Guidelines - Patellofemoral Pain

This tool provides information to facilitate the management of patellofemoral pain (PFP) in adolescents and adults.

Focused examination

1. Patient History 

  • Rule out risk factors for major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery.

Major structural or other pathologies (red flags):

  • Sharp pain, persistent nagging ache, unexplained deformity, swelling, or redness of the skin, weakness not due to pain, fever/chills/feeling ill, pain at rest

Examples of other conditions/co-morbidities:

  • Physical conditions: back pain, headache

  • Psychological conditions: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Rule out major structural or other pathologies.

  • Assess for neurological signs.

  • Appropriately diagnose PFP.

Criteria for PFP:

  1. Presence of retropatellar or peripatellar pain AND;

  2. Reproduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the patellofemoral joint (PFJ) in a flexed position AND;

  3. Exclusion of all other conditions that may cause anterior knee pain including tibiofemoral pathologies

3. Management 

  • Offer information on nature, management, and the course of PFP. See patient handouts for more information to provide to patients.

  • Discuss the range of effective interventions with the patient and, together, select a therapeutic intervention.

Patient Handouts

CCGI_Patellofemoral knee pain_patient ha
 

Therapeutic Management of PFP

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider multimodal care

    • Cobination of hip– and knee-targeted exercise therapy and one or more of the following:

      • tailored patellar taping in combination with exercise therapy

      • prefabricated foot orthoses for those with greater than normal pronation

      • physical therapy

      • gait retraining 

      • acupuncture

  • Consider load management education, body weight management (when appropriate)

  • Consider blood flow restriction plus high-repetition knee exercise therapy

  • Do not offer dry needling

  • Do not offer manual therapy including lumbar, knee, or patellofemoral manipulation/mobilization

  • Do not offer patellofemoral knee orthoses, including braces, sleeves, or straps

  • Do not offer EMG-based biofeedback on medial vastii activity to augment knee-targeted (quadriceps) exercise therapy

  • Do not offer visual biofeedback on lower extremity alignment during hip- and knee-targeted exercises

  • Do not offer biophysical agents, including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, and therapeutic laser

*Interventions are recommended if guidelines used terms such as ‘recommended for consideration’ (e.g., ‘offer’, ‘consider’), ‘strongly recommended’, ‘recommended without any conditions required’, or ‘should be used’. Recommendations from low-quality evidence are not listed.
ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines.

Care Pathway for the management of patellofemoral pain

(click here for French version)

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors that may delay recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms.

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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