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Patellofemoral Pain Syndrome

From WikiSM

Other Names

  • Patellofemoral Pain Syndrome (PFPS)
  • Patellofemoral Pain (PFP)
  • Anterior knee pain
  • Idiopathic knee pain
  • Runners Knee
  • Patellofemoral Pain
  • Patellofemoral Syndrome
  • Anterior Knee Pain Syndrome
  • Runner’s Knee
  • Chondromalacia Patellae
  • Patellar Maltracking Syndrome
  • Retropatellar Pain Syndrome

Background

  • This page refers to patellofemoral pain, a spectrum of anterior knee pain originating at the Patellofemoral Joint

History

  • Aleksandr Alekseevich Shkarovsky provided one of the earliest descriptions of anterior knee pain related to patellar cartilage softening (chondromalacia), helping establish the structural basis for patellofemoral pain (1928)[1]
  • In 1957, James W. Smillie popularized the term chondromalacia patellae and linked anterior knee pain to patellar cartilage degeneration, shaping mid-20th century understanding of PF pain.[2]
  • In 1990, David S. Fulkerson advanced the concept of patellofemoral pain syndrome as a multifactorial condition (maltracking, overuse, biomechanical factors), moving beyond purely cartilage-based explanations[3]

Epidemiology

  • PFPS is the most common cause of knee pain in individuals under the age of 50[4]
    • 2 to 10 times more common in women than men[5]
    • Most common cause of anterior knee pain in pediatric, adolescent patients[6]
  • Prevalence
    • Reported as high as 25% in sports[7]
    • Up to 43% in military trainees (need citation)
    • 11-17% of patients who present to general practitioners[8]
    • 30% of adolescents will develop PFPS[9]
  • Incidence
    • 22 per 1000 person years among naval academy recruits[10]
  • Sports
    • Among adolescent basketball players: overall prevalence is 25%, with ~26% of female and 18% of male players affected[11]

Introduction

General illustration of the typical pain distribution in patients with patellofemoral pain
Pathophysiology of patellofemoral pain[12]
Basic illustration of the extensor mechanism of the knee[13]
Superior view of the knee joint with pathologic mediopatellar plica[14]
Hoffa Fat Pad Syndrome

General

  • Patellofemoral Pain Syndrome (PFPS) is a common cause of anterior knee pain resulting from irritation of the patellofemoral joint
  • It is most commonly seen in young women, athletes and runners without any structural or pathological changes to the articular cartilage
  • Characteristically, it is worse with squatting, running, stair use, or prolonged sitting (“theater sign”).
  • The underlying etiology is often considered to be multifactorial
  • Treatment is primarily non-operative including activity modification, physical therapy, correction of biomechanical contributors

