Patellofemoral Pain
Publication Date: August 31, 2019
Last Updated: March 14, 2022
Summary of Recommendations
DIAGNOSIS
Clinicians should use reproduction of retropatellar or peripatellar pain during squatting as a diagnostic test for patellofemoral pain (PFP). Clinicians should also use performance of other functional activities that load the patellofemoral joint (PFJ) in a flexed position, such as stair climbing or descent, as diagnostic tests for PFP. (A)
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Clinicians should make the diagnosis of PFP using the following criteria: (1) the presence of retropatellar or peripatellar pain, (2) reproduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position, and (3) exclusion of all other conditions that may cause anterior knee pain, including tibiofemoral pathologies. (B)
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Clinicians may use the patellar tilt test with the presence of hypomobility to support the diagnosis of PFP. (C)
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CLASSIFICATION
Given the absence of a previously established valid classification system for PFP, the clinical practice guideline group proposes a classification consisting of 4 subcategories associated with the International Classification of Functioning, Disability and Health. The proposed classification system is based on published evidence. The subcategories are named according to predominant impairments previously documented in people with PFP. Clinicians may consider using the proposed impairment/function-based PFP classification system to guide patient/ client management. (F)
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PFP IMPAIRMENT/FUNCTION-BASED CLASSIFICATION SUBCATEGORIES
1. Overuse/overload without other impairment: a subcategory of individuals with PFP may have pain primarily due to overuse/ overload. Classification into the overuse/overload without other impairment subcategory is made with a fair level of certainty when the patient presents with a history suggesting an increase in magnitude and/or frequency of PFJ loading at a rate that surpasses the ability of his or her PFJ tissues to recover.
2. Muscle performance deficits: a subcategory of individuals with PFP may respond favorably to hip and knee resistance exercises. Classification into the muscle performance deficits subcategory is made with a fair level of certainty when the patient presents with lower extremity muscle performance deficits in the hip and quadriceps.
3. Movement coordination deficits: a subcategory of individuals with PFP may respond favorably to gait retraining and movement re-education interventions leading to improvements in lower extremity kinematics and pain, suggesting the importance of assessing dynamic knee valgus during movement. The diagnosis of PFP with movement coordination deficits is made with a fair level of certainty when the patient presents with excessive or poorly controlled knee valgus during a dynamic task, but not necessarily due to weakness of the lower extremity musculature.
4. Mobility impairments: a subcategory of individuals with PFP may have impairments related to either hypermobile or hypomobile structures. The diagnosis of PFP with mobility deficits is made with a fair level of certainty when the patient presents with higher than normal foot mobility and/ or flexibility deficits of 1 or more of the following structures: hamstrings, quadriceps, gastrocnemius, soleus, lateral retinaculum, or iliotibial band. (-)
2. Muscle performance deficits: a subcategory of individuals with PFP may respond favorably to hip and knee resistance exercises. Classification into the muscle performance deficits subcategory is made with a fair level of certainty when the patient presents with lower extremity muscle performance deficits in the hip and quadriceps.
3. Movement coordination deficits: a subcategory of individuals with PFP may respond favorably to gait retraining and movement re-education interventions leading to improvements in lower extremity kinematics and pain, suggesting the importance of assessing dynamic knee valgus during movement. The diagnosis of PFP with movement coordination deficits is made with a fair level of certainty when the patient presents with excessive or poorly controlled knee valgus during a dynamic task, but not necessarily due to weakness of the lower extremity musculature.
4. Mobility impairments: a subcategory of individuals with PFP may have impairments related to either hypermobile or hypomobile structures. The diagnosis of PFP with mobility deficits is made with a fair level of certainty when the patient presents with higher than normal foot mobility and/ or flexibility deficits of 1 or more of the following structures: hamstrings, quadriceps, gastrocnemius, soleus, lateral retinaculum, or iliotibial band. (-)
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EXAMINATION – OUTCOME MEASURES: ACTIVITY LIMITATIONS/SELF-REPORT MEASURES
Clinicians should use the Anterior Knee Pain Scale (AKPS), the patellofemoral pain and osteoarthritis subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS-PF), or the visual analog scale (VAS) for activity or Eng and Pierrynowski Questionnaire (EPQ) to measure pain and function in patients with PFP. In addition, clinicians should use the VAS for worst pain, VAS for usual pain, or the numeric pain-rating scale (NPRS) to measure pain. Clinicians should use one of the translations and cross-cultural adaptations with demonstrated validity, reliability, and responsiveness to change for patients in different countries and for those requiring questionnaires in languages other than English. (A)
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EXAMINATION – ACTIVITY LIMITATIONS/ PHYSICAL PERFORMANCE MEASURES
Clinicians should administer appropriate clinical or field tests that reproduce pain and assess lower-limb movement coordination, such as squatting, step-downs, and single-leg squats. These tests can assess a patient’s baseline status relative to pain, function, and disability; global knee function; and changes in status throughout the course of treatment. (B)
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EXAMINATION – ACTIVITY LIMITATIONS/ PHYSICAL IMPAIRMENT MEASURES
When evaluating a patient with PFP over an episode of care, clinicians may assess body structure and function, including measures of patellar provocation, patellar mobility, foot position, hip and thigh muscle strength, and muscle length. (C)
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INTERVENTIONS – SPECIFIC MODES OF EXERCISE THERAPY
