Patellofemoral Pain Syndrome, also known as PFPS, is a common knee injury which classically presents as insidious onset of poorly defined pain, localized to the anterior (front of your knee) retropatellar (behind the knee cap), and/or below the patella. Onset of symptoms can be slow or quick to develop with worsening pain typically with lower limb loading activities i.e. squatting, prolonged sitting, stairs, etc. Patients with PFPS frequently present to us as health care professionals for diagnosis and treatment, and we’re here to help!
PFPS accounts for 25% of all sports-related knee injuries. Incidence is greater in females. Patellofemoral pain occurs across the life span, from young children to older individuals with the highest prevalence observed in adolescents/teens. Recurrence rate is very high with this diagnosis, with reports of 70-90% of individuals having recurrent symptoms. This can have a substantial impact on QOL, such as loss of physical function and fear avoidance behaviours where people stop participating in the activities that they love.
PFPS is multifactorial in origin and any combination of these variables may result in a diagnosis:
- abnormal lower limb biomechanics during single leg squat/jump/landing
- decreased quadriceps force production
- quads atrophy/inhibition
- decreased hip force production i.e. weak hip abductors, extensors and external rotators
- excessive exercise, overload/overuse
- psychological factors
PFPS can be broken down into patterns of pain:
- Pain only during activity – this is likely a biomechanical issue
- Pain only after activity especially much later or next day – this is likely an inflammatory issue
- Pain that improves with exercise – this is likely a tendon/muscle length issue
signs & symptoms
- knee pain with lower limb loading activities i.e. squatting, prolonged sitting, walking up/down stairs, jumping, running
- joint crepitus is common but not a definitive sign of PFPS
- symptoms can restrict participation in physical activity, sports, and work
- symptoms can recur and persist on/off for years – can be brought on by overloading or underloading
Education: Education is a big part of your recovery journey. Make sure you find someone that you connect with and communicate well with! Individualized education on load management, the importance of adherence to active treatments like exercise therapy, biomechanics that may contribute to relative overload of the patellofemoral joint, the evidence for various treatment options, and the psychological factors such as fear avoidance behaviours and reduced participation in activities. By empowering our patients through education + movement, we hope to guide you along the recovery journey so that you can maintain the results of treatment in the long term and prepare you with the strategies for prevention.
Exercise: Exercise therapy is a critical component of recovery with PFPS and should be the focus in any combined therapy approach. Clinical practice guidelines (2019) support the use of 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. Preference to hip-targeted exercise may be given in the early stages of treatment of PFPS, however the combination approach produces the best outcomes. We wish we could do it all for you, but we’re in this together!!
Manual Therapy: Therapists may use manual therapy (active release technique, soft tissue therapy, joint mobilizations) in conjunction with exercise prescription, but should not be done in isolation. We always include a combined approach to treatment whether you are visiting chiropractic, physiotherapy, or massage therapy
Acupuncture: Clinicians may use acupuncture to reduce pain in patients with PFPS. Our team of chiropractors and physiotherapists are all trained in acupuncture ranging from dry needling, electroacupuncture, and traditional methods.
Taping: Patellar taping in combination with exercise therapy may help you in immediate pain reduction and enhance your outcomes of exercise therapy in the short term (4 weeks).
Orthotics: Your clinician may suggest orthotics for those patients with greater than normal pronation to reduce pain in the short term (up to 6 weeks). A registered chiropodist can perform an evaluation of your feet and take a cast moulding to manufacture a custom orthotic based on your individual needs.
Return to Running: Gait re-training consisting of cuing to adopt a forefoot-strike pattern (for rearfoot-strike runners) and cuing to increase running cadence/reduce stride length may help for those who have running-related knee pain. Additionally, using a progressive guided approach to return to running will help you have a more successful outcome.
All in all, a combination approach of manual therapy, education and strength + conditioning should be established with your clinician. Your rehab should also be specific to YOU! Our clinicians at Function101 can determine which risk factors may be driving your pain and help you move forward.
Here’s a generalized example of what your rehab program could look like with PFPS:
- tibialis anterior raises
- banded squat iso with support
- closed chain clamshell with band
- side plank from knee and hip circles
- curtsey lunge small step with weight
- reverse nordics with plate
- hamstring sliders
- side plank from foot doing hip flexion with band
- single leg deadlift with kettlebell
- lunge with knees over toes with weight
- side lunge with a band
- single leg pall off press