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Patellofemoral pain syndrome
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of patellofemoral pain syndrome are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023,2019), the American College of Radiology (ACR 2020,2018), the American Physical Therapy Association (APTA 2019), and the International Patellofemoral Research Network (iPFRN 2016).
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Screening and diagnosis
Diagnostic criteria: as per APTA 2019 guidelines, reproduce retropatellar or peripatellar pain during squatting as a diagnostic test for PFPS. Perform other functional activities loading the patellofemoral joint in a flexed position, such as stair climbing or descent, as diagnostic tests for PFPS.
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Classification and risk stratification
Classification: as per APTA 2019 guidelines, consider using the proposed impairment/function-based PFPS classification system to guide management:
Situation
Guidance
Overuse/overload without other impairment
Patients presenting with a history suggesting an increase in magnitude and/or frequency of patellofemoral joint loading at a rate surpassing the ability of patellofemoral joint tissues to recovery
Muscle performance deficits
Patients presenting with lower extremity muscle performance deficits in the hip and quadriceps
Patients may respond favorably to hip and knee resistance exercises
Movement coordination deficits
Patients presenting with excessive or poorly controlled knee valgus during a dynamic task, but not necessarily due to weakness of the lower extremity musculature
Patients may respond favorably to gait retraining and movement re-education interventions leading to improvements in lower extremity kinematics and pain, suggesting the importance of assessing dynamic knee valgus during movement
Mobility impairments
Patients presenting with higher than normal foot mobility and/or flexibility deficits of ≥ 1 of the following structures
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Diagnostic investigations
Clinical assessment: as per APTA 2019 guidelines, use the AKPS, the KOOS-PF, or the VAS for activity or EPQ to measure pain and function in patients with PFPS.
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Diagnostic imaging (acute knee pain)
Diagnostic imaging (chronic knee pain)
Medical management
Nonpharmacologic interventions
Physical therapy: as per AAFP 2023 guidelines, offer targeted physical therapy with hip and knee exercises in patients with PFPS.
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Orthoses and taping
Alternative and complementary therapies (manual therapy)
Alternative and complementary therapies (biophysical therapies)
Alternative and complementary therapies (biofeedback)
Alternative and complementary therapies (acupuncture and dry needling)
Patient education
General counseling: as per APTA 2019 guidelines, consider providing specific patient education on load management, body-weight management when appropriate, the importance of adherence to active treatments like exercise therapy, biomechanics contributing to relative overload of the patellofemoral joint, the evidence for various treatment options, and kinesiophobia, to improve compliance and adherence to active management and self-management strategies.
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