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Update of Risk Factors, Diagnosis, and Management of Patellofemoral Pain

  • Daniel SiskEmail author
  • Michael Fredericson
Non-Operative Management of Anterior Knee Pain (M Fredericson and T Besier, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Non-Operative Management of Anterior Knee Pain

Abstract

Purpose of Review

Patellofemoral pain is the most common cause of anterior knee pain. The purpose of this review is to examine the latest research on risk factors, physical examination, and treatment of patellofemoral pain to improve accuracy of diagnosis and increase use of efficacious treatment modalities.

Recent Findings

The latest research suggests patellofemoral pain pathophysiology is a combination of biomechanical, behavioral, and psychological factors. Research into targeted exercise therapy and other conservative therapy modalities have shown efficacy especially when used in combination. New techniques such as blood flow restriction therapy, gait retraining, and acupuncture show promise but require further well-designed studies.

Summary

Patellofemoral pain is most commonly attributed to altered stress to the patellofemoral joint from intrinsic knee factors, alterations in the kinetic chain, or errors in training. Diagnosis can be made with a thorough assessment of clinical history and risk factors, and a comprehensive physical examination. The ideal treatment is a combination of conservative treatment modalities ideally individualized to the risk factors identified in each patient. Ongoing research should continue to identify biomechanical risk factors and new treatments as well as look for more efficient ways to identify patients who are amenable to treatments.

Keywords

Patellofemoral pain Anterior knee pain Biomechanical risk factors Diagnosis Management 

Notes

Compliance with Ethical Standards

Conflict of Interest

Daniel Sisk declares that he has no conflict of interest.

