Patellofemoral pain syndrome is commonly described as anterior or retropatellar knee pain in the absence of other specific knee pathology, and is characterized by pain associated with activities that place increased stress into the patellofemoral joint, such as squatting, descending stairs, long-duration sitting, running, and biking. Patellofemoral pain is one of the most difficult orthopaedic clinical challenges, with the majority of patients still suffering from knee symptoms years after treatment, despite over 25% of patients with knee pain present with suspected patellofemoral problems. Abnormal patellar tracking or patellar malalignment is thought to be one of the precursors of patellofemoral pain, with various interventions directed at treating patellar motion (e.g. patellar taping, vastus medialis strengthening, stretching, patellar bracing, patellar mobilizations, foot orthoses). Because of the difficulty getting consistent results in treating this condition, there has been a call to question the root cause for patellofemoral pain and the most effective treatment techniques.
Recent research has focused on treatment of patellofemoral pain through regional interdependence, which emphasizes the importance of understanding lower extremity biomechanics, allowing physical therapists to identify dysfunctions in the kinetic chain away from the patellofemoral joint that may be contributing to the patellofemoral pain. There have been associations with lower extremity positioning during dynamic activities (dynamic Q-angle) that potentially increases stress through the patellofemoral joint and causes pain. Problems in the ankle and foot, knee, hip, sacroiliac joint, and lumbar spine can all influence the positioning of the knee during dynamic activities, affecting the amount of stress in the patellofemoral joint. In an initial evaluation, a physical therapist should be able to identify the pain as patellofemoral in nature, and also look for other reasons as to why the pain originated in the first place. This thought process is known as identification of the ‘victims’ (i.e. patellofemoral joint), while also searching for the ‘culprits’ (i.e. hip weakness, ankle stiffness). Failure to treat the culprits, which may even be pain-free areas of dysfunction, will make long-term success of the victims more unlikely.
With knee pain, it is also common for the individual to compensate in standing and while performing functional activities, in order to protect the leg from pain. These compensation strategies, though protective in nature, can actually increase the stress in the patellofemoral joint by altering normal movement patterns. If these patterns are not addressed within rehabilitation, it is unlikely the long-term success of knee rehabilitation will be effective. The physical therapist should address these strategies early on in rehabilitation, which will then help the other treatments become more successful.
Long-term success for patellofemoral pain can be successful with a thorough evaluation, to determine what structures are truly involved and what other areas are contributing to the problem. Because so many things have the ability to affect the patellofemoral joint, treatment should be individualized to the problems of each patient, and progression exercises should be specific to the functional demands of that person. Physical therapy is a great option for patients with anterior knee pain, and should be a first-line option for patients looking to get back to their normal activities pain-free.