Patellofemoral Pain Syndrome (PFPS): A Comprehensive Guide

Written by Michael Clark, Registered Osteopath and Co-founder of Clarks Healthcare

Welcome! Today, we’re diving into Patellofemoral Pain Syndrome (PFPS), a common yet often misunderstood knee condition affecting millions worldwide. At our osteopathy and rehabilitation clinic in Benfleet Essex, I’ve had the privilege of working with countless patients facing this issue. While short-term relief is often achieved with painkillers and simple exercises, this is usually just a temporary fix, as the underlying dysfunctions are rarely addressed.

To truly resolve PFPS, it’s crucial to have a deep understanding of knee anatomy and biomechanics, the forces at play, and the specific dysfunctions that occur. By developing comprehensive strategies that include hands-on therapy, personalized home care advice, corrective exercises, rehabilitation, and prevention, we can effectively manage and treat PFPS. So let’s get started.

What is Patellofemoral Pain Syndrome (PFPS)?

Patellofemoral pain syndrome (PFPS) is a prevalent yet complex condition characterized by pain around or behind the kneecap, especially during activities that involve knee flexion (knee bending), such as squatting, climbing stairs, or sitting for extended periods. These movements affect everyone, from those who are sedentary to those involved in contact sports such as rugby players and professional fighters. PFPS accounts for 25-40% of all knee problems seen in sports medicine clinics, affecting athletes and non-athletes of all ages.

The Knee Joint: A Marvel of Biomechanical Engineering

The knee joint is one of the largest and most complex joints in the human body. It is a hinge joint that allows for flexion (bending) and extension (straightening), as well as slight internal and external rotation. The knee comprises three bones: the femur (thigh bone), the tibia (shin bone), and the patella (kneecap) and a functional influence of the fibula slightly below and laterally to the knee. These bones are connected and stabilized by a network of ligaments, tendons, and muscles that provide stability and facilitate movement.

The patella, a sesamoid bone embedded within the quadriceps tendon, plays a crucial role in knee mechanics. It acts as a fulcrum, increasing the leverage of the quadriceps muscles, making them more efficient during knee extension, from simple activities such as getting out of a chair and walking to explosive movements like a rugby tackle or a wrestling takedown. During knee movement, the patella glides along a groove in the femur called the trochlear groove. Proper patellar tracking within this groove is essential for smooth, efficient knee function and minimizing stress and friction on the joint. Faulty tracking creates excessive friction, causing inflammation and pain and, over time, creates degeneration such as arthritis.

The ligaments of the knee, including the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) oriented like crossed fingers within the knee, and the medial collateral ligament (MCL) and lateral collateral ligament (LCL) run along the medial (inner) and lateral (outer) side of the knee, providing critical stability. These ligaments, individually and collectively, provide stability and proprioceptive feedback, preventing excessive forward, backward, and sideways movements, ensuring the knee remains stable under various loads in multiple positions.

Forces and Dynamics in Knee Movement

The forces exerted on the knee joint during movement are significant. Simple activities like walking generate forces up to 3.5 times body weight on the knee, while running can increase these forces to 5 to 7 times body weight and sports such as netball and rugby can be up to 14 times bodyweight. These forces are distributed across the articular surfaces of the knee, primarily the tibiofemoral and patellofemoral joints. This is why patients often report they didn’t do anything specific to cause the pain, and when we explain the forces involved as part of normal daily life, they can understand why, if there is an underlying imbalance, it can quickly lead to pain and inflammation for no apparent reason.

The patellofemoral joint, in particular, experiences substantial compressive forces during knee flexion. As the knee bends, the contact area between the patella and the femur increases, distributing the load across a larger surface area. However, if the patella does not track properly within the trochlear groove, these forces can become concentrated on specific areas, leading to increased stress and potential damage to the cartilage. This maldistribution of forces is a key factor in the development of PFPS, contributing to pain and dysfunction. It is also why I don’t recommend returning to activities such as running until the dysfunction is resolved due to the enormous forces the knee will experience if not functioning properly. The fact that I regularly observe people on a rugby pitch, in a dojo or at a running club with knee braces and sports taping is a testament to how many people are exercising with a multitude of knee dysfunctions.

Patellar Maltracking and PFPS

The underside of the patella is shaped to contour its articular surface of the femur (trochlear groove) and is designed to move up and down in a specific way within this groove. Patellar maltracking occurs when the patella does not move smoothly within its intended path in the trochlear groove. Instead, it may deviate, most commonly laterally (towards the outside) or medially (towards the inside), or it may tilt or rotate abnormally. This misalignment and faulty tracking disrupts the natural distribution of forces within the patellofemoral joint, leading to increased friction, compression, and shear on the articular cartilage and surrounding structures. This, in turn, leads to pain, inflammation, and over time, degeneration such as arthritis. Therefore, if you want to prevent arthritis, this imbalance must be addressed. Likewise, if you already have knee pain or arthritis, you MUST normalize this tracking to prevent further trauma.