Michael Fredericson declares he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Thomas M, Wood L, Selfe J, Peat G. Anterior knee pain in younger adults as a precursor to subsequent patellofemoral osteoarthritis: a systematic review. BMC Musculoskelet Disord. 2010.  https://doi.org/10.1186/1471-2474-11-201.
  2. 2.
    Farrokhi S, Keyak J, Powers C. Individuals with patellofemoral pain exhibit greater patellofemoral joint stress: a finite element analysis study. Osteoarthr Cartil. 2011;19:287–94.  https://doi.org/10.1016/j.joca.2010.12.001.CrossRefPubMedGoogle Scholar
  3. 3.
    Heino BJ, Powers C. Patellofemoral stress during walking in persons with and without patellofemoral pain. Med Sci Sports Exerc. 2002;34:1582–93.CrossRefGoogle Scholar
  4. 4.
    Brechter J, Powers C. Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. Gait Posture. 2002;16:115–23.PubMedCrossRefGoogle Scholar
  5. 5.
    Wirtz A, Willson J, Kernozek T, Hong D. Patellofemoral joint stress during running in females with and without patellofemoral pain. Knee. 2012;19:703–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Chen Y, Powers C. Comparison of three-dimensional patellofemoral joint reaction forces in persons with and without patellofemoral pain. J Appl Biomech. 2014;30:493–500.PubMedCrossRefGoogle Scholar
  7. 7.
    Pattyn E, Verdonk P, Steyaert A, Vanden Bossche L, Van den Broecke W, Thijs Y, et al. Vastus medialis obliquus atrophy. Am J Sports Med. 2011;39:1450–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Giles L, Webster K, McClelland J, Cook J. Atrophy of the quadriceps is not isolated to the vastus medialis oblique in individuals with patellofemoral pain. J Orthop Sports Phys Ther. 2015;45:613–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Lankhorst N, Bierma-Zeinstra S, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012;42:81–A12.PubMedCrossRefGoogle Scholar
  10. 10.
    Pappas E, Wong-Tom W. Prospective predictors of patellofemoral pain syndrome. Sports Health: A Multidisciplinary Approach. 2012;4:115–20.CrossRefGoogle Scholar
  11. 11.
    Chester R, Smith T, Sweeting D, Dixon J, Wood S, Song F. The relative timing of VMO and VL in the aetiology of anterior knee pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2008.  https://doi.org/10.1186/1471-2474-9-64.
  12. 12.
    Cowan S, Hodges P, Bennell K, Crossley K. Altered vastii recruitment when people with patellofemoral pain syndrome complete a postural task. Arch Phys Med Rehabil. 2002;83:989–95.PubMedCrossRefGoogle Scholar
  13. 13.
    Voight M, Wieder D. Comparative reflex response times of vastus medialis obliquus and vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction. Am J Sports Med. 1991;19:131–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Pal S, Besier T, Draper C, Fredericson M, Gold G, Beaupre G, et al. Patellar tilt correlates with vastus lateralis: vastus medialis activation ratio in maltracking patellofemoral pain patients. J Orthop Res. 2012;30:927–33.PubMedCrossRefGoogle Scholar
  15. 15.
    Pal S, Draper C, Fredericson M, Gold G, Delp S, Beaupre G, et al. Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients. Am J Sports Med. 2010;39:590–8.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Briani R, de Oliveira SD, Pazzinatto M, Ferreira A, Ferrari D, de Azevedo F. Delayed onset of electromyographic activity of the vastus medialis relative to the vastus lateralis may be related to physical activity levels in females with patellofemoral pain. J Electromyogr Kinesiol. 2016;26:137–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Souza R, Draper C, Fredericson M, Powers C. Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther. 2010;40:277–85.PubMedCrossRefGoogle Scholar
  18. 18.
    Powers C, Ward S, Fredericson M, Guillet M, Shellock F. Patellofemoral kinematics during weight-bearing and non-weight-bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. J Orthop Sports Phys Ther. 2003;33:677–85.PubMedCrossRefGoogle Scholar
  19. 19.
    Hetsroni I, Finestone A, Milgrom C, Sira D, Nyska M, Radeva-Petrova D, et al. A prospective biomechanical study of the association between foot pronation and the incidence of anterior knee pain among military recruits. J Bone Joint Surg Br. 2006;88-B:905–8.CrossRefGoogle Scholar
  20. 20.
    Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A. A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome. Am J Sports Med. 2009;37:2108–16.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Reischl S, Powers C, Rao S, Perry J. Relationship between foot pronation and rotation of the tibia and femur during walking. Foot Ankle Int. 1999;20:513–20.PubMedCrossRefGoogle Scholar
  22. 22.
    Powers C, Berke G, Clary M, Fredericson M. Patellofemoral pain: is there a role for orthoses? PM&R. 2010;2:771–6.CrossRefGoogle Scholar
  23. 23.
    Powers C. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639–46.PubMedCrossRefGoogle Scholar
  24. 24.
    Dowling G, Murley G, Smith M, Munteanu S, Collins N. Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review. J Sci Med Sport. 2014;18:e110.CrossRefGoogle Scholar
  25. 25.
    Van Cant J, Pineux C, Pitance L. Hip muscle strength and endurance in females with patellofemoral pain: a systematic review with meta-analysis. International journal of Sports Phsyaical Therapy. 2014;9(5):564–82.Google Scholar
  26. 26.
    Prins M, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Australian J Physiotherapy. 2009;55:9–15.CrossRefGoogle Scholar
  27. 27.
    Rathleff M, Rathleff C, Crossley K, Barton C. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. Br J Sports Med. 2014;48:1088.PubMedCrossRefGoogle Scholar
  28. 28.
    Nakagawa T, Moriya É, Maciel C, SerrãO F. Trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during a single-leg squat in males and females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2012;42:491–501.  https://doi.org/10.2519/jospt.2012.3987.CrossRefPubMedGoogle Scholar
  29. 29.
    Souza R, Powers C. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39:12–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Neal B, Barton C, Birn-Jeffery A, Morrissey D. Increased hip adduction during running is associated with patellofemoral pain and differs between males and females: a case-control study. J Biomech. 2019;91:133–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Merican A, Amis A. Anatomy of the lateral retinaculum of the knee. J Bone Joint Surg Br. 2008;90-B:527–34.CrossRefGoogle Scholar
  32. 32.
    Hudson Z, Darthuy E. Iliotibial band tightness and patellofemoral pain syndrome: a case-control study. Man Ther. 2009;14:147–51.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Schoots E, Tak I, Veenstra B, Krebbers Y, Bax J. Ultrasound characteristics of the lateral retinaculum in 10 patients with patellofemoral pain syndrome compared to healthy controls. J Bodyw Mov Ther. 2013;17:523–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Kang S, Choung S, Park J, Jeon H, Kwon O. The relationship between length of the iliotibial band and patellar position in Asians. Knee. 2014;21:1135–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Merican A, Amis A. Iliotibial band tension affects patellofemoral and tibiofemoral kinematics. J Biomech. 2009;42:1539–46.PubMedCrossRefGoogle Scholar
  36. 36.
    Lack S, Anthony L, Noake J, Brennan K, Zhang B, Morrissey D. Medial and lateral patellofemoral joint retinaculum thickness in people with patellofemoral pain: a case-control study. J Ultrasound Med. 2018;38:1483–90.PubMedCrossRefGoogle Scholar
  37. 37.
    Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G. Intrinsic risk factors for the development of anterior knee pain in an athletic population: a two-year prospective study. Am J Sports Med. 2000;28:480–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Smith A, Stroud L, McQueen C. Flexibility and anterior knee pain in adolescent elite figure skaters. J Pediatr Orthop. 1991;11:77–82.PubMedCrossRefGoogle Scholar
  39. 39.
    Piva S, Goodnite E, Childs J. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2005;35:793–801.PubMedCrossRefGoogle Scholar
  40. 40.
    Post W, Dye S. Patellofemoral pain: an enigma explained by homeostasis and common sense. Am J Orthop. 2017;46:92–100.PubMedGoogle Scholar
  41. 41.
    Dye S, Chew M. The use of scintigraphy to detect increased osseous metabolic activity about the knee. J Bone Joint Surg. 1993;75:1388–406.CrossRefGoogle Scholar
  42. 42.
    Draper C, Fredericson M, Gold G, Besier T, Delp S, Beaupre G, et al. Patients with patellofemoral pain exhibit elevated bone metabolic activity at the patellofemoral joint. J Orthop Res. 2011;30:209–13.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    dos Santos A, Nakagawa T, Serrão F, Ferber R. Patellofemoral joint stress measured across three different running techniques. Gait Posture. 2019;68:37–43.PubMedCrossRefGoogle Scholar
  44. 44.
