Patellofemoral pain Patellofemoral pain (PFP) is a common running injury and is also known as runner’s knee (Bump & Lewis, 2023). It is defined as pain around or under the patella that increases with weightbearing activities on a flexed knee. During running, ground reaction forces are transferred from the foot to the flexed knee where the contracting quadriceps compresses the patella in the trochlear groove with a force that is 4 times the runner’s body weight (Esculier et al., 2020). Symptoms PFP is characterized by pain in the anterior part of the knee, around or under the patella. Knee effusion and/or crepitus may be present. This pain is aggravated by activities such as stairs, jumping, squatting and running as these activities load the patellofemoral joint (de Vasconcelos et al., 2022). Structures involved in generating pain with PFP include subchondral bone, synovium, retinaculum, skin, nerve, and muscle (Bump & Lewis, 2023). Etiology The cause of patellofemoral pain is considered multifactorial, and the following contributing factors have been identified: Biomechanical alignment issues and muscle imbalances Pain-free and effective patellar function in the trochlear groove depends on the function of several dynamic and static structures. Biomechanical influences include decreased hip abductor and external rotation strength, decreased quadriceps strength, and reduced ankle dorsiflexion (Esculier et al., 2020). Increased and limited foot pronation have been shown to contribute to onset of PFP as have angular or rotational deformities in the lower extremity, such as is seen with increased hip anteversion. Hamstring and hip muscle tightness are also considered potential contributing factors (Bump & Lewis, 2023). Overload Runners without any identifiable biomechanical deficits may still develop PFP. In these instances, the primary contributory factor is overactivity with overloading of the patellofemoral joint structures (Bump & Lewis, 2023). Most often, onset is related to a combination of these two things. For runners, onset of PFP generally correlates with the subjective report of increased training volume, and runners should be asked about weekly mileage, longest run, addition of speed work or hills, and so on. An elevated body mass index (BMI) can also contribute to patellofemoral joint overload (Bump & Lewis, 2023). Physical examination Physical examination should include observation of the peripatellar area for swelling and muscle atrophy and palpation of this area for tenderness and/or warmth. Strength testing of the quadriceps, hip abductors, and hip external rotators is indicated, as is flexibility testing of the hamstrings, hip, and gastrocnemius-soleus muscles (Bump & Lewis, 2023). Tightness of the iliotibial band can lead to lateral tracking of the patella, so the flexibility of this structure should also be assessed (Patellofemoral Pain Syndrome, 2024). Biomechanical assessment should look for abnormalities such as hip anteversion, genu valgus, and increased pronation. Video analysis of running mechanics can yield important information but should not be completed if the runner’s normal movement is hindered by pain.
The following outline can help connect subjective findings to specific structures (Patellofemoral Pain Syndrome, 2024):
Possible Clinical Correlate(s)
Subjective Complaint
Pain while sitting with a flexed knee
Tight quadriceps (compresses patellofemoral joint (PFJ))
Pain sitting with legs crossed
Tight iliotibial band
Pain walking/running uphill Tight calf muscles
Impaired gluteal control
Pain with running downhill, descending stairs Muscle length issues, limited eccentric quad function Pain with ascending stairs Impaired gluteal control Pain with coming up from a squat Impaired gluteal control Treatment Acute phase The acute phase of treatment for PFP should focus on pain reduction via activity modification, ice, modalities, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) (Bump & Lewis, 2023). Exercise therapy Exercise therapy consisting of open and closed kinetic chain exercises including focusing on proprioception and neuromuscular control are considered the core components of treatment for patellofemoral pain syndrome (de Vasconcelos et al., 2022). A study by Jellad et al. (2021) found that adding strengthening exercises for the hip external rotators and abductors and stretching to the hip internal rotators to a standard rehabilitation protocol (patellar mobilizations, hamstring, quadriceps, and tensor fasciae latae, concentric quadriceps strengthening, and proprioceptive exercises) led to greater improvements in pain and function in individuals with PFP. Orthotics Chen et al. (2022) conducted a systematic review and meta-analysis on the effect of foot orthoses on patients with patellofemoral pain. They found that foot orthoses helped improve knee function in patients with patellofemoral pain, especially when combined with a lower extremity strengthening exercises. Kinesiotapin A study by Lee et al. (2023) found that adding kinesiotaping to exercise therapy provided no additional benefit over exercise alone. By contrast, Bump and Lewis state that patellar taping has been shown to decrease overall pain when combined with physical therapy compared to physical therapy alone, but this difference does not hold true for patients with higher BMI’s. Joint mobilization Joint mobilizations are not recommended for treating PFP (Patellofemoral Pain Syndrome, 2024). Electrotherapy Electrotherapy is not recommended for treating PFP (Patellofemoral Pain Syndrome, 2024).
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