Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

acute pain

1st line – activity modification + cold application

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INITIAL
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acute pain
1st line – 

activity modification + cold application

The treatment programme should focus on relative rest and activity modification (i.e., lower levels of activity, particularly of those exerting compressive force).

During the acute phase, ice or other methods of cold application may be used for 10 to 15 minutes, 2 to 3 times daily, to further reduce symptoms. Heat is generally not recommended.[23]

Consider – NSAIDs

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INITIAL
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acute pain
Consider – 

NSAIDs

Additional treatment recommended for SOME patients in selected patient group

There is limited evidence for the effectiveness of NSAIDs for short-term pain reduction.

Primary options

diclofenac potassium: 25-50 mg orally (immediate-release) three times daily when required, maximum 150 mg/day

OR

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

indometacin: 25-50 mg orally (immediate-release) two to three times daily when required, maximum 200 mg/day

OR

naproxen: 250-500 mg orally (immediate-release) twice daily when required, maximum 1250 mg/day

OR

celecoxib: 200 mg orally once daily when required; or 100 mg twice daily when required

Consider – patellar taping or patellar bracing

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INITIAL
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acute pain
Consider – 

patellar taping or patellar bracing

Additional treatment recommended for SOME patients in selected patient group

Taping the patella may reduce symptoms, increase quadriceps activity, and permit increased loading of the knee joint, although evidence regarding the efficacy of patellar taping from trials reporting clinically relevant outcomes is insufficient and of low quality, and further trials measuring the long-term effects of such taping are required.[55][56][57]

Patients may report decreased pain from wearing a properly fitted dynamic patellar stabilisation brace.

ACUTE

abnormal patellofemoral joint mechanics

1st line – open or closed kinetic chain exercises

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ACUTE
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abnormal patellofemoral joint mechanics
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abnormal patellofemoral tracking/alignment and quadriceps muscle weakness
1st line – 

open or closed kinetic chain exercises

Quadriceps strength, function, and activation patterns may be restored through an open- and closed-chain exercise programme. The mechanism is not clear; it is possible that improved quadriceps strength alters patellar tracking, but subtle changes in contact location and pressure distribution may also explain observed benefits.[88]

Examples of open-chain exercises include knee extension exercises, and closed-chain exercises include lunges, wall slides, and leg press machine exercises. Many practitioners prefer closed-chain exercises because they better replicate the demands of athletic activity by requiring co-contraction of muscle groups and loading of the joint in functional positions.[89][90]

There is good evidence that open and closed kinetic chain exercises are equally effective.

Regardless of the type of exercise, improving muscular endurance, as well as strength, is important especially for endurance athletes. High-dose, high-repetition exercise therapy is more efficacious than low-dose, low-repetition exercise therapy.[91]Furthermore, there appear to be long-term effects of high-dose, high-repetition exercise therapy in patients with patellofemoral pain syndrome with respect to pain and functional outcomes.[92]

The addition of foot targeted exercises and orthoses was more effective than knee targeted exercises alone in one study.[83]

Consider – patellar taping or patellar bracing

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ACUTE
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abnormal patellofemoral joint mechanics
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abnormal patellofemoral tracking/alignment and quadriceps muscle weakness
Consider – 

patellar taping or patellar bracing

Additional treatment recommended for SOME patients in selected patient group

Correcting abnormal patellar posture using the McConnell taping technique may help to align the patella within the trochlea (or in some way decrease patellofemoral contact stresses) for those patients unable to perform strengthening exercises due to pain.[54] Taping the patella may reduce symptoms, increase quadriceps activity, and permit increased loading of the knee joint, although evidence regarding the efficacy of patellar taping from trials reporting clinically relevant outcomes is insufficient and of low quality, and further trials measuring the long-term effects of such taping are required.[55][56][57] There is limited evidence of sufficient quality to determine whether taping is an effective treatment in addition to physiotherapy alone.[58]

Patients may report decreased pain from wearing a properly fitted dynamic patellar stabilisation brace. Kinematic imaging studies have shown a mechanical effect of knee braces on reducing patellar tracking abnormalities.[62]Improvement may be related to increasing contact area (through compression), dispersing joint reaction forces over a greater surface, and decreasing joint stress.[63] Studies have shown inconsistent results in evaluating the efficacy of the patellofemoral brace. Use of a brace is recommended if a long-term solution is needed. It is likely that a subgroup of patients, such as those with increased patellar displacement, will respond favourably to brace therapy.[64][65][66][67]

1st line – deep longitudinal massage + passive stretch

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ACUTE
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abnormal patellofemoral joint mechanics
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abnormal patellofemoral tracking/alignment and tightness of soft tissue structures
1st line – 

deep longitudinal massage + passive stretch

Tightness of soft tissue structures typically includes the iliotibial band or lateral retinaculum.