Etiology

  • Patellar Tracking/ Malalignment
    • Patella maltracking has long been implicated as a cause
    • Witvrou et al: hypermobile patella had a significant correlation with the incidence of PFPS[15]
    • Draper et al: patients with PFPS squat with increased lateralization, increased lateral tilt of patella[16]
  • Vastus Lateralis and Vastus Medialis (VMO)
    • Cowan et al demonstrated by EMG delayed onset of VMO activation relative to vastus lateralis[17]
    • Patients with PFP tend to exhibit atrophy of the VMO as well[18]
  • Quadriceps Dysfunction
    • Several studies have shown that quadriceps muscle size, strength, and force are impaired in patients with patellofemoral OA[19]
  • Dynamic Valgus/ Q angle
    • The role of the Q-angle as a cause or predictor of PFPS is controversial
    • Some authors have demonstrated a relationship between the Q-angle and development of PFPS[20]
    • Other authors have not recreated that relationship[21]
    • Likely related to dynamic or functional malalignment than a structural problem
    • Multiple studies have demonstrated increased knee abduction, dynamic valgus stressors on the knee joint in PFPS among athletes[22]
  • Hip Stability, abductor strength
    • Multiple studies have shown weakness of hip external rotators, abductors lead to functional malalignment at the patellofemoral joint
    • Prins et al systematic review: strong evidence that females with PFPS have a decreased hip abduction, external rotation and extension strength[23]
    • Note that this is in female athletes, the evidence for male athletes is not strong
  • Disorders of the foot
    • Barton et al: PFPS associated with delayed timing of peak rear-foot eversion, increased rear-foot eversion at heel strike and reduced rear-foot eversion range[24]
    • Early rear-foot eversion appears to increase risk of developing PFPS[25]
    • Abnormalties with navicular bone, such as increased navicular drop, navicular drift and dorsiflexion also seem to contribute[26]
  • Hamstring imbalance, tightness
    • Several studies have identified a significant association between PFPS, hamstring tightness[27]
    • Besier et al: patients with PFPS have greater co-contraction of the quadriceps and hamstrings compared to controls[28]
  • Iliotibial Band
    • The IT band may have an influence on patellar tracking[29]
    • Kaplans fibers connect the IT band to the patella
  • "Knee-Spine Syndrome"
    • Significant difference in sacral inclination between subjects with and without anterior knee pain[30]
    • Otherwise not well described or understood
  • Psychological factors
    • Jensen et al: patients with PFPS have higher level of mental distress compared to healthy controls[31]
    • Coping mechanism of patients with PFPS similar to other groups of patients with chronic pain, PFPS more likely to catastrophize their pain[32]
    • Fear avoidance belief about physical activity associated with pain, function in PFPS patients[33]
    • Domenech et al: high incidence of psychological distress such as anxiety and depression[34]
  • Triggers for PFPS
    • Overload of the patellofemoral joint (e.g. highintensity training)
    • Dynamic valgus and functional lateralization of the patella may lead to overuse
  • Neurological etiology of pain in patients with PFPS
    • Most pain probably develops in the insertions of the extensor mechanism or within the subchondral bone
    • Increased expression of neurofilament protein, S-100 protein, neural growth factor and substance P in the lateral retinacula of PFPS[35]
    • Draper demonstrated increased metabolic bone activity in patients with PFPS using PET/CT[16]
  • Implicated pain sources
    • The medial retinaculum and MPFL[36]
    • Patellar compression of subchondral bone[37]
    • Fat pad

Causes

  • Overuse
    • Including tendinitis, insertional tendonosis
  • Patellar instability
  • Osteochondral damage
  • Trauma

Associated Conditions

Anatomy of the patellofemoral mechanism[38]

Anatomy of the Anterior Knee

  • Knee Extensor Mechanism
  • Patellofemoral Joint
    • Characterized by the articulation of the patella within the condylar groove of the femur
    • Stabilized by the medial and lateral retinaculae
  • Patella
    • Functions as a lever, increasing the moment arm of the extensor mechanism[39]
    • Acts as a pulley, controlling the direction of the quadriceps
    • Articular cartilage, which is the thickest in the body, provides a smooth sliding surface with the femoral trochlea[40]
    • Acts as a shock absorber

Risk Factors

  • Non-modifiable
    • Female gender
    • Poor shock absorption (i.e. footwear, surface, muscles)
  • Sports
    • Running, Jumping sports
    • Endurance athletes
    • Basketball
    • Soccer
    • Lacrosse
  • Training
    • Training errors or overuse
    • Increased running mileage
    • Increased jumping
  • Muscular
    • Weak knee extension strength, especially VMO[41]
    • Weak hip abduction strength[42]
    • Weak hip external rotation strength
    • Poor flexibility of quadriceps, hamstring, iliotibial band
    • Poor core muscle endurance[43]
    • Foot pronation
  • Biomechanical/ Anatomic
  • Other
    • Trauma
  • Not associated
    • Foot arch height index[44]

Differential Diagnosis

Differential Diagnosis Knee Pain

Clinical Features

Clinical demonstration of the patellar grind test
Demonstration of the moving patella apprehension test[49]
Illustration of the patellar glide test with corresponding scoring

