Objective: This guideline provides recommendations regarding diagnosis, examination, and interventions/treatment of patellofemoral pain (PFP).

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Definition: 

• PFP is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee.

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Target Population: Primary adolescents (12 years of age or older) and adult persons with PFP

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Target Users: Physical therapists and other rehabilitation

Title of guideline: Patellofemoral Pain: clinical practice guideline linked to the International Classification of Functioning, Disability and Health from the Academy of Orthopaedic Physical Therapy of the American Physcial Therapy Association

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Author(s): Willy R, Hoglund LT, et al. 

Year of publication: 2019

Link to full guideline: Link

Levels of Evidence

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I: Evidence obtained from systematic reviews, high-quality diagnostic studies, prospective studies, or randomized controlled trials

II: Evidence obtained from systematic reviews, lesser-quality diagnostic studies, prospective studies, or randomized controlled trials (e.g., weaker diagnostic criteria and reference standards, improper randomization, no blinding, less than 80% follow-up)

III: Case-control studies or retrospective studies

IV: Case series

V: Expert opinion

Grades of Recommendation

A: Strong Evidence: A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I study

B: Moderate Evidence: A single high-quality randomized controlled trial or a preponderance of level II studies support the recommendation

C: Weak Evidence: A single level II study or a preponderance of level III and IV studies, including statements of consensus by content experts, support the recommendation

D: Conflicting Evidence: Higher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies

E: Theoretical/ foundational Evidence: A preponderance of evidence from animal or cadaver studies, from conceptual models/ principles, or from basic science/bench research support this conclusion

F: Expert Opinion: Best practice based on the clinical experience of the guideline development team

• Use reproduction of retropatellar or peripatellar pain during squatting as a diagnostic test to PFP. Clinicians should also use performance of other functional activities that load the patellofemoral joint (PFJ) in a flexed position, such as stair climbing or descent, as diagnostic tests for PFP

• Make the diagnosis of PFP using the following criteria:

  • The presence of retropatellar or peripatellar pain AND

  • Reproduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position AND

  • Exclusion of all other conditions that may cause anterior knee pain (AKP) including tibiofemoral pathologies

• Use the patellar tilt test with the presence of hypomobility to support the diagnosis of PFP

Key Recommendations - Examination

• Use the AKPS, KOOS-PF, VAS for activity, or EPQ questionnaires to measure pain and function in patients with PFP. In addition, cli­nicians should use the VAS for worst pain, the VAS for usual pain, or the NPRS to measure pain. Clinicians should use one of the translations and cross-cultural adaptations with dem­onstrated validity, reliability, and responsiveness to change for patients in different countries and for those requiring questionnaires in languages other than English.

• Administer appropriate clinical or field tests that reproduce pain and assess lower-limb movement coordination, such as squatting, step-downs, and the single-leg squats. These tests can assess a patient’s baseline status relative to pain, function, and disability; glob­al knee function; and changes in the patient’s status throughout the course of treatment.

• When evaluating a patient with PFP over an epi­sode of care, assess body structure and function, including measures of patellar provo­cation, patellar mobility, foot position, hip and thigh muscle strength, and muscle length.

Key Recommendations - Interventions

• Include exercise therapy with combined hip- and knee-targeted exercises in the treatment of individuals with PFP to reduce pain and improve patient-reported outcomes and functional per­formance in the short, medium, and long term. Hip-target­ed exercise therapy should target the posterolateral hip musculature. Knee-targeted exercise therapy includes ei­ther weight-bearing (resisted squats) or non–weight-bear­ing (resisted knee extension) exercise, as both exercise techniques target the knee musculature. Preference to hip-targeted exercise over knee-targeted exercise may be given in the early stages of treatment of PFP. Overall, the combi­nation of hip- and knee-targeted exercises is preferred over solely knee-targeted exercises to optimize outcomes in pa­tients with PFP.

• Use tailored patellar taping in com­bination with exercise therapy to assist in immedi­ate pain reduction, and to enhance outcomes of exercise therapy in the short term (4 weeks). Importantly, taping techniques may not be beneficial in the longer term or when added to more intensive physical therapy. Taping ap­plied with the aim of enhancing muscle function is not recommended.

• Prescribe prefabricated foot or­thoses for those with greater than normal prona­tion to reduce pain in individuals with PFP, but only in the short term (up to 6 weeks). If prescribed, foot orthoses should be combined with an exercise therapy pro­gram. There is insufficient evidence to recommend custom foot orthoses over prefabricated foot orthoses.

• Use gait retraining consisting of multiple sessions of cuing to adopt a forefoot-strike pattern (for rearfoot-strike runners), cuing to in­crease running cadence, or cuing to reduce peak hip adduc­tion while running for runners with PFP.

• Use blood flow restriction plus high-repetition knee exercise therapy, while monitoring for adverse events, for those with limiting painful resisted knee extension.

• Use acupuncture to reduce pain in individuals with PFP. However, caution should be exercised with this recommendation, as the superi­ority of acupuncture over placebo or sham treatments is un­known. This recommendation should only be incorporated in settings where acupuncture is within the scope of practice of physical therapy.

• Include specific patient education on load management, body-weight management when appropriate, the importance of adherence to active treatments like exercise therapy, biomechanics that are thought to contribute to relative overload of the PFJ, the evi­dence for various treatment options, and kinesiophobia. Pa­tient education may improve compliance and adherence to active management and self-management strategies and is unlikely to have adverse effects.

• Combine physical therapy inter­ventions for the treatment of individuals with PFP, which results in superior outcomes compared with no treatment, flat shoe inserts, or foot orthoses alone in the short and medium term. Exercise therapy is the critical com­ponent and should be the focus in any combined intervention approach. Interventions to consider combining with exercise therapy include foot orthoses, patellar taping, patellar mobi­lizations, and lower-limb stretching.

• Do not use dry needling for the treat­ment of individuals with PFP.

Grades

of Recommendation

• Do not use manual therapy, includ­ing lumbar, knee, or patellofemoral manipulation/ mobilization, in isolation for patients with PFP.

• Do not use patellofemoral knee or­thoses, including braces, sleeves, or straps, for the treatment of individuals with PFP.

• Do not use EMG-based biofeed­back on medial vastii activity to augment knee-targeted (quadriceps) exercise therapy for the treatment of PFP.

• Do not use visual biofeedback on lower extremity alignment during hip- and knee-targeted exercises for the treatment of individuals with PFP.

• Do not use biophysical agents, in­cluding ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, and therapeu­tic laser, for the treatment of patients with PFP.