Patellofemoral (Kneecap) Pain
Tips for Diagnosing Patellofemoral Pain (PFP)
To diagnose look for:
- Pain behind or around the patella,
- Reproduction of pain with activities that load the knee in flexion (i.e. squatting, descending stairs, running, prolonged sitting),
- Exclusion of all other conditions that can cause anterior knee pain e.g. patellar tendinopathy, fat pad irritation, knee osteoarthritis, patellar instability.
Patients with PFP really value been given a diagnosis. An explanation of the condition
can help them move forwards with a treatment plan and improve outcomes.
Clinical Assessment of PFP
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- Typically, pain is diffuse or poorly localised. People often place their hand over the entire front of the knee.
- Clinical tests- Look for pain reproduction during a squat or step-down and tenderness on palpation of the patellar edges.
- Expect to find full knee range of motion.
- Crepitus (audible grinding noise and/or palpable vibrations) is associated with PFP but has no relationship with function, physical activity level, or worse pain.
- Consider psychosocial characteristics such as pain self- efficacy and pain catastrophising in your assessment as these are predictors of pain and function in the PFP population.
- Night pain or an effusion are uncommon and may indicate systemic pathology.
- Diagnostic imaging is usually not necessary or helpful. Where there is uncertainty about the diagnosis, it can help rule out other pathology.
- For people aged over 40 years with PFP, a diagnosis of patellofemoral osteoarthritis should be considered if a PF x-ray shows joint space narrowing and osteophytes.
Tips for Managing Patellofemoral Pain
Educating patients
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- Education around load management is key. Sedentary patients should know the importance of gradual and progressive loading. Help athletes with PFP or active adolescents to understand the importance of temporarily reducing aggravating activities, while building knee strength and capacity.
- Complete rest is rarely indicated.
- Educate patients that it is safe to experience some pain while exercising, once it is tolerable and and settled by the following day.
- PFP can result in a reduction in physical activity. Associated weight gain can further increase patellofemoral joint loading and pain. Clinicians need to work with patients to break this vicious cycle.
- PFP is a persistent condition. One in 3 people continue to experience symptoms 12 months following treatment. Education around long-term self- management strategies is needed for people with chronic symptoms.
- Patients should know that evidence for the benefits of surgery for PFP is lacking.
Exercise and Physical Activity
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- A combination of hip- and knee-targeted exercise is recommended over solely knee-targeted exercises for better clinical outcomes.
- Knee-targeted exercise therapy can include weight-bearing (wall slides) or non–weight-bearing (resisted knee extension) exercise.
- Bridging exercise, banded hip abduction and adduction or banded crab walking are some examples of hip targeted exercises.
- With irritable PFP symptoms focus initially on hip strengthening or exercises in sitting or lying positions.
- The vastus medius oblique (VMO) muscle and patellar mal-tracking are not a primary target, instead strengthening all parts of the quadriceps muscle is important.
Running and PFP
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- Gait retraining that involves increasing running cadence, or cueing to reducing peak hip adduction may be helpful. Running on a treadmill with an upward incline can also reduce patellofemoral joint loading.
- Maintaining muscle flexibility around the knee is also important. Experts in PFP recommend stretching the hip flexors, quadriceps and hamstring.
Orthotics and Taping
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- Foot orthotics are recommended for short-term use and can have a comparable effect to exercise.
- Off-the-shelf are as effective as custom-made orthotics.
- Prefabricated foot orthotics should be customised for comfort (i.e hardness of the insole, addition of cushioning) and bring about an immediate reduction in pain during a provocative task (e.g. lunge or a single leg squat).
- No foot type or biomechanical factors has been identified that predicts who will respond well to orthotics.
- Taping the kneecap can be a useful add-on treatment to modify pain in the short-term. This temporary relief may allow a patient to progress an exercise programme.
- No specific taping technique has been found to be superior but experts agree a technique (e.g. medial glide) that the patient can repeat themselves at home is important.
- The video link below demonstrates a taping technique you can try.
Limitations
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- There is no evidence to support the use of dry needling, or hyaluronic acid injections in combination with exercise therapy for PFP.
- Most interventions that have proven effective in the short-term have not been tested with long-term follow-up.
The information in this website page was informed by the following sources/references:
- Davis LS et al. Gait retraining as an intervention for patellofemoral pain. Curr Rev Musculoskelet Med. 2020 Feb;13:103-14.
- de Oliveira Silva et al. Patient education for patellofemoral pain: A systematic review. J Orthop Sports Phys Ther. 2020 Jul;50(7):388-396.
- Crossley, K et al. “Patellofemoral pain.” British journal of sports medicine 50.4 (2016): 247-250.
- Lankhorst et al. Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: A multicentre observational analysis. Br J Sports Med. 2016;50(14): 881-886.
- Matthews et al. Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial. Br J Sports Med. 2020;54:1416-1422.
- Neal BS et al. Six treatments have positive effects at 3 months for people with patellofemoral pain: A systematic review with meta-analysis. J Orthop Sports Phys Ther. 2022 Oct;52(11):750-768.
- Neal, B et al. “Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning. ” British Journal of Sports Medicine 58.24 (2024): 1486-1495.
- Willy RW et al. Clinical practice guidelines patellofemoral pain. J Orthop Sports Phys Ther. 2019;49(9):1-95.