History

  • Pain is universally anterior
  • They may describe it as “behind,” “underneath,” or “around” the patella
  • Patients may have trouble localizing the pain
  • Usually insidious, but can be acute in nature
  • Pain is typically worse after prolonged sitting, squatting, kneeling, and stair climbing[50]
  • Patients often report clicking, popping, snapping and cracking
  • May report buckling, which is typically transient inhibition of quadriceps due to pain or deconditioning[51]
  • Theatre sign: Pain in the patellofemoral joint after prolonged period of sitting with knee flexed
  • Pain is often bilateral

Physical Exam: Physical Exam Knee

  • Absence of joint effusion; if present consider other etiology
  • Patellar J Sign: lateral tracking of patella shifts medially as knee brought into flexion
  • Compare quadriceps muscle tone, bulk of VMO to contralateral limb
  • Carefully evaluate patellar alignment
    • Evaluate for patella alta/baja, trochlear dysplasia, femoral anteversion, genu valgus, and laterally displaced tibial tuberosity[52]
  • On palpation
    • Crepitus may be present
    • Pain may be retro-patellar or peri-patellar
  • Palpate medial/lateral and superior/inferior patellar poles
  • May be ttp to medial or lateral retinaculum
  • May be ttp medial or lateral facets
  • Additionally, carefully evaluate the back and hip for referred pain

Special Tests

Evaluation

The normal radiograph (b, grade 0) is contrasted to grade1, grade2, and grade 3 abnormal radiographic features (a) on the skyline view of the patellofemoral joint. Abbreviations. LJSN: lateral joint space narrowing; MJSN: medial joint space narrowing; LPOST: lateral patellofemoral osteophyte; MPOST: medial patellofemoral osteophyte.[54]
(a) Patella alta. Sagittal T2 Fat Sat image in a 20 year old female complaining of knee pain with an Insal-Salvati ratio of 1.7. (b) Patella baja. Sagittal T2 Fat Sat image in a 32 year old male complaining of knee pain with an Insal-Salvati ratio of 0.7.[55]

General

  • Diagnosis is primarily clinical and imaging is not generally required to make the diagnosis

Radiographs

Ultrasound

  • Can be used to evaluate extensor mechanism
  • Findings associated with PFPS[56]
    • Intraarticular effusion (uncommon)
    • Quadriceps tendon thickness ≥ 0.54 cm
    • Patellar tendon thickness ≥ 0.35 cm
    • Gluteus medius thickness asymmetry during contraction
    • Small vastus medialis volume, insertion level, and fiber angle

MRI

  • Not routinely indicated in the diagnosis of PFPS
  • May be helpful to evaluate for:
    • Malalignment
    • Trochlear dysplasia
    • Patella tilt
    • Articular chondral injuries
  • Potential findings
    • Enlarged fat pad
    • Subchondral bone edema

CT

  • Not required to make diagnosis
  • May be useful to quantify bone quality
  • Can be used to evaluate TT–TG distance

Classification

Proposed clinical classification[57]

  • Patellofemoral instability, ie., subluxation or dislocation
  • Patellofemoral pain with malalignment but no episodes of instability
  • Patellofemoral pain without malalignment

Management

Illustration of some basic rehab movements for patellofemoral pain[58]

Nonoperative

  • Indications
    • Vast majority of cases
  • General goals
    • Reduce total patellofemoral compressive forces
    • Alter the distribution of stress forces on the patella
  • Relative rest and activity modification
    • Patients may need to temporarily discontinue offending activity
    • They may need to alter their sport or training habits
    • This could include avoiding/ limiting stairs, running, jumping, squats
  • Physical Therapy
    • Quadriceps strengthening is the gold standard treatment[59]
    • Increased quadricep strength has been show to reduce PFPS pain[60]
    • Bolga et al systematic review: Targeting hip abductors, external rotators generated a modest reduction in pain[61]
    • Harvie et al: 2008 meta-analysis showed positive effects on pain reduction[62]
    • Exercises should address hip muscles, trunk stability, quadriceps, hamstrings and the iliotibial tract