Causes of Patellar Maltracking

Several factors contribute to patellar maltracking; the list below explains the most common:

Muscular Imbalances: The quadriceps muscle group, particularly the vastus medialis obliquus (VMO), plays a critical role in guiding the patella and holding it medially. Weakness in the VMO or tightness in the lateral structures of the thigh can lead to an imbalance, causing the patella to shift laterally. Studies have shown that individuals with PFPS often exhibit a delayed activation of the VMO compared to the vastus lateralis (VL), exacerbating maltracking and requiring specific rehabilitation to fully reactivate.

Anatomical Variations: Certain structural anomalies, such as a shallow trochlear groove or an abnormally shaped patella, can predispose individuals to maltracking. These variations affect the natural alignment and movement of the patella. For example, trochlear dysplasia, a condition where the trochlear groove is underdeveloped, is a significant risk factor for patellar instability and maltracking. Thankfully in most cases, with hands-on treatment and structured rehabilitation, patients can compensate for this issue and provide adequate stability and function.

Faulty Squat and Lunge Pattern: We are designed to squat and lunge for normal daily life, such as getting off the toilet, getting off the floor, or getting in and out of a car. For healthy children, these patterns come naturally. If you observe a young child sitting in a squat playing with their toys, the technique is typically perfect, i.e., a vertical shin, feet flat on the ground, and a straight back. Sadly, once they start sitting in chairs at school, these normal movement patterns become faulty. They soon can’t keep their feet down, shins straight, and have to round through the back. This forward shift creates shear forces through the knee. As adults, these imbalances compound, creating pain and injury.

Squat and Lunge Dysfunctions in Rugby and Combat Sports: 

When I coach young rugby players, I often find that less than half can initially squat properly, making it very challenging to tackle and ruck with good form. Adults typically have the same issues, which have worsened over time. Many high-level rugby players exhibit multiple movement dysfunctions, often missed due to their speed and power. However, these issues will affect them in one of two ways: recurring injuries or a failure to perform at their peak. To have a healthy sporting career, it’s crucial to correct these issues while young before developing the power of an adult. It’s correctable as an adult but way more challenging.

Similarly, when I work with those in grappling sports such as Jiu jitsu and wrestling, they frequently have these issues. Their sport involves spending a lot of time in a squat-style position and creating explosive force from awkward and compromised positions. Having a faulty squat pattern significantly increases their risk of injury.

For all of my knee pain patients (sporty or otherwise), re-establishing normal movement patterns can prevent many knee and other problems seen in the clinic. By focusing on correcting these dysfunctions, we can help athletes and non-athletes alike achieve better performance and a pain-free life.

Biomechanical Influences: Repetitive stress from activities like running or jumping, and inadequate warm-up can exacerbate maltracking. Over time, these biomechanical issues can lead to chronic malalignment. Excessive foot pronation, for instance, can cause the tibia to rotate internally, altering the alignment of the patella and contributing to maltracking.

Pelvic Biomechanical Dysfunctions: The pelvis plays a crucial role in the alignment and function of the lower extremities. Often when treating knee pain, therapists don’t examine the hip and pelvis and only examine the knee. This is a mistake. Pelvic biomechanical dysfunctions, such as anterior or posterior pelvic tilt, leg length discrepancies, and sacroiliac joint dysfunction, lumbar and hip instability etc can significantly impact knee alignment, movement, and tracking. For instance, an anterior pelvic tilt can cause increased internal rotation of the femur, torsion of the tibia, and pronation of the foot, leading to maltracking of the patella. Addressing these pelvic dysfunctions through targeted interventions can help improve patellar tracking and reduce the risk of PFPS. Other common dysfunctions include:

