Patellofemoral Pain – 3 Treatment Tips
Patellofemoral Pain (PFP) is one of the most common causes of knee pain, and can significantly impact your patient’s quality of life. The lack of quality, long-term evidence can leave physiotherapists scratching their heads as to the best management options for their PFP patients. For physiotherapists wanting to help their patients with PFP achieve their goals, here are a few tips based on the current evidence.
Before we start, if you want to dive deeper into PFP then be sure to check out Claire “Patella” Robertson’s Masterclass.
1) Combination treatment over stand-alone treatment
A recent systematic review and meta-analysis identified six treatment modalities which were effective in reducing pain and improving function of the knee at 3 months (1). They were:
- Knee-targeted exercise
- Combined interventions
- Foot orthoses
- Lower quadrant manual therapy
- Knee-targeted exercises combined with perineural dextrose injection
- Hip-and-knee-targeted exercise
Knee-targeted exercises combined with perineural dextrose injection, as well as hip-and-knee targeted exercise were found to be superior to knee-targeted exercises alone for pain and function. Ultimately, individualised treatment selection should be multi-modal, made in collaboration with your patient, and take an active rehabilitative approach. This may require some trial and error; maintaining a good understanding of your patient’s pain and function through reassessment will be key in identifying the most meaningful treatment modalities for them.
2) Educate, educate, educate
Education is the cornerstone of any physiotherapy intervention – without a solid understanding of the condition, how can we empower the patient to self-manage with active rehabilitation? Firstly, education regarding load management strategies, positioning, and graded activity can be useful in pain management and increasing your patient’s self-efficacy. Secondly, a transparent discussion regarding treatment options, and the lack of long-term evidence to support the efficacy of these modalities is recommended to ensure patients are informed (1), and therefore able to actively participate in treatment planning.
It may also be important to address your patient’s concerns and provide reassurance regarding the integrity of the patellofemoral joint. Qualitative research regarding the beliefs around crepitus found it causes negative emotions and leads to altered, fear avoidant behaviours (2). Therefore, taking the time to educate the patient about symptoms such as crepitus, and de-escalate their concerns could help to reduce unhelpful coping strategies.
3) Treat the whole person
Research suggests a high prevalence of anxiety, depression and kinesiophobia among patients with PFP (3, 4). With any condition, it is important to consider the range of factors which may influence your patient’s pain, function, and quality of life. Asking questions regarding sleep habits, mood changes, coping strategies, and knee confidence can all help to paint a picture of the impact PFP has on your patient’s life. For some, interventions such as sleep strategies and mindfulness may have a positive influence on their pain and function.
Additionally, kinesiophobia can influence movement patterns, and has been linked to pain and disability in stair ascent for women (5). Therefore, assessment and management of kinesiophobia to avoid counterproductive movement strategies could be valuable. For example, pain-free exercises similar to the patient’s aggravating factor may help to increase your patient’s confidence in their knee, reduce kinesiophobia and improve function.
The lack of high-quality evidence to guide conservative intervention for PFP can be tricky for physiotherapists. However, the emerging qualitative information may help to guide clinicians toward a more patient-centred approach when it comes to PFP, with the aim of improving outcomes in the long-term. It is vital to work in collaboration with the patient to select the most appropriate treatment options for them.
Active rehabilitation approach
Inform about treatment options and be transparent regarding lack of long-term evidence Address patient’s concerns regarding symptoms eg. crepitus, “wear and tear” Address psychosocial factors influencing condition
Assess and manage potential kinesiophobia
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- Neal B, Bartholomew C, Barton C, Morrissey D, Lack S (2022) Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther, 52(11), 750-768.
- Robertson CJ, Hurley M, Jones F (2017) People’s beliefs about the meaning of crepitus in patellofemoral pain and the impact of these beliefs on their behaviour: A qualitative study. Musculoskelet Sci Pract. ;28:59-64.
- Maclachlan LR, Collins NJ, Matthews MLG, Hodges PW, Vicenzino B (2017) The psychological features of patellofemoral pain: a systematic review. Br J Sports Med, 51(9), 732-742.
- Maclachlan, LR, Collins, NJ, Hodges, PW, Vicenzino, B (2020) Psychological and pain profiles in persons with patellofemoral pain as the primary symptom. Eur J Pain, 24, 1182– 1196.
- De Oliveira Silva D, Willy RW, Barton CJ, Christensen K, Pazzinatto MF, Azevedo FM (2020) Pain and disability in women with patellofemoral pain relate to kinesiophobia, but not to patellofemoral joint loading variables. Scand J Med Sci Sports, 30(11), 2215-2221.
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