    Willson J, Ratcliff O, Meardon S, Willy R. Influence of step length and landing pattern on patellofemoral joint kinetics during running. Scand J Med Sci Sports. 2015;25:736–43.PubMedCrossRefGoogle Scholar
  45. 45.
    Macera C. Predicting lower-extremity injuries among habitual runners. Arch Intern Med. 1989;149(2565–2568):69.Google Scholar
  46. 46.
    Marti B, Vader J, Minder C, Abelin T. On the epidemiology of running injuries. Am J Sports Med. 1988;16:285–94.PubMedCrossRefGoogle Scholar
  47. 47.
    Nielsen R, Parner E, Nohr E, Sørensen H, Lind M, Rasmussen S. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther. 2014;44:739–47.PubMedCrossRefGoogle Scholar
  48. 48.
    Fredericson M, Patellofemoral pain syndrome, O’Connor F, Wilder R, Nirschl R. Textbook of running medicine. New York: McGraw-Hill, Medical Pub. Division; 2001. p. 169–79.Google Scholar
  49. 49.
    Lopes Ferreira C, Barton G, Delgado Borges L, dos Anjos RN, Politti F, Garcia Lucareli P. Step down tests are the tasks that most differentiate the kinematics of women with patellofemoral pain compared to asymptomatic controls. Gait Posture. 2019;72:129–34.PubMedCrossRefGoogle Scholar
  50. 50.
    Fredericson M, Yoon K. Physical examination and patellofemoral pain syndrome. Am J Phys Med Rehabil. 2006;85:234–43.PubMedCrossRefGoogle Scholar
  51. 51.
    Brattström H. Shape of the intercondylar groove normally and in recurrent dislocation of patella: a clinical and X-ray anatomical investigation. Acta Orthop Scand. 1964;35:1–148.CrossRefGoogle Scholar
  52. 52.
    Aglietti P, Insall J, Cerulli G. Patellar pain and incongruence. Clinical Orthopaedics and Related Research &NA. 1983:217–24.Google Scholar
  53. 53.
    Caylor D, Fites R, Worrell T. The relationship between quadriceps angle and anterior knee pain syndrome. J Orthop Sports Phys Ther. 1993;17:11–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Draper C, Chew K, Gold G, Fredericson M. Comparison of quadriceps angle measurements using short-arm and long-arm goniometers. PM&R J. 2011;3(2):111–6.CrossRefGoogle Scholar
  55. 55.
    Boden B, Pearsall A, Garrett W, Feagin J. Patellofemoral instability: evaluation and management. J Am Acad Orthop Surg. 1997;5:47–57.PubMedCrossRefGoogle Scholar
  56. 56.
    Nunes G, Stapait E, Kirsten M, de Noronha M, Santos G. Clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. Physical Therapy in Sport. 2013;14:54–9.PubMedCrossRefGoogle Scholar
  57. 57.
    Fredericson M, Powers C. Practical management of patellofemoral pain. Clin J Sport Med. 2002;12:36–8.PubMedCrossRefGoogle Scholar
  58. 58.
    •• Collins N, Barton C, van Middelkoop M, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52:1170–8 Consensus statement recommendations for treatment modalities for patellofemoral pain based on literature review of studies up to 2018. PubMedCrossRefGoogle Scholar
  59. 59.
    • Kooiker L, Van De Port I, Weir A, Moen M. Effects of physical therapist–guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review. Journal of Orthopaedic & Sports Physical Therapy. 2014;44:391-B1 Systematic review showing the benefit of generalized quadriceps strengthening in treatment of patellofemoral pain. CrossRefGoogle Scholar
  60. 60.
    Mason M, Keays S, Newcombe P. The effect of taping, quadriceps strengthening and stretching prescribed separately or combined on patellofemoral pain. Physiother Res Int. 2010;16:109–19.PubMedCrossRefGoogle Scholar
  61. 61.
    Powers C. Rehabilitation of patellofemoral joint disorders: a critical review. J Orthop Sports Phys Ther. 1998;28:345–54.PubMedCrossRefGoogle Scholar
  62. 62.
    Fredericson M. Lift less and gain more muscle with blood flow restriction training. Men's Health. 2019.Google Scholar
  63. 63.
    • Giles L, Webster K, Mc Clelland J, Cook J. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med. 2017;51:1688–94 A randomized control trial showed short-term benefits of blood flow restriction therapy adjunct to traditional quadriceps strengthening. PubMedCrossRefGoogle Scholar
  64. 64.
    Syme G, Rowe P, Martin D, Daly G. Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Man Ther. 2009;14:252–63.PubMedCrossRefGoogle Scholar
  65. 65.
    Yip S, Ng G. Biofeedback supplementation to physiotherapy exercise programme for rehabilitation of patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2006;20:1050–7.PubMedCrossRefGoogle Scholar
  66. 66.
