Abstract
Anterior knee pain is one of the most common knee problems in physically active individuals. The reason for anterior knee pain has been suggested to be multifactorial with patella abnormalities or extensor mechanism disorder leading to patellar malalignment during flexion and extension of the knee joint. Some patients complain mostly of non-specific knee pain, while others report patellar instability problems. The patients present with a variety of symptoms and clinical findings, meaning that a thorough clinical examination is the key for optimal treatment. Weakness of the quadriceps muscle, especially during eccentric contractions, is usually present in the majority of anterior knee pain patients. However, irrespective of whether pain or instability is the major problem, hypotrophy and reduced activity of the vastus medialis are often found, which result in an imbalance between vastus medialis and vastus lateralis. This imbalance needs to be corrected before quadriceps exercises are started. The non-operative rehabilitation protocol should be divided into different phases based on the patient’s progress. The goal of the first phase is to reduce pain and swelling, improve the balance between vastus medialis and vastus lateralis, restore normal gait, and decrease loading of the patello-femoral joint. The second phase should include improvement of postural control and coordination of the lower extremity, increase of quadriceps strength and when needed hip muscle strength, and restore good knee function. The patient should be encouraged to return to or to start with a suitable regular physical exercise. Therefore, the third phase should include functional exercises. Towards the end of the treatment, single-leg functional tests and functional knee scores should be used for evaluating clinical outcome. A non-operative treatment of patients with anterior knee pain should be tried for at least 3 months before considering other treatment options.
Similar content being viewed by others
References
Aglietti P, Buzzi R, Pisaneschi A (1990) Patella pain. J Sports Trauma Rel Res 12:131–150
Baltzopoulos V, Brodie DA (1989) Isokinetic dynamometry. Applications and limitations. Sports Med 8:101–116
Beckman M, Craig R, Lehman RC (1989) Rehabilitation of patellofemoral dysfunction in the athlete. Clin Sports Med 8(4):841–860
Bentley G, Dowd G (1984) Current concepts of etiology and treatment of chondromalacia patellae. Clin Orthop 189:209–228
Bizzini M, Biedert R, Maffiuletti N, Impellizzeri F (2008) Biomechanical issues in patellofemoral joint rehabilitation. Orthopade 37(9):864 (866–871)
Bockrath K, Wooden C, Worrel T, Ingersoll CD, Farr J (1993) Effects of patella taping on patella position and perceived pain. Med Sci Sports Exerc 25:989–992
Bose K, Kanagasuntherum R, Osman M (1980) Vastus medialis oblique: an anatomical and physiologic study. Orthopedics 3:880–883
Brewerton DA (1955) The function of the vastus medialis muscle. Ann Phys Med 2:164–168
Carlsson AM, Werner S, Mattlar C-E, Edman G, Puukka P, Eriksson E (1993) Personality in patients with long-term patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1:178–183
Carson WG (1985) Diagnosis of extensor mechanism disorders. Clin Sports Med 4:231–246
Cerny K (1995) Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome. Phys Ther 75(8):672–683
Cesarelli M, Bifulco P, Bracale M (2000) Study of the control strategy of the quadriceps muscles in anterior knee pain. Trans Rehabil Eng 8(3):330–341
Chesworth BM, Culham EG, Tata GE, Peat M (1989) Validation of outcome measures in patients with patellofemoral syndrome. J Orthop Sports Phys Ther 10:302–309
Christou EA (2004) Patellar taping increases vastus medialis oblique activity in the presence of patellofemoral pain. J Electromyogr Kinesiol 14(4):495–504
Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell J (2003) Simultaneous feedforward recruitment of the vasti in untrained postural tasks can be restored by physical therapy. J Orthop Res 21(3):553–558
Cowan SM, Crossley KM, Bennell KL (2008) Altered hip and trunk muscle function in individuals with patellofemoral pain. Br J Sports Med 43(8):584–588
Crossley KM, Bennell KL, Cowan SM, Green S (2004) Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil 85(5):815–822
Doucette SA, Goble EM (1992) The effect of exercise on patellar tracking in lateral patellar compression syndrome. Am J Sports Med 20(4):434–440
Doucette SA, Child DP (1996) The effect of open and closed chain exercise and knee joint position on patellar tracking in lateral patellar compression syndrome. J Orthop Sports Phys Ther 23(2):104–110
Fairbank J, Pynsent P, van Poortvliet J, Phillips H (1984) Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br 66:685–693