Clinicians should include exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve patient-reported outcomes and functional performance in the short, medium, and long term. Hip-targeted exercise therapy should target the posterolateral hip musculature. Knee-targeted exercise therapy includes either weight-bearing (resisted squats) or non–weight-bearing (resisted knee extension) exercise, as both exercise techniques target the knee musculature. Preference to hip-targeted exercise over knee-targeted exercise may be given in the early stages of treatment of PFP. Overall, the combination of hip- and knee-targeted exercises is preferred over solely knee-targeted exercises to optimize outcomes in patients with PFP. (A)
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INTERVENTIONS – PATELLAR TAPING
Clinicians may use tailored patellar taping in combination with exercise therapy to assist in immediate pain reduction, and to enhance outcomes of exercise therapy in the short term (4 weeks). Importantly, taping techniques may not be beneficial in the longer term or when added to more intensive physical therapy. Taping applied with the aim of enhancing muscle function is not recommended. (B)
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INTERVENTIONS – PATELLOFEMORAL KNEE ORTHOSES (BRACING)
Clinicians should not prescribe patellofemoral knee orthoses, including braces, sleeves, or straps, for patients with PFP. (B)
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INTERVENTIONS – FOOT ORTHOSES
Clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only in the short term (up to 6 weeks). If prescribed, foot orthoses should be combined with an exercise therapy program. There is insufficient evidence to recommend custom foot orthoses over prefabricated foot orthoses. (A)
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INTERVENTIONS – BIOFEEDBACK
Clinicians should not use electromyography-based biofeedback on medial vastii activity to augment knee-targeted (quadriceps) exercise therapy for the treatment of PFP. (B)
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Clinicians should not use visual biofeedback on lower extremity alignment during hip- and knee-targeted exercises for the treatment of patients with PFP. (B)
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INTERVENTIONS – RUNNING GAIT RETRAINING
Clinicians may use gait retraining consisting of multiple sessions of cuing to adopt a forefoot-strike pattern (for rearfoot-strike runners), cuing to increase running cadence, or cuing to reduce peak hip adduction while running for runners with PFP. (C)
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INTERVENTIONS – BLOOD FLOW RESTRICTION TRAINING PLUS HIGH-REPETITION KNEETARGETED EXERCISE THERAPY
Clinicians may use blood flow restriction plus high-repetition knee exercise therapy, while monitoring for adverse events, for those with limiting painful resisted knee extension. (F)
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INTERVENTIONS – NEEDLING THERAPIES
Clinicians should not use dry needling for the treatment of patients with PFP. (A)
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Clinicians may use acupuncture to reduce pain in patients with PFP. However, caution should be exercised with this recommendation, as the superiority of acupuncture over placebo or sham treatments is unknown. This recommendation should only be incorporated in settings where acupuncture is within the scope of practice of physical therapy. (C)
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INTERVENTIONS – MANUAL THERAPY AS A STAND-ALONE TREATMENT
Clinicians should not use manual therapy, including lumbar, knee, or patellofemoral manipulation/mobilization, in isolation for patients with PFP. (A)
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INTERVENTIONS – BIOPHYSICAL AGENTS
Clinicians should not use biophysical agents, including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, and therapeutic laser, for the treatment of patients with PFP. (B)
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INTERVENTIONS – PATIENT EDUCATION
Clinicians may include specific patient education on load management, body-weight management when appropriate, the importance of adherence to active treatments like exercise therapy, biomechanics that may contribute to relative overload of the PFJ, the evidence for various treatment options, and kinesiophobia. Patient education may improve compliance and adherence to active management and self-management strategies, and is unlikely to have adverse effects. (F)
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INTERVENTIONS – COMBINED INTERVENTIONS
Clinicians should combine physical therapy interventions for the treatment of patients with PFP, which results in superior outcomes compared with no treatment, flat shoe inserts, or foot orthoses alone in the short and medium term. Exercise therapy is the critical component and should be the focus in any combined intervention approach. Interventions to consider combining with exercise therapy include foot orthoses, patellar taping, patellar mobilizations, and lower-limb stretching. (A)
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Recommendation Grading
Overview
Title
Patellofemoral Pain
Authoring Organization
American Physical Therapy Association
Publication Month/Year
August 31, 2019
Last Updated Month/Year
January 31, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Describe evidence-based physical therapy practice, including diagnosis, prognosis, intervention, and assessment of outcome, for musculoskeletal disorders commonly managed by orthopaedic physical therapists. Classify and define common musculoskeletal conditions using the World Health Organization's terminology related to impairments of body function and body structure, activity limitations, and participation restrictions. Identify interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions associated with common musculoskeletal conditions. Identify appropriate outcome measures to assess changes resulting from physical therapy interventions in body function and structure as well as in activity and participation of the individual. Provide a description to policy makers, using internationally accepted terminology, of the practice of orthopaedic physical therapists. Provide information for payers and claims reviewers regarding the practice of orthopaedic physical therapy for common musculoskeletal conditions. Create a reference publication for orthopaedic physical therapy clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regarding the best current practice of orthopaedic physical therapy
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Home health, Hospital, Long term care, Outpatient, Radiology services
Intended Users
Physical therapist, occupational therapist, athletics coaching, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Rehabilitation, Management, Treatment
Diseases/Conditions (MeSH)
D007718 - Knee Injuries, D057071 - Patellofemoral Joint, D046788 - Patellofemoral Pain Syndrome, D007717 - Knee
Keywords
knee pain, patellofemoral pain, knee cap pain, acute knee pain