatism, 61(12), pp. 1719-1725. Link here (link correct as at 21/8/15)

HEINTJES, E., BERGER, M.Y., BIERMA-ZEINSTRA, S.M., BERNSEN, R.M., VERHAAR, J.A. and KOES, B.W., 2003. Exercise therapy for patellofemoral pain syndrome. The Cochrane database of systematic reviews, (4)(4), pp. CD003472. Link here (link correct as at 21/8/15)

JENSEN, R., GOTHESEN, O., LISETH, K. and BAERHEIM, A., 1999. Acupuncture treatment of patellofemoral pain syndrome. Journal of alternative and complementary medicine (New York, N.Y.), 5(6), pp. 521-527. Link here (link correct as at 21/8/15)

NHS SCOTLAND, 2011. National musculoskeletal guidelines for knee pain. NHS Scotland. Link here (link correct as at 21/8/15)