Felicio LR, Do Prado Baffa A, Liporacci RF, Saad MC, De Oliveira AS, Bevilaqua-Grossi D (2011) Analysis of patellar stabilizers muscles and patellar kinematics in anterior knee pain subjects. J Electromyogr Kinesiol 21:148–153
Ferrari D, Kuriki HU, Silva CR, Alves N, de Azevedo FM (2014) Diagnostic accuracy of the electromyography parameters associated with anterior knee pain in the diagnosis of patellofemoral pain syndrome. Arch Phys Med Rehabil 2–6 (in press)
Flandry F, Hunt JP, Terry GC, Hughston JC (1991) Analysis of subjective knee complaints using visual analog scales. Am J Sports Med 19(2):112–118
Fox TA (1975) Dysplasia of the quadriceps mechanism, hypoplasia of the vastus medialis as related to the hypermobile patella syndrome. Surg Clin North Am 55:199–226
Fukuda TY, Rossetto FM, Magalhães E, Bryk FF, Lucareli PR, de Almeida Aparecida Carvalho N (2010) Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther 40:736–742
Fulkerson JP, Hungerford DS (1990) Biomechanics of the patellofemoral joint. In: Fulkerson JP, Hungerford DS (eds) Disorders of the patellofemoral joint, 2nd edn. Williams & Wilkins, Baltimore, pp 25–41
Fulkerson JP, Shea KP (1990) Current concepts review disorders of patellofemoral alignment. J Bone Joint Surg Am 72:1424–1429
Gilleard W, McConnell J, Parsons D (1998) The effect of patellar taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 78(1):25–32
Goldberg B (1991) Chronic anterior knee pain in adolescents. Pediatr Ann 20:186–193
Goodfellow J, Hungerford DS, Zindel M (1976) Patello-femoral joint mechanics and pathology: I. Functional anatomy of the patella-femoral joint. J Bone Joint Surg Br 58:287–290
Gunther KP, Thielemann F, Bottesi M (2003) Anterior knee pain in children and adolescents: diagnosis and conservative treatment. Orthopäde 32(2):110–118
Hazneci B, Yildiz Y, Sekir U, Aydin T, Kalyon TA (2005) Efficacy of isokinetic exercise on joint position sense and muscle strength in patellofemoral pain syndrome. Am J Phys Med Rehabil 84(7):521–527
Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW (2003) Exercise therapy for patellofemoral pain syndrome. Cochrane Database Syst Rev (4):CD003472
Insall J, Goldberg V, Salvati E (1972) Recurrent dislocation and high-riding patella. Clin Orthop Relat Res 88:67–69
Insall J (1982) Current concepts review, patellar pain. J Bone Joint Surg Am 64:147–152
Jacobson KE, Flandry FC (1989) Diagnosis of anterior knee pain. Clin Sports Med 8:179–195
Kowall MG, Kolk G, Nuber GW, Cassisi JE, Stern SH (1996) Patellar taping in the treatment of patellofemoral pain: a prospective randomized study. Am J Sports Med 24(1):61–66
Laprade J, Culham E, Brouwer B (1998) Comparison of five isometric exercises in the recruitment of the vastus medialis oblique in persons with and without patella-femoral pain syndrome. J Orthop Sports Phys Ther 27(3):197–204
Lee C-H, Ha C-W, Kim S, Kim M, Song Y-J (2013) A novel patellofemoral scoring system for patellofemoral joint status. J Bone Joint Surg Am 95:620–626
Lieb F, Perry J (1968) Quadriceps function. J Bone Joint Surg Am 50:1535–1548
Loudon JK, Wiesner D, Goist-Foley HL, Asjes C, Loudon KL (2002) Intrarater reliability of functional performance tests for subjects with patellofemoral pain syndrome. J Athl Train 37(3):256–261
Lysholm J, Nordin M, Ekstrand J, Gillquist J (1984) The effect of a patella brace on performance in knee extension strength test in patients with patellar pain. Am J Sports Med 12:110–112
Mariani PP, Caruso I (1989) An electromyographic investigation of subluxation of the patella. J Bone Joint Surg Br 61:169–171
Martin JA, Londeree BR (1979) EMG comparison of quadriceps femoris activity during knee extension and straight leg raises. Am J Phys Med Rehabil 58:57–69
McCarthy MM, Strickland SM (2013) Patellofemoral pain: an update on diagnostic and treatment options. Curr Rev Musculoskelet Med 6:188–194
McConnell J (1986) The management of chondromalacia patellae: a long term solution. Austr J Physiother 32(4):215–223
McConnell J (1998) Examination of the patellofemoral joint: the physical therapist´s perspective. In: Grelsamer RP, McConnell J (eds) The patella. A team approach. Aspen Publishers, Gaithersburg, pp 109–118
Nakagawa TH, Muniz TB, Baldon RM, Maciel CD, Amorim C, Serrão F (2011) Electromyographic preactivation pattern of the gluteus medius during weight-bearing functional tasks in women with and without anterior knee pain. Rev Bras Fisioter 15(1):59–65
Ng GYF, Wong PYK (2009) Patellae taping affects vastus medialis obliquus activation in subjects with patellofemoral pain before and after quadriceps muscle fatigue. Clin Rehabil 23:705–713