    Bennell K, Duncan M, Cowan S, McConnell J, Hodges P, Crossley K. Effects of vastus medialis oblique retraining versus general quadriceps strengthening on vasti onset. Med Sci Sports Exerc. 2010;42:856–64.PubMedCrossRefGoogle Scholar
  67. 67.
    Crossley K, Cowan S, McConnell J, Bennell K. Physical therapy improves knee flexion during stair ambulation in patellofemoral pain. Med Sci Sports Exerc. 2005;37:176–83.PubMedCrossRefGoogle Scholar
  68. 68.
    Fukuda T, Melo W, Zaffalon B, Rossetto F, Magalhães E, Bryk F, et al. Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys Ther. 2012;42:823–30.PubMedCrossRefGoogle Scholar
  69. 69.
    Khayambashi K, Mohammadkhani Z, Ghaznavi K, Lyle M, Powers C. The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with patellofemoral pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2012;42:22–9.  https://doi.org/10.2519/jospt.2012.3704.CrossRefPubMedGoogle Scholar
  70. 70.
    Nakagawa T, Muniz T, Baldon R, Dias Maciel C, de Menezes RR, Serrão F. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2008;22:1051–60.PubMedCrossRefGoogle Scholar
  71. 71.
    Rogan S, Haehni M, Luijckx E, Dealer J, Reuteler S, Taeymans J. Effects of hip abductor muscles exercises on pain and function in patients with patellofemoral pain. J Strength Cond Res. 2018;1.Google Scholar
  72. 72.
    Keays S, Mason M, Newcombe P. Three-year outcome after a 1-month physiotherapy program of local and individualized global treatment for patellofemoral pain followed by self-management. Clin J Sport Med. 2016;26:190–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Moyano F, Valenza M, Martin L, Caballero Y, Gonzalez-Jimenez E, Demet G. Effectiveness of different exercises and stretching physiotherapy on pain and movement in patellofemoral pain syndrome: a randomized controlled trial. Clin Rehabil. 2012;27:409–17.PubMedCrossRefGoogle Scholar
  74. 74.
    • Roper J, Harding E, Doerfler D, Dexter J, Kravitz L, Dufek J, et al. The effects of gait retraining in runners with patellofemoral pain: a randomized trial. Clin Biomech. 2016;35:14–22 A randomized control trial showing gait retraining to be helpful for knee pain and alteration of biomechanics. CrossRefGoogle Scholar
  75. 75.
    Esculier J, Bouyer L, Dubois B, Fremont P, Moore L, McFadyen B, et al. Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain? A randomised clinical trial. Br J Sports Med. 2017;52:659–66.PubMedCrossRefGoogle Scholar
  76. 76.
    Davis I. Optimising the efficacy of gait retraining. Br J Sports Med. 2017;52:624–5.PubMedCrossRefGoogle Scholar
  77. 77.
    Collins N, Bisset L, Crossley K, Vicenzino B. Efficacy of nonsurgical interventions for anterior knee pain. Sports Med. 2012;42:31–49.PubMedCrossRefGoogle Scholar
  78. 78.
    Espí-López G, Serra-Añó P, Vicent-Ferrando J, Sánchez-Moreno-Giner M, Arias-Buría J, Cleland J, et al. Effectiveness of inclusion of dry needling in a multimodal therapy program for patellofemoral pain: a randomized parallel-group trial. J Orthop Sports Phys Ther. 2017;47:392–401.PubMedCrossRefGoogle Scholar
  79. 79.
    Rathleff M, Petersen K, Arendt-Nielsen L, Thorborg K, Graven-Nielsen T. Impaired conditioned pain modulation in young female adults with long-standing patellofemoral pain: a single blinded cross-sectional study. Pain Medicine. 2015:pnv017.Google Scholar
  80. 80.
    Noehren B, Shuping L, Jones A, Akers D, Bush H, Sluka K. Somatosensory and biomechanical abnormalities in females with patellofemoral pain. Clin J Pain. 2016;32:915–9.PubMedPubMedCentralCrossRefGoogle Scholar
  81. 81.
    Rathleff M, Roos E, Olesen J, Rasmussen S, Arendt-Nielsen L. Lower mechanical pressure pain thresholds in female adolescents with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2013;43:414–21.PubMedCrossRefGoogle Scholar
  82. 82.
    Maclachlan L, Collins N, Matthews M, Hodges P, Vicenzino B. The psychological features of patellofemoral pain: a systematic review. Br J Sports Med. 2017;51:732–42.PubMedCrossRefGoogle Scholar
  83. 83.
    Smith B, Moffatt F, Hendrick P, Bateman M, Selfe J, Rathleff M, et al. Barriers and facilitators of loaded self-managed exercises and physical activity in people with patellofemoral pain: understanding the feasibility of delivering a multicentred randomised controlled trial, a UK qualitative study. BMJ Open. 2019;9:e023805.PubMedPubMedCentralCrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Division of Physical Medicine and Rehabilitation, Department of Orthopedic SurgeryStanford UniversityStanfordUSA

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