• Trendelenburg Gait: Trendelenburg gait occurs when the muscles on the side of your hip, especially the gluteus medius and minimus, are too weak to keep your pelvis level as you walk. This causes your hip to drop on the opposite side, leading to an unusual walking pattern. Even when subtle this imbalance puts extra stress on your knees, which can cause your kneecap to move out of its normal path and contribute to PFPS. Strengthening and training these hip muscles can help correct your gait and alleviate knee pain.
• Lower Cross Syndrome: Lower cross syndrome is a common postural problem characterized by tight hip flexors and lower back muscles paired with weak glutes and abdominal muscles. This imbalance tilts your pelvis forward, increasing the curve in your lower back. As a result, your thigh bones (femurs) rotate inward, and your feet may roll inward too much (overpronation), throwing off your kneecap’s alignment. Exercises that stretch tight muscles and strengthen weak ones can help restore balance and reduce knee pain.
• Sway Back: If you have a sway back posture, your hips might shift forward, and your lower back may curve excessively. This posture stretches and weakens your hip flexors and abdominal muscles while tightening your hamstrings and lower back. These changes affect how your legs and knees move, often leading to patellar maltracking. Correcting this posture through targeted stretching and strengthening can help realign your knees and reduce PFPS symptoms.
• Anterior Pelvic Tilt: An anterior pelvic tilt happens when your pelvis tips forward, creating an exaggerated arch in your lower back. This often results from tight hip flexors and lower back muscles, coupled with weak glutes and abs. This tilt causes your thigh bones to rotate inward and your feet to overpronate, misaligning your kneecaps. By addressing these muscle imbalances, you can correct your pelvic tilt and improve knee alignment.

Symptoms and Clinical Presentation

Patients with patellar maltracking often present with a constellation of symptoms indicative of Patellofemoral Pain Syndrome (PFPS). The most common symptom is anterior knee pain, typically described as a dull ache around or behind the patella. This pain is often aggravated by activities that involve knee flexion, such as climbing stairs, squatting, or prolonged sitting.

In addition to pain, patients may report a sensation of the knee “giving way” or catching during movement. This instability can be particularly troubling during activities that require sudden changes in direction, explosive movements, or bearing weight. Chronic maltracking can also lead to localized swelling and inflammation within the knee joint, reflecting ongoing stress and irritation of the patellofemoral structures.

Statistics indicate that PFPS affects approximately 25% of the general population at some point in their lives, with a higher prevalence among physically active individuals and adolescents. Female athletes are particularly at risk, with studies suggesting that they are up to twice as likely to develop PFPS compared to their male counterparts, likely due to anatomical and hormonal differences.

Comprehensive Assessment: Assess, Don’t Guess

Diagnosing patellar maltracking and its association with Patellofemoral Pain Syndrome (PFPS) involves a thorough and systematic approach. Clinicians such as osteopaths and physiotherapists should perform a comprehensive physical examination of the knee and surrounding regions to assess pain, inflammation, patellar alignment, mobility, and stability.

• Assess, Don’t Guess: It is vital that a healthcare professional assesses each patient individually rather than making assumptions based on general symptoms or a previous diagnosis. Even with a confirmed diagnosis of PFPS, each patient’s condition is unique, and this can only be determined by examining and testing the patient. The adage “assess, don’t guess” is critical in clinical practice. Research supports the importance of individualized assessments in developing effective treatment plans. For instance, a study published in the Journal of Orthopaedic & Sports Physical Therapy found that personalized assessment and tailored interventions significantly improved outcomes for patients with knee pain compared to standardized treatment protocols.

Moreover, taking advice from a friend, teammate, or coach who had a similar problem and following what worked for them can be misleading and potentially harmful. Each individual’s body mechanics, underlying issues, and recovery needs are different. What works for one person might not work for another, and in some cases, it could even exacerbate the condition. A comprehensive study in the British Journal of Sports Medicine emphasized that multifactorial assessment, including hip and foot function, is essential for accurately diagnosing and treating PFPS. This highlights the necessity for professional evaluation and individualized treatment plans.

• Physical Examination of the Knee: During the physical examination, clinicians should perform a thorough examination of the entire knee to determine the symptom-causing tissues. In addition to multiple specific patella tests, clinicians should perform tests such as the patellar glide test, the patellar tilt test, and the Q-angle measurement. The Q-angle, or quadriceps angle, is the angle formed by the line of pull of the quadriceps muscle and the patellar tendon. An increased Q-angle is often associated with lateral patellar tracking and PFPS.
• Vital Additional Examination: From my clinical experience treating thousands of patients with differing knee issues, it is vital to assess the knee in detail but also examine and test for dysfunctions of the hips, pelvis, foot, and ankle, as well as posture. Conservatively, any additional dysfunction will be an important contributing factor to your knee pain; however, on many occasions, they can indeed be the primary underlying reason your patellofemoral pain syndrome developed in the first place. If you only treat the symptomatic area, you may not recover fully. Missing these other dysfunctions is, in my clinical experience, the primary reason traditional care plans fail and lead to surgery. Research has shown that around 70% of knee pain cases have contributing factors from the hip or foot, reinforcing the need for comprehensive assessment. For example, a study published in the Journal of Orthopaedic & Sports Physical Therapy found that hip strengthening significantly reduced knee pain in patients with PFPS, highlighting the interconnectedness of the kinetic chain. Another study in the Clinical Journal of Sport Medicine emphasized the importance of foot and ankle alignment in managing knee pain, demonstrating that orthotic interventions to correct foot posture can lead to substantial improvements in knee function.
• Functional Tests: Functional tests such as gait, bodyweight squats, single-leg squats, step-down tests, flexibility and strength tests, dynamic movement tests, and also recreating sports-specific movements (e.g., rucking position in rugby, guard positions in Jiu jitsu), can help identify abnormal movement patterns and muscular imbalances that contribute to maltracking and pain. These tests assess the patient’s ability to control knee motion during normal functional activities as well as sports specificity, providing insights into the underlying biomechanical issues. According to a review in the Journal of Strength and Conditioning Research, incorporating sport-specific movement assessments can significantly enhance the accuracy of PFPS diagnoses and the effectiveness of subsequent treatment plans.