Osborne AH, Farquharson-Roberts MA (1983) The aetiology of patella-femoral pain. J Roy Nav Med Serv 69:97–103
Owings TM, Grabiner MD (2002) Motor control of the vastus medialis oblique and vastus lateralis muscles is disrupted during eccentric contractions in subjects with patellofemoral pain. Am J Sports Med 30(4):483–487
Palmitier RA, An K-N, Scott SG, Chao EYS (1991) Kinetic chain exercise in knee rehabilitation. Sports Med 11(6):404–413
Palumbo PM (1981) Dynamic patellar brace: patellofemoral disorders. A preliminary report. Am J Sports Med 9:45–49
Paoloni M, Fratocchi G, Mangone M, Murgia M, Santilli V, Cacchio A (2012) Long-term efficacy of a short period of taping followed by an exercise program in a cohort of patients with patellofemoral pain syndrome. Clin Rheumatol 31:535–539
Pattyn E, Mahieu N, Selfe J, Verdonk P, Steyaert A, Witvrouw E (2012) What predicts functional outcome after treatment for patellofemoral pain? Med Sci Sports Exerc 1827–1833
Percy EC, Strother RT (1985) Patellalgia. Physician Sports Med 13:43–59
Piva SR, Goodnite EA, Childs JD (2005) Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 35:793–801
Portney LG, Sullivan PE, Daniell JL (1986) EMG activity of vastus medialis obliquus and vastus lateralis in normal and patients with patellofemoral arthralgia. Phys Ther 66:808
Powers CM, Perry J, Hislop HJ (1997) Are patellofemoral pain and quadriceps femoris muscle torque associated with locomotor function? Phys Ther 77(10):1063–1075
Powers CM, Landel E, Sosnick T, Kirby J, Mengel K, Cheney A, Perry J (1997) The effects of patellar taping on stride characteristics and joint motion in subjects with patellofemoral pain. J Orthop Sports Phys Ther 26(6):286–291
Robinson RL, Nee RJ (2007) Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther 37(5):232–238
Sega L, Galante M, Fortina A, Squazzini Viscontini G, Bertolotti G, Benedetti MG (1988) Association of dynamic bandage with kinesitherapy in the treatment of patellar instability. Ital J Sports Traum 10:89–94
Smith AD, Stroud L, McQueen C (1991) Flexibility and anterior knee pain in adolescent elite figure skaters. J Pediatr Orthop 11:77–82
Steadman JR (1979) Nonoperative measures for patellofemoral problems. Am J Sports Med 7:374–375
Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman KR (1993) Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 21(3):438–444
Thomeé R (1997) A comprehensive treatment approach for patellofemoral pain syndrome in young women. Phys Ther 77(12):1690–1703
Tiberio D (1987) The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Orthop Sports Phys Ther 9:160–165
Voight ML, Wieder DL (1991) Comparative reflex response times of vastus medialis obliquus and vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction: an electromyographic study. Am J Sports Med 19:131–137
Werner S, Arvidsson H, Arvidsson I, Eriksson E (1993) Electrical stimulation of vastus medialis and stretching of lateral thigh muscles in patients with patello-femoral symptoms. Knee Surg Sports Traumatol Arthrosc 1:85–92
Werner S, Eriksson E (1993) Isokinetic quadriceps training in patients with patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1:162–168
Werner S, Knutsson E, Eriksson E (1993) Effect of taping the patella on concentric and eccentric torque and EMG of the knee extensor and flexor muscles in patients with patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1:169–177
Werner S (1995) An evaluation of knee extensor and knee flexor torques and EMGs in patients with patellofemoral pain syndrome in comparison with matched controls. Knee Surg Sports Traumatol Arthrosc 3:89–94
Whittingham M, Palmer S, Macmillan F (2004) Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. J Orthop Sports Phys Ther 34(9):504–510
Witvrouw E, Sneyers C, Lysens R, Victor J, Bellemans J (1996) Reflex response times of vastus medialis oblique and vastus lateralis in normal subjects and in subjects with patellofemoral pain syndrome. J Orthop Sports Phys Ther 24(3):160–165
Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G (2000) Intrinsic risk factors for the development of anterior knee pain in an athletic population: a two year prospective study. Am J Sports Med 28(4):480–489
Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D (2004) Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med 32(5):1122–1130
Witvrouw E, Werner S, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G (2005) Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc 13:122–130
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Werner, S. Anterior knee pain: an update of physical therapy. Knee Surg Sports Traumatol Arthrosc 22, 2286–2294 (2014). https://doi.org/10.1007/s00167-014-3150-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-014-3150-y