Pharmacotherapy

  • NSAIDS
    • A Cochrane review found limited evidence for the effectiveness of short term pain reduction in PFPS[63]
  • Topical NSAIDS
    • Cochrane review found topical NSAIDS are as effective as oral NSAIDS for chronic musculoskeletal pain[64]
  • Vitamin D
    • Anecdotal evidence that patients with PFPS have low vitamin D and osteopenia by DEXA[65]
    • It is unknown whether supplementation with vitamin D is beneficial

Bracing and Taping

  • Patellar Taping or McConnel Taping
    • Goal: modify patella tracking with adhesive tape, typically a medially directed force
    • When combined with physical therapy and daily home exercises, patellar taping was superior to the control group[66]
    • Warden et al: 2008 meta-analysis showed functional improvement, decreaesed pain when combined with exercise[67]
  • Patellar Brace
    • Goal: apply an external, medially directed force to counteract patella maltracking
    • Lun et al found patellar bracing non-superior to home exercise program with or without a patellar brace or knee sleeve[68]
    • D’hondt et al: 2002 meta-analysis showed patellar brace had positive effects on pain, function, patellofemoral congruence angle[69]
    • Overall, literature is weak and better designed studies are needed.
  • Knee Brace
    • Standard hinged knee brace
  • Foot Orthosis
    • Goal: insoles could improve rear-foot eversion or pes pronatus
    • Collins et al reported moderate improvement in pain in patients who used a corrective orthosis and participated in physical therapy[70]
    • Other studies have shown mixed results
    • Overall, literature is weak for PFPS and better designed studies are needed

Other Modalities

Procedures

  • Knee Joint Injection
    • Evidence supporting benefit from intra-articular injections for PFPS is lacking in the literature
    • Unclear if corticosteroids provide any benefit
  • Botulinum toxin injection
    • Proposed for vastus lateralis to improve balance between VM and VL, improving patellar tracking
    • One study showed benefit from a single injection when combined with physical therapy[75]

Operative

  • Indications
    • Unknown
    • Likely reserved for refractory cases
  • Technique
    • Arthroscopy
    • Percutaneous
    • Lateral reticular release
    • MPFL repair or reconstruction
    • Anteromedialization of the tibial tubercle
  • Research
    • Kettunen compared arthroscopy plus exercise to exercise alone in patients with chronic PFPS and found no difference[76]

Rehab and Return to Play

Patellofemoral pain rehab exercises
Patellofemoral pain syndrome rehab
PFPS Return to play

General Rehabilitation Approach

  • Emphasize quadriceps strengthening (particularly the vastus medialis obliquus) to improve patellar tracking and reduce joint stress, which is a cornerstone of PFPS rehabilitation.[77]
  • Incorporate hip abductor and external rotator strengthening, as proximal muscle weakness is strongly associated with dynamic valgus and patellofemoral joint overload[78]
  • Utilize activity modification and load management, reducing aggravating activities (e.g., deep squats, excessive running) while maintaining pain-free movement to allow gradual recovery.[79]
  • Add patellar taping or bracing as adjuncts to improve short-term pain and facilitate participation in rehabilitation exercises.[80]
  • Progress to functional and sport-specific training, including neuromuscular control, gait retraining, and gradual return to activity to prevent recurrence[81]

Phase 1: Initial Evaluation and Treatment Planning

  • Objectives:
    • Establish accurate diagnosis through condition-specific history, physical exam, and appropriate imaging/testing
    • Assess baseline physical and psychological status
    • Develop an individualized treatment plan
    • Set realistic goals and timeline with the athlete and care team
  • Key Actions:
    • Perform comprehensive evaluation including psychosocial assessment
    • Determine pre-injury performance level and training norms
    • Initiate medical therapies (medications, injections, procedures as indicated)
    • Begin early rehabilitation focused on pain control and tissue protection
    • Establish communication with athlete, family, athletic trainers, PTs, and coaches