In summary, individualized assessment is paramount in effectively diagnosing and treating PFPS. Studies show that personalized assessment and treatment plans lead to a 60% faster recovery and a 45% reduction in recurrence rates compared to generalized approaches. By thoroughly examining and testing each patient, clinicians can develop tailored treatment plans that address the unique aspects of their condition, leading to better outcomes and long-term recovery. Listening to non-professionals or using a one-size-fits-all approach based on another person’s experience is not advisable. Professional evaluation and personalized care are essential for achieving optimal recovery and preventing future injuries.

Imaging Studies

Imaging studies are often utilized to visualize the anatomical structures and assess the severity of maltracking. X-rays can reveal patellar alignment and any structural abnormalities, while MRI or CT scans provide detailed images of the soft tissues, including the ligaments, tendons, and cartilage. These imaging modalities in certain instances can help clinicians identify underlying factors contributing to maltracking and plan appropriate interventions.

• Radiographs (X-rays): Standard radiographs can show patellar alignment in various positions, such as the Merchant view, which provides a clear view of the patellofemoral joint. This can help in assessing patellar tilt, displacement, and the depth of the trochlear groove.
• Magnetic Resonance Imaging (MRI): MRI can evaluate soft tissue structures, including the patellar tendon, quadriceps tendon, and articular cartilage. It can also detect signs of chondromalacia patellae, a condition characterized by the softening and deterioration of the cartilage on the underside of the patella, often associated with PFPS.
• Computed Tomography (CT): CT scans can provide a three-dimensional view of the patellofemoral joint, allowing for precise measurement of patellar tilt, displacement, and the morphology of the trochlear groove. This detailed imaging is beneficial for planning surgical interventions in severe cases of maltracking.

Why Imaging is Rarely Needed

In clinical practice, I am often asked by patients if they need an x-ray or some type of scan. In a very small number (less than 5% of cases), I will need to refer for additional imaging; however, this is rare. Despite the insights that imaging studies can provide, they are rarely needed for diagnosing, treating, rehabilitating, and managing PFPS. Here are some reasons why:

• High Effectiveness of Clinical Diagnosis: Clinical examinations and functional tests are often sufficient to diagnose PFPS accurately. A study published in the British Journal of Sports Medicine found that clinical assessment alone can reliably identify PFPS without the need for imaging in most cases.
• Focus on Conservative Treatment: Since the majority of PFPS cases respond well to conservative treatments such as physical therapy, orthotic interventions, and lifestyle modifications, imaging is not typically required to guide these non-invasive approaches. Research shows that 75-90% of patients with PFPS improve significantly with structured exercise programs and physical therapy such as osteopathy.
• Limited Impact on Treatment Outcomes: Imaging studies often do not change the course of treatment for PFPS. According to a review in the Journal of Orthopaedic & Sports Physical Therapy, only a small percentage of patients with PFPS require surgical intervention, and imaging is primarily useful for planning these rare cases.
• Cost and Accessibility: Imaging studies, particularly MRI and CT scans, can be expensive and may not be readily accessible for all patients. Relying on clinical assessments helps reduce unnecessary healthcare costs and avoids delays in starting effective treatment.
• Avoiding Over-Reliance on Imaging: Over-reliance on imaging can sometimes lead to overdiagnosis and overtreatment. For instance, minor abnormalities seen on an MRI might not be clinically significant but could lead to unnecessary concern or interventions. A study in the Journal of Bone and Joint Surgery emphasizes the importance of correlating imaging findings with clinical symptoms and signs.
• Unnecessary Treatment Delays: Long wait times for imaging can delay the start of necessary treatment, which could have been initiated immediately based on clinical assessment. According to a report by the NHS, patients often face significant delays in accessing MRI and CT scans, which can lead to prolonged pain and disability. It’s important to understand that imaging is not treatment, and early intervention with conservative treatments such as osteopathy can begin without the need for imaging, ensuring that patients receive timely care.

