Patellofemoral Pain Syndrome

Anterior knee pain from the patellofemoral joint with no other identifiable pathology. A clinical diagnosis of exclusion.

Mechanism and risk

Repetitive patellofemoral loading, often after a sudden rise in training load. The modern view is a load-tolerance and pain-sensitisation problem, not purely a tracking problem.

Sports: running (especially downhill), cycling, basketball, volleyball, football, netball, skiing
Who: adolescents in growth spurts, women

Modifiable	Non-modifiable	Biomechanical
Quadriceps and hip abductor weakness, load spikes, poor recovery, footwear	Female sex, growth phase, patella alta, previous knee injury	Hip adduction and internal rotation, dynamic valgus, rearfoot eversion

Pain catastrophising and anxiety predict worse outcomes. Screen for them.

Presentation

Diffuse pain around or behind the patella
Worse with squatting, stairs (especially descending), running
Theatre sign: pain when sitting with knees flexed
Pain on patellar compression, crepitus (common, non-specific)
No significant effusion or instability. If present, look elsewhere.

Exclude

patellar tendinopathy, patellofemoral instability, meniscal tear, fat pad impingement, plica, osteochondral lesion, Osgood-Schlatter.

Management

Exercise therapy, combined hip and knee strengthening. First-line and the cornerstone. Knee-only programmes are inferior.
Load management. No programme works without it.
Gait retraining in runners (strong emerging evidence).
Taping or bracing: short-term relief to enable exercise, an adjunct only.
Foot orthoses: modest benefit if excessive pronation.

Avoid

corticosteroid injection (short-term relief, worse outcomes at 1 year), arthroscopy, lateral release. Isolated VMO training and taping as a cure have weak evidence. Surgery is rarely needed.

Prognosis

Be honest with patients: up to 50% still report symptoms at 1 to 5 years. Early active, exercise-based management improves this. Passive treatments do not.

References

Willy et al., J Orthop Sports Phys Ther 2019, doi:10.2519/jospt.2019.0302
Barton & Crossley, Best Pract Res Clin Rheumatol 2019, doi:10.1016/j.berh.2019.02.004

Medical disclaimer: this article is general information, not personal medical advice. Always consult a qualified doctor about your own situation.