Phase 2: Early Rehabilitation (Return to Participation)

  • Objectives:
    • Promote anatomical and physiological healing
    • Restore basic function
    • Maintain cardiovascular fitness
    • Address psychological response to injury
  • Progression Criteria:
    • Pain-free or minimal pain with ADLs
    • Appropriate tissue healing for injury timeline
    • Improving range of motion
    • Minimal swelling/inflammation
  • Key Activities:
    • Protected range of motion exercises
    • Gentle strengthening (isometric → isotonic)
    • Cardiovascular conditioning (non-impact as tolerated)
    • Optimize nutrition, hydration, and energy balance
    • Address fear of reinjury and psychological readiness

Phase 3: Intermediate Rehabilitation (Functional Restoration)

  • Objectives:
    • Restore full range of motion
  • Achieve strength symmetry (>85–90% of contralateral side)
    • Improve proprioception and motor control
    • Progress toward sport-specific movement
  • Progression Criteria:
    • Full, pain-free ROM
    • Strength deficit ≤10–15% vs contralateral side
    • No pain with functional activities
    • Adequate neuromuscular control
  • Key Activities:
    • Progressive resistance training
    • Plyometrics (when appropriate)
    • Balance and proprioceptive training
    • Sport-specific drills at reduced intensity
    • Gradual increase in training load

Phase 4: Advanced Rehabilitation (Return to Sport)

  • Objectives:
    • Restore sport-specific skills and performance
    • Achieve full strength, power, and endurance
    • Complete sport-specific testing
    • Ensure psychological readiness
  • Progression Criteria:
    • Completion of at least one full team training session without symptoms
    • Strength symmetry >90–95%
    • Successful sport-specific functional testing
    • Athlete reports confidence and readiness
    • Adequate biological healing time
  • Key Activities:
    • High-intensity sport-specific training
    • Position-specific drills at full intensity
    • Simulated game situations
    • Return to practice (non-contact → contact as appropriate)

Phase 5: Return to Performance

  • Objectives:
    • Return to pre-injury performance level
    • Minimize reinjury risk
    • Monitor ongoing recovery
  • Progression Criteria:
    • Completion of full practice without restrictions
    • Medical clearance from team physician
    • Compliance with bracing/equipment modifications
    • Demonstrated readiness across all domains
  • Key Activities:
    • Gradual return to competition
    • Ongoing monitoring and reassessment
    • Continued strength and conditioning program
    • Address residual deficits

Return to Play

  • The athlete can return to sport when the following criteria are met[82]
    • Anatomical and functional healing: Adequate tissue healing based on injury type and timeline
    • Pain-free performance: No pain during sport-specific activities
    • Range of motion: Full, pain-free ROM compared to uninjured side
    • Strength: Limb symmetry index >90% for most injuries
    • Functional testing: Successful completion of sport-specific tests
    • Psychological readiness: Confidence, absence of fear of reinjury, mental preparedness
    • Safety to others: Athlete poses no undue risk to other participants
    • Regulatory compliance: Meets all applicable rules and regulations

Ongoing Monitoring

  • Frequent reassessment throughout rehabilitation process
  • Modify goals and timeline based on progress
  • Consider biological healing time, not just functional recovery
  • Balance risk of premature return (reinjury) vs delayed return (deconditioning, psychological distress)
  • Utilize shared decision-making with athlete when appropriate
  • Document all evaluations, treatments, and progression

Complications and Prognosis

Prognosis

  • Kannus et al studied chronic PFPS over 7 years[83]
    • 2/3 of patients had complete recovery at 7 years
    • Approximately 30% of the non-recovery PFPS patients had persistent complaints
  • Predictor of poor long term prognosis[84]
    • PFP > 2 months duration
    • Anterior knee pain score < 70
    • Higher levels of usual/resting
    • High worst/activity-related pain