In summary, while imaging studies can provide valuable information in a small number of cases, the majority of PFPS cases can be effectively managed through clinical diagnosis and conservative treatment. This approach not only reduces healthcare costs but also focuses on addressing the underlying biomechanical issues, promoting long-term joint health and functional recovery.

Conservative Treatment Measures

Effective management of patellar maltracking and Patellofemoral Pain Syndrome (PFPS) typically begins with conservative, non-invasive measures aimed at reducing pain and inflammation and restoring balance within the knee joint. A study published in the Journal of Orthopaedic & Sports Physical Therapy reported that 75-95% of patients with PFPS improved significantly with structured exercise programs and manual therapy such as osteopathy.

• Hands-On Therapy: Hands-on therapy from medically trained professionals, such as osteopaths, plays a significant role in the conservative and non-invasive management of PFPS. With our patients, we use a range of hands-on techniques such as articulation, joint pumping, soft tissue therapy, and myofascial stretching to improve joint mobility, reduce muscle tension and inflammation, and enhance circulation. These techniques have been shown to help alleviate pain and improve recovery times. Research supports the effectiveness of osteopathy in managing musculoskeletal conditions, including PFPS. For example, a study published in the Journal of Bodywork and Movement Therapies found that osteopathic manipulative treatment significantly improved pain and function in patients with knee pain. Additionally, a review in the International Journal of Osteopathic Medicine highlighted that hands-on therapy could reduce pain and improve quality of life in patients with various musculoskeletal disorders, including PFPS. Statistics indicate that around 75% of patients experience substantial relief from symptoms with hands-on osteopathic treatment alone. When combined with evidence-based, tailored corrective exercise plans, this offers tremendous benefits to knee pain sufferers, including those with arthritis, PFPS, bursitis, ligament, and cartilage injuries.
• Strengthening Exercises: Specific strengthening exercises, which may include the quadriceps, particularly the VMO, are crucial for improving patellar tracking. Strengthening other areas such as the hip abductors and external rotators, like the gluteus medius, is also essential for stabilizing the pelvis and improving lower limb alignment.
• Flexibility Exercises: Stretching shortened, tight structures can help improve overall knee function. Stretching exercises might include quadriceps stretches, hamstring stretches, calf stretches, and specific myofascial techniques. A clinician can provide a targeted stretching program tailored to your needs, as standardized programs are rarely perfect for everyone.
• Proprioceptive and Balance Training: Enhancing proprioception, balance, and neuromuscular control is vital for maintaining knee stability and proper alignment. The knee functions differently depending on whether the ground is stable (righting reflexes) or unstable (tilting reflexes), and how we are moving, such as walking versus rugby tackling or a judo throw. Tailored exercises such as single-leg stands, using balance boards, and performing dynamic movements are examples of ways to help improve proprioception and ensure the knee functions optimally regardless of the activity.

The Dangers of DIY Exercises

It’s important to understand that not all exercise programs are suitable for everyone. In clinical practice, I often see patients attempting exercises they found online or doing the same exercises as their friends or someone they follow on YouTube. This approach can be ineffective or even harmful if the exercises are not appropriate for their specific condition. While online resources can be helpful, they should not replace professional guidance.

I’ve seen many patients who have tried to self-treat their PFPS with exercises they found on the internet, only to exacerbate their condition. Seeking professional advice ensures that you are performing the right exercises in the correct manner for you, reducing the risk of injury and improving the likelihood of a successful recovery. I always advise seeking a professional evaluation to develop a personalized treatment and exercise plan tailored to your individual needs and biomechanics. This personalized approach not only addresses the specific dysfunctions but also promotes long-term recovery and prevention of future problems.

In summary, conservative measures including hands-on therapy, individualized exercise programs, and proprioceptive training are essential for effectively managing PFPS. These approaches not only address the symptoms but also tackle the underlying biomechanical issues, promoting long-term joint health and functional recovery.

Orthotic Interventions

Orthotic interventions such as patellar braces and taping techniques can provide temporary relief by realigning the patella and reducing pain during activities. These interventions may be useful for some during the initial phases of treatment or for managing symptoms during high-impact activities, but for others, they can slow recovery.

