Broadly described as anterior or retropatellar knee pain,1 patellofemoral pain (PFP) has gone through many evolutions in terms of definition, and pathoanatomic causes. While the focus has traditionally been on more anatomical and biomedical factors, recent evidence suggests that psychosocial factors (like depression and fear avoidance) are important to consider when evaluating these patients..2
Specific pathophysiological causes of the pain remain elusive. One model describes a system that prescribes graded and progressive tolerance to load to increase the envelope of function.3, 4 With this context in mind, here are some quick tips for treating PFP.
1. Quads, Quads, Quads
Yes, go after the quads! We are relatively certain that progressive loading and strengthening of the quads is helpful for PFP.
You have many options, including eccentrics, decline single leg squats, and open chain knee extension. A leg extension likely isolates the quad better than any version of squat, but you’re probably better off including both squats and leg extension rather than either one in isolation.
Young, et al., found some improved outcomes comparing eccentric single leg squats on a 25° slant board over a single squat off a 10 centimeter step.5 Importantly, the decline group was encouraged to load the joint up to moderate pain in this study, which could account for some of the difference between groups.5 Arguably, it’s yet to be determined if eccentrics are necessarily superior to progressive loading.
Here are a few quad-focused exercise examples:
Eccentric Single Leg Decline Squat on Slant Board
Single Leg Knee Extension with Weight Machine
Single Leg Chair Squat with Touch
2. Include the Hips
Some studies seem to indicate hip-plus-knee exercise is superior to knee-focused exercise alone,6 but we can’t say this is true with much certainly, per a recent Cochrane systematic review.7 Meira and Brumitt are more confident in their systematic review that hip abductor and hip ER strength deficits are associated with PFP, however.8
If your assessment finds hip deficits, it’s worth addressing at this time. Here are a few basic exercises (and don’t forget to add resistance as appropriate!):
Sidelying Hip Abduction with ER
Hip Hiking on Step
Clamshell with Resistance
3. Identify Overtraining
Taking a careful history from your patients with PFP may help identify if there have been recent changes in training loads that could be associated with the new onset of pain. If so, temporarily modifying these loads and progressively building the patient back to prior levels of activity (and hopefully beyond!) may be protective and ease PFP.4
4. Just Say No to the VMO
We can’t isolate the vastus medialis oblique (VMO); it’s well established at this time.9 You’re better off ensuring that you’re prescribing resistance activity at a sufficient level of intensity. If you’re spending too much time worrying about the degree that the lower extremity is internally or externally rotated in attempts to isolate VMO, you’re probably not meeting this primary objective.
5. PFP—More Than Meets the Eye
A growing body of research seems to indicate that there are more than just biomechanical factors that influence recovery from PFP syndrome, as psychosocial factors can also contribute to a patient’s prognosis.2, 4 In other words, effective treatment strategies should consider taking a biopsychosocial approach
• Is your patient displaying fear-avoidance behavior?
• Does your patient lack self-efficacy to reach their goals?
Graded, progressive exercise with shared goal-setting is likely to improve outcomes in this scenario.
Physical therapy has the potential to improve the outcomes and function of a large population of individuals affected by patellofemoral pain. Exercise appears to be an overall effective intervention; however, we still have much more research to do to maximize the effects of our interventions, including addressing the questions of dosage, intensity, frequency, and duration.
- Crossley, K., Bennell, K., Green, S., & McConnell, J. (2001). A systematic review of physical interventions for patellofemoral pain syndrome. Clinical Journal of Sport Medicine, 11(2): 103–110.
- Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of Rehabilitation Medicine, 41(8): 604–612.
- Dye, S. F. & Dye, C. C. (2018). An overview of patellofemoral pain—from a tissue homeostasis perspective. Annals of Joint, 3.
- Willy, R. W. & Meira, E. P. (2016)."Current concepts in biomechanical interventions for patellofemoral pain. International Journal of Sports Physical Therapy, 11(6): 877–890.
- Young, M., Cook, J., Purdam, C., Kiss, Z., & Alfredson, H. (2005). Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. British Journal of Sports Medicine, 39(2): 102–105.
- Baldon, Rde. M., Serrão, F. V., Scattone Silva, R., & Piva, S. R. (2014). Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 44(4): 240–251.
- van der Heijden, R. A., Lankhorst, N. E., van Linschoten, R., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2015). Exercise for treating patellofemoral pain syndrome. Cochrane Database of Systematic Reviews, 20(1): CD010387.
- Meira, E. P. & Brumitt, J. (2011). Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health, 3(5): 455–465.
- Smith, T. O., Bowyer, D, Dixon, J., Stephenson, R., Chester, R., & Donell, S. T. (2009). Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. Physiotherapy Theory and Practice, 25(2): 69–98.