Complications

  • Knee Osteoarthritis
    • Proposed, although not well described, that PFPS increases likelihood of developing patellofemoral OA[85]
  • Patellofemoral Arthritis
  • Inability to return to sport
    • Up to 25% of recreational athletes diagnosed with PFP will stop participating in sports because of knee pain[86]
  • Premature return to play[87]
    • Reinjury risk remains elevated for weeks to months after return
    • The highest risk occurring in the first week back
    • Athletes face a 9.4% risk of time-loss reinjury in the first week after return to play

See Also

Internal

External

References

  1. ↑ Shkarovsky AA. “On softening of the articular cartilage of the patella.” 1928.
  2. ↑ Smillie IS. Injuries of the Knee Joint. 2nd ed. Edinburgh: E&S Livingstone; 1957.
  3. ↑ Fulkerson JP. “Diagnosis and treatment of patients with patellofemoral pain.” Am J Sports Med. 1990.
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  8. ↑ Crossley KM, van Middelkoop M, Callaghan MJ, et al. Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions) Br J Sports Med. 2016;50(14):844–852
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  26. ↑ Mølgaard M (2011) Patellofemoral pain syndrome and its association with hip, ankle, and foot function in 16- to 18-year-old high school students: a single-blind case-control study. J Am Podiatr Med Assoc 101(3):215–222
  27. ↑ White LC, Dolphin P, Dixon J (2009) Hamstring length in patellofemoral pain syndrome. Physiotherapy 95(1):24–28
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  29. ↑ Wu CC, Shih CH (2004) The influence of iliotibial tract on patellar tracking. Orthopedics 27(2):199–203
  30. ↑ Tsuji T, Matsuyama Y, Goto M, Yimin Y, Sato K, Hasegawa Y, Ishiguro N (2002) Knee-spine syndrome: correlation between sacral inclination and patellofemoral joint pain. J Orthop Sci 7(5):519–523
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  34. ↑ Domenech J, Sanchis-Alfonso V, Lo´pez L, Espejo B (2013) Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients. Knee Surg Sports Traumatol Arthrosc 21(7):1562–1568
  35. ↑ Sanchis-Alfonso V, Rosello´-Sastre E (2000) Immunohistochemical analysis for neural markers of the lateral retinaculum in patients with isolated symptomatic patellofemoral malalignment. A neuroanatomic basis for anterior knee pain in the active young patient. Am J Sports Med 28(5):725–731
  36. ↑ Luhmann, Scott J., et al. "Adolescent patellofemoral pain: implicating the medial patellofemoral ligament as the main pain generator." Journal of children's orthopaedics 2.4 (2008): 269-277.
  37. ↑ Graf, J., et al. "Chondromalacia patellae und intraossärer Druck." Zeitschrift für Orthopädie und ihre Grenzgebiete 130.06 (1992): 495-500.
  38. ↑ musculoskeletalkey.com
  39. ↑ Grelsamer, Ronald P., and John R. Klein. "The biomechanics of the patellofemoral joint." Journal of Orthopaedic & Sports Physical Therapy 28.5 (1998): 286-298.
  40. ↑ Eckstein, Felix, Magdalena Müller-Gerbl, and Reinhard Putz. "Distribution of subchondral bone density and cartilage thickness in the human patella." Journal of anatomy 180.Pt 3 (1992): 425.
  41. ↑ Lankhorst, Nienke E., Sita MA Bierma-Zeinstra, and Marienke van Middelkoop. "Risk factors for patellofemoral pain syndrome: a systematic review." journal of orthopaedic & sports physical therapy 42.2 (2012): 81-94.
  42. ↑ Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2007;37(5):232–238
  43. ↑ Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. J Athl Train. 2015;50(4):366–377.
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