• Patellar Braces and Knee Supports: Patellar stabilizing braces, such as J-shaped or donut-shaped braces, provide external support to help maintain proper patellar alignment. These braces can reduce lateral patellar displacement and tilt, thereby decreasing pain. While braces can be beneficial for pain relief, it’s important to recognize that they are a temporary solution. For example, a builder may need to use a knee support to continue working without significant pain, but this does not address the underlying dysfunction. Over-reliance on braces can lead to a false sense of security and may delay proper recovery. Research published in the Work journal highlights that while knee braces can offer short-term pain relief and support, they should be used in conjunction with a comprehensive rehabilitation program to address the root causes of PFPS. Additionally, a study in the Journal of Science and Medicine in Sport found that rugby players using knee braces reported reduced pain but emphasized the need for concurrent rehabilitation to ensure long-term recovery and performance.
• Sports Taping: Patellar taping involves applying adhesive tape to the skin around the patella to guide it into a better position. Taping is currently a popular treatment method, particularly with its range of colours, and sportspeople often feel proud to have it on show. Although for some, taping can provide pain relief and improve patellar tracking (only whilst it is on), for others, it can delay recovery by restricting movement and cause overuse of other areas, leading to secondary injuries. Furthermore I frequently observe people at competitions and matches who have taping applied incorrectly, which offers little to no benefit and only acts as a placebo. Simply put, it helps some and not others. Therefore, it should be used on a case-by-case basis.

Research published in the British Journal of Sports Medicine and Journal of Orthopaedic & Sports Physical Therapy indicates that while taping can be effective for short-term symptom management, it does not replace the need for proper rehabilitation and strengthening. A similar study published in the Journal of Orthopaedic & Sports Physical Therapy found that while patellar taping can reduce pain and improve knee function in the short term, it does not address the underlying issues causing PFPS. Another study in the American Journal of Sports Medicine showed that athletes who relied heavily on taping without following a structured rehabilitation program had a higher incidence of secondary injuries. This suggests that while taping can be part of a comprehensive treatment plan, it should not be the sole method of managing PFPS.

• Competing vs Recovering: The presence of numerous athletes with taped knees on a rugby pitch or in a dojo raises important questions. Should they be playing and competing? From a health and recovery perspective, it is often advisable to be cautious and seek further recovery and more time to develop muscular stability to reduce the risk of a career-ending injury. Balancing the importance of a match or competition vs. risk and recovery is a delicate balance.

The Role of Orthotics in Managing PFPS

Orthotic interventions such a knee braces and sports taping can play a supportive role in managing PFPS, but they are not a cure. Here are some key points to consider:

• Temporary Relief: Orthotics can provide relief from pain, allowing patients to continue their daily activities or sports with reduced discomfort. However, they should be seen as a temporary measure rather than a permanent solution.
• Supporting Rehabilitation: While orthotics can help reduce symptoms, they should be used alongside a structured treatment and rehabilitation program that includes hands-on therapy such as osteopathy and strengthening, flexibility, and proprioceptive exercises to address the underlying biomechanical issues.
• Avoiding Over-Reliance: It’s important not to become overly reliant on supports and taping. These interventions can mask symptoms and lead to a delay in addressing the root causes of PFPS. Professional guidance is essential to ensure that orthotics are used appropriately and effectively.

Patient Education

Educating patients about proper movement techniques and injury prevention strategies is crucial for promoting long-term joint health. This includes guidance on posture, ergonomics, and safe exercise practices to minimize the risk of re-injury. Once patients are pain-free, they often stop doing their exercises and mistakenly assume all is well. It’s important for practitioners to explain the stages of recovery, emphasizing that although they may be pain-free, the underlying dysfunctions, weaknesses, and imbalances often take longer to resolve than the initial pain. Therefore, to ensure a full recovery and prevent further injury, it is vital they continue their exercises and complete their care plan.

• Activity Modification: Advising patients to modify activities that exacerbate their symptoms is essential. This might include avoiding deep knee bends, limiting high-impact activities, and delaying return to sports, matches, or competitions until adequate recovery has been achieved. Research published in the Journal of Orthopaedic & Sports Physical Therapy supports activity modification as a critical component of effective PFPS management, highlighting reduced symptom severity and improved function in patients adhering to modified activity recommendations.
• Posture and Ergonomics: Teaching patients’ proper posture and ergonomic principles can help prevent unnecessary stress on the knees. For instance, advising on correct sitting posture, desk setup, and lifting techniques can reduce strain on the patellofemoral joint. A study in Applied Ergonomics found that ergonomic interventions in the workplace significantly decreased musculoskeletal complaints, including knee pain, among office workers. By incorporating these strategies, patients can minimize undue pressure on their knees during daily activities.
• Phased Return to Sports: As discussed earlier, it is a delicate balance between the risks of returning to activity and sports too early versus sufficient recovery and phased return. Research in the British Journal of Sports Medicine indicates that athletes who adhere to a phased return-to-sport protocol, guided by a healthcare professional, have significantly lower re-injury rates compared to those who rush their return. Having competed myself at a high level, I understand the frustrations that injuries can cause, preventing training and competing at full intensity. However, as a clinician, I have treated thousands of sportsmen and women and have seen first-hand countless incidences of patients disregarding advice and returning too early or at too high an intensity, resulting in disastrous, career-ending injuries. Be sensible; don’t listen to friends or someone online. Follow advice from a practitioner who understands your injury, and you’ll be able to return to sport safely

By providing patients with thorough education on proper movement techniques, posture, ergonomics, and phased return-to-sport strategies, we can help them achieve sustained recovery and minimize the risk of re-injury. This approach not only addresses the immediate symptoms but also promotes long-term joint health and functional recovery.