Reducing adhesions between the iliotibial band and the overlying fascia may be facilitated through deep longitudinal massage.

Passive stretches may also be applied to the lateral patellar retinacular structures through a sustained medial glide of the patella.

Subjects with patellofemoral pain also have a higher prevalence of myofascial trigger points in the gluteus medius and quadratus lumborum muscles. These areas should be targeted with deep tissue myofascial release as part of the therapy programme. These trigger points may become less prevalent once the proximal hip abductor muscles are better activated.[93]

1st line – patellar mobilisation techniques

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ACUTE
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abnormal patellofemoral joint mechanics
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abnormal patellofemoral tracking/alignment and decreased patellar mobility
1st line – 

patellar mobilisation techniques

Patients with global patellar hypomobility can benefit from mobilisation techniques.

These techniques should be performed with care to prevent excessive patellofemoral joint compression.

To facilitate mobilisation of the patella, the knee should be in extension or slightly flexed (no more than 20°).

If the knee is flexed beyond 20°, the patella becomes seated within the trochlear groove, and passive tension of the quadriceps will restrict patellar mobility.[5]

lower kinetic chain problems

1st line – orthotics

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ACUTE
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lower kinetic chain problems
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subtalar joint pronation
1st line – 

orthotics

Orthotics may be used to reduce the dynamic Q angle by controlling lower-extremity rotation.

If the Q angle does not change more than 5° between relaxed standing and placing the patient in subtalar joint neutral, then the use of an orthotic may not significantly influence lower-extremity alignment.

Forefoot stability may also play a key role in rear-foot stability, as instability in the forefoot at push-off can create rear-foot instability.[94] For this reason, orthotics need to extend to the sulcus or web space of the toes for control of forefoot instability in athletes.[95]

The addition of orthoses and foot targeted exercises was more effective than knee targeted exercises alone in one study.[83]

1st line – strengthening of hip extensors, abductors, and external rotators

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ACUTE
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lower kinetic chain problems
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hip internal rotation
1st line – 

strengthening of hip extensors, abductors, and external rotators

In this group, observations show that the femur collapses into internal rotation during gait, and this motion appears to originate from the pelvis (as opposed to being influenced by tibial rotation). The functional significance of an internally rotated femur is that the trochlear groove can rotate beneath the patella, placing the patella in a relatively lateral position.[96][97]

Patients may benefit from weight-bearing exercises that emphasise strengthening of the hip abductors and external rotators to control femoral rotation.

Young women with patellofemoral pain are more likely to demonstrate external rotation and weakness in hip abduction than age-matched non-symptomatic women.[49][84] The addition of knee-stretching and -strengthening exercises supplemented by hip posterolateral musculature-strengthening exercises was more effective than knee exercises alone in improving long-term function and reducing pain in sedentary women with patellofemoral pain syndrome.[98]

1st line – normalisation of gait mechanics

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ACUTE
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lower kinetic chain problems
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gait deviations
1st line – 

normalisation of gait mechanics

The restoration of normal gait function is essential to an overall treatment plan.

Real-time video feedback while running on a treadmill can be used as an effective tool.[99]

By reducing the common error of excessive hip internal rotation and adduction during stance, patients may be able to improve lower-extremity alignment and decrease pain.

overuse in athletes

1st line – training regime modification

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ACUTE
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overuse in athletes
1st line – 

training regime modification

Patients likely to have overuse as the aetiology of their patellofemoral pain syndrome (e.g., athletes) should have their training programme evaluated for obvious errors, including increasing exercise intensity too quickly, inadequate time for recovery, and excessive hill work.[5]

Runners should reduce mileage to a level that does not provoke pain (while running or the day after running).

Alternative activities such as cycling, swimming, or the use of an elliptical trainer can be used to maintain fitness while treatment is ongoing.[23]

ONGOING

post initial and reactivation-phase treatment

1st line – comprehensive home exercise programme

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ONGOING
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post initial and reactivation-phase treatment
1st line – 

comprehensive home exercise programme

All patients should be given a comprehensive independent exercise programme after completing initial and reactivation-phase treatments. Exercise therapy reduces pain, and improves function and symptoms in the short to long term.[86] The majority of patients have success with conservative treatment programmes and a generalised rehabilitation programme.

Symptoms of some patients will return when rehabilitation is terminated or when they return to their previous activity level, especially athletes with a hypermobile patella.[1][100]

Plus – surgery

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ONGOING
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post initial and reactivation-phase treatment
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bony and structural abnormalities with deviation in patella alignment and inadequate response to treatment and rehabilitation
Plus – 

surgery

Treatment recommended for ALL patients in selected patient group

Surgery for patellofemoral pain syndrome is indicated in patients who have persistent symptoms in spite of rehabilitation and who have structural alignment abnormalities that are potentially correctable with surgery, especially those with x-ray evidence of chronic subluxation or dislocation.[7]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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