The Role of Footwear in PFPS

Footwear can play a significant role in the development and management of PFPS. Shoes that provide adequate support and cushioning can help maintain proper foot and lower limb alignment, reducing stress on the patellofemoral joint. Conversely, inappropriate footwear, such as high heels or shoes with poor arch support, can exacerbate patellar maltracking. Recommending appropriate footwear or orthotic devices can be an effective strategy in preventing and managing PFPS.

Pharmacological Management

In cases where pain and inflammation are significant, pharmacological management may be considered. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, have been shown to help reduce pain and inflammation. However, it is important to understand that these medications provide symptom relief rather than addressing the underlying causes of Patellofemoral Pain Syndrome (PFPS).

• Symptom Relief, Not a Cure: NSAIDs can be effective in reducing the pain and inflammation associated with PFPS, but they do not correct the biomechanical dysfunctions or muscular imbalances that contribute to the condition. A study published in the Journal of Orthopaedic & Sports Physical Therapy found that while NSAIDs can alleviate pain, they do not improve functional outcomes in the long term when used alone.
• Potential Side Effects: Prolonged use of NSAIDs can lead to a range of side effects, including gastrointestinal issues, cardiovascular risks, and kidney damage. According to research in the New England Journal of Medicine, long-term NSAID use is associated with an increased risk of gastrointestinal bleeding and cardiovascular events, particularly in individuals with pre-existing conditions.
• Importance of a Comprehensive Approach: Pharmacological management should be used judiciously and in conjunction with other treatment modalities, such as physical therapy and osteopathy, to effectively manage PFPS. These approaches focus on addressing the root causes of the condition, promoting long-term recovery and preventing recurrence. A review in the British Journal of Sports Medicine emphasized that combining NSAIDs with therapeutic exercise and manual therapy leads to better outcomes than relying on medication alone.

In summary, while NSAIDs can play a role in managing the symptoms of PFPS, they should not be viewed as a standalone treatment. Effective management requires a comprehensive approach that includes addressing the underlying biomechanical issues through conservative treatments and lifestyle modifications.

Injections

For patients who do not respond adequately to conservative measures, corticosteroid injections may be considered to reduce inflammation and pain. These injections can provide temporary relief, allowing patients to engage in rehabilitation exercises. However, they should not be the first option for several reasons:

• Potential Adverse Effects: Repeated corticosteroid injections can lead to significant adverse effects on joint tissues, including cartilage degeneration, tendon weakening, and joint infection. A study published in the Journal of Bone and Joint Surgery found that frequent corticosteroid injections can accelerate joint cartilage loss, potentially worsening the condition over time.
• Temporary Relief: While corticosteroid injections can provide immediate pain relief, this effect is usually temporary and does not address the underlying biomechanical issues causing PFPS. According to research in the British Journal of Sports Medicine, the pain relief from corticosteroid injections typically lasts only a few weeks to months, and the underlying dysfunctions remain unaddressed.
• Risk of Overuse: The pain relief provided by injections can lead to overuse of the affected joint, as patients may feel capable of engaging in activities that could further harm the knee. This overreliance on temporary pain relief can delay the implementation of necessary conservative treatments. Clinical guidelines from the American Academy of Orthopaedic Surgeons recommend limiting the use of corticosteroid injections due to these risks.
• Clinical Justification: Conservative treatments, such as physical therapy and osteopathy, focus on addressing the root causes of PFPS, such as muscular imbalances and improper biomechanics. These treatments have been shown to provide longer-term benefits without the risks associated with injections. A systematic review in the Journal of Orthopaedic & Sports Physical Therapy concluded that exercise therapy and manual therapy are more effective in managing PFPS and improving knee function sustainably than corticosteroid injections.

In summary, while corticosteroid injections can be useful in specific cases, they should not be the first line of treatment due to their potential adverse effects and temporary nature. Research and my own clinical experience shows that conservative measures that address the root causes of PFPS provides a more effective and safer approach to long-term recovery.

Surgical Interventions

For severe cases or recurrent patellar dislocations, surgical intervention may be necessary. Procedures such as medial patellofemoral ligament (MPFL) reconstruction, lateral release, or trochleoplasty aim to correct anatomical abnormalities and stabilize the patella. These surgeries are typically followed by a structured rehabilitation program to ensure optimal recovery and functional restoration.

• MPFL Reconstruction: This procedure involves reconstructing the medial patellofemoral ligament using a graft, often harvested from the patient’s hamstring tendons. The reconstructed ligament helps prevent lateral patellar dislocation and improves patellar stability.
• Lateral Release: Lateral release involves cutting the tight lateral retinaculum to reduce lateral pull on the patella. This procedure can help correct lateral patellar tilt and displacement, allowing for better alignment within the trochlear groove.
• Trochleoplasty: Trochleoplasty is a more complex procedure aimed at deepening a shallow trochlear groove to provide better containment for the patella. This surgery is typically reserved for patients with significant trochlear dysplasia and recurrent patellar instability.

Post-Surgical Rehabilitation

Post-surgical rehabilitation is critical for achieving optimal outcomes following patellar stabilization procedures. A structured rehabilitation program focuses on restoring range of motion, rebuilding muscle strength, and improving neuromuscular control. Unfortunately, due to constraints in healthcare, it is not uncommon that patients are not provided with all the stages they require. I frequently need to pick up where the NHS left off and take patients through the remaining stages. The rehabilitation process is typically divided into phases:

Phase 1: Immediate Post-Operative Phase: This phase focuses on pain management, reducing swelling, and protecting the surgical repair. Gentle range of motion exercises and isometric quadriceps contractions are initiated to prevent muscle atrophy. Early motion is crucial to prevent joint stiffness. Studies have shown that early mobilization can lead to better long-term outcomes. For instance, a study published in the Journal of Bone and Joint Surgery found that patients who began early mobilization after knee surgery had significantly improved outcomes compared to those who delayed rehabilitation.

Phase 2: Early Rehabilitation Phase: The emphasis shifts to gradually increasing range of motion, continuing quadriceps strengthening, and beginning weight-bearing activities. Closed kinetic chain exercises, such as mini squats, are introduced to enhance muscle function without putting undue stress on the healing structures. Research in the American Journal of Sports Medicine has highlighted the benefits of early weight-bearing in improving knee function post-surgery. The study noted that patients who began weight-bearing exercises early had a 20% faster recovery in knee function compared to those who delayed these exercises.

Phase 3: Advanced Rehabilitation Phase: This phase involves more vigorous strengthening exercises, proprioceptive training, and functional activities. Plyometric exercises and sport-specific drills may be incorporated for athletes to restore dynamic stability and performance. Proprioceptive training, such as balance exercises, is essential for retraining the neuromuscular system to react appropriately to various stimuli. A study in the Clinical Rehabilitation journal demonstrated that proprioceptive deficits can persist after surgery if not adequately addressed, and incorporating these exercises significantly improved long-term knee stability.

Phase 4: Return to Activity Phase: The final phase aims to prepare the patient for a safe return to full activity. This includes functional exercises for daily life, sport-specific training, proprioception exercises, and continued strength and flexibility work. The goal is to ensure that the patient can perform all necessary activities without pain or instability. Research published in the Journal of Orthopaedic & Sports Physical Therapy found that a structured return-to-sport program can significantly reduce the risk of re-injury, with athletes who followed such programs having a 50% lower re-injury rate compared to those who did not.

Effective post-surgical rehabilitation is a comprehensive process that addresses all aspects of recovery, from initial pain management to full functional restoration. By following a structured program and ensuring that all stages of rehabilitation are completed, patients can achieve optimal outcomes and reduce the risk of future issues.

Conclusion

Understanding Patellofemoral Pain Syndrome (PFPS) and its complexities is crucial for keeping your knees healthy and pain-free. Whether you wish to age gracefully or are fully committed to high-level sports, addressing the various factors that contribute to PFPS with targeted treatments can help ease your symptoms, restore your knee function, and greatly improve your knee health.

From my experience working with thousands of patients, combining hands-on treatment, customized exercise programs, and preventive strategies is highly effective. I hope you have found this guide informative and that it has improved your understanding of knee biomechanics and the many factors involved in Patellofemoral Pain Syndrome.

Take Action: If you’re experiencing knee pain or have been diagnosed with PFPS, consider seeking professional help. Whether you seek treatment from a practitioner near you or decide to work with myself and my team, my goal is to help as many people as possible enjoy and live an active, pain-free life.

Warm regards,

Michael Clark
Registered Osteopath
Rehabilitation and Corrective Exercise Specialist
Co-founder of Clarks Healthcare

For personalized support regarding the issues discussed in this article, or if you wish to reduce pain and enhance your overall health, consider consulting with me or my team at Clarks Healthcare. You can reach us at 01268795705

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Meet Michael Clark, a registered Osteopath, rehabilitation specialist, and holistic lifestyle coach. As the co-founder of Clarks Healthcare in Benfleet, Essex, Michael, alongside Lisa and their dedicated team, has guided over 8,000 patients towards pain relief and improved health over the past 20 years.

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