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Non-Traumatic Anterior Knee Pain Care Pathway

Date of last update: September, 2024

About Non-Traumatic Anterior Knee Pain

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Overview: Non-traumatic anterior knee pain is common, with multiple mechanisms of injury. Examples include patellofemoral pain syndrome and knee bursitis. Anterior knee pain that is not due to serious underlying pathology requiring medical attention, such as infection, tumor, or fracture, is typically amenable to conservative care (e.g., education, manual therapy, exercise).

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Effective Management: Given the varied etiologies of non-traumatic anterior knee pain and the potential influence of physical, psychological, social, and environmental elements, there is no one-size-fits-all treatment. Effective management is ethical, evidence-driven, transparent, flexible and responsive to the person’s needs. Essential interventions include education, reassurance, addressing psychosocial factors, maintaining activities of daily living, and self-care practices. Additional interventions are selected through shared decision-making to align with patient goals, ultimately optimizing their ability to function and participate in life. Continuous monitoring of progress and consistent assessment of outcomes against goals are crucial to ensure that care strategies remain aligned with the patient's objectives and best interests. Management can be conducted in-person, or through virtual or hybrid care.

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About the Care Pathway

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  • Principles: Based on recommendations drawn from established clinical guidelines, integrating the best available evidence, clinical expertise, and patient preferences. Treatments are aligned with current guideline-supported practices. Developed with input from professional leaders, clinicians, and researchers.

 

  • Target Audience: Supports clinicians who deliver conservative care, and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.

 

  • Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current and evidence driven.

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  • ​Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

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***CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Non-Traumatic Anterior Knee Pain Quick Guide

1. Record Keeping

  • Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standards.

3. Health History

  • ​Apply cultural awareness and trauma-informed care principles.

  • Sociodemographic: Age, gender, sex.

  • Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.

  • Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

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Meaningful Outcomes:

4. Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer to emergency care immediately for red flags:

  • Deep Vein Thrombosis (DVT): Throbbing pain in calf/thigh, entire leg swollen, active cancer, paralysis/paresis/recent plaster immobilization of lower extremity, recently bedridden for 3 days, major surgery within 12 weeks requiring general anesthesia, previous DVT, shortness of breath, chest pain.

  • Infection: Severe acute pain; erythema, edema, and warmth around knee joint; night sweats; night pain; fever; chills; recent trauma/surgery/IV drug use.

 

ACTION: Refer to appropriate medical provider:

  • Peripheral Arterial Disease (PAD): Leg pain/cramping while walking; cold lower extremities; absent/weak pulses in lower extremities; leg numbness/weakness; history of coronary heart disease, cerebrovascular disease, diabetes, hypertension, hypercholesterolemia; family history of PAD; smoking; previous vascular problems; cancer; COPD; previous thromboembolic events.

  • Inflammatory Arthritides: Rheumatoid Arthritis: Morning stiffness > 1 hour, symmetrical joint pain, joint swelling and deformity. Reactive Arthritis: Joint pain and swelling following an infection. Gout: Severe acute pain, redness, swelling, warmth in knee.

  • Referred Pain: Slipped Capital Femoral Epiphysis: Referred knee pain from hip joint pathology, typically in adolescence; limp, toe-out gait, leg length discrepancy. Hip Osteoarthritis: Referred knee pain from hip; hip pain and stiffness; reduced hip ROM. Lumbar Radiculopathy: Referred pain from lower back to knee; radiating pain, numbness, or tingling; positive straight leg raise test.

  • Tumor (e.g., Giant Cell Tumor): Noticeable lump in knee, pain worsening with movement, swelling tenderness.

  • Peripheral Neuropathy (e.g., saphenous neuritis/gonalgia paresthetica): Anterior/medial knee pain; pain to touch along the nerve, activity-related pain or pain at rest; aggravated by limb movements that tension the nerve

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9, GAD-7.

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

  • Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims; maladaptive coping mechanisms.

  • Screening tools: PHQ-9, GAD-7, FABQ, ORT, PCS.

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

  • Observation: Colour, patellar position, genu valgum/varum/recurvatum/Q-angle, unilateral asymmetries, edema/effusion, muscle wasting, posture, gait, movements.

  • Range of Motion: Active, passive, resisted (flexion, extension, internal/external rotation). Assess for pain, limitation/laxity, crepitus.

  • Palpation: Superficial: edema/effusion, patella, proximal and distal patellar tendon, bursae, medial and lateral tib-femoral joint line, tibial tuberosity. Deep: e.g., thigh muscles, pes anserine, popliteus muscles, lower leg muscles.

  • Functional tests: E.g., gait, sit to stand, squat, jump, hop, run, kneel, stair climbing up/down. Evaluate antalgia, reduced ROM, pain, fluidity of movement, compensatory movement.

  • Neurological Examination: Motor strength, sensory and reflex testing (L2, L3, L4, L5, S1, S2); upper and lower motor neuron signs.

  • Special/Orthopedic Tests: Select as appropriate based on clinical judgment.

  • Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment).

8. Diagnostic Criteria for Non-Traumatic Anterior Knee Pain

A. Patellofemoral Pain Syndrome (PFPS) (includes chondromalacia patellae, plica syndrome, quadriceps tendinopathy, patellar       tendinopathy/Jumper’s Knee/infrapatellar tendinopathy, IT band syndrome).

  • Location: Anterior retropatellar or peripatellar regions.

  • Signs/Symptoms: Pain with lower limb loading activities (squatting, stairs, jumping, walking).

  • Exam: Pain with functional testing (squatting, stairs, jumping), no neurological deficits.

B. Knee Bursitis (prepatellar, infrapatellar, suprapatellar, pes anserine)

  • Location: Anterior or medial knee depending on the affected bursa.

  • Signs/Symptoms: Pain, swelling, occasionally redness.

  • Exam: Point tenderness, no warmth to touch, no neurological deficits.

C. Osgood-Schlatter Disease

  • Location: Tibial tuberosity.

  • Signs/Symptoms: Pain and swelling at the tibial tuberosity, often in adolescents during growth spurts.

  • Exam: Tenderness and swelling over tibial tuberosity, no neurological deficits.

D. Hoffa's Syndrome (Infrapatellar Fat Pad Impingement)

  • Location: Infrapatellar region.

  • Signs/Symptoms: Anterior knee pain, especially when the knee is in extension.

  • Exam: Tenderness around the fat pad, pain with knee extension, no neurological deficits.

E. Osteoarthritis (OA)

  • Location: Affects the medial/lateral/patellofemoral compartments of the knee.

  • Signs/Symptoms: Pain with activity, stiffness after rest, crepitus, and sometimes swelling.

  • Exam: Joint line tenderness, bony enlargement, decreased ROM, crepitus with movement, and possibly effusion; no neurological deficits.

9. Treatment Considerations for Non-Traumatic Anterior Knee Pain

After providing a report of findings and obtaining written informed consent.

  • Core Interventions:

    • Education and reassurance: Provide Information about the condition and its typically favourable prognosis.

    • Address yellow flags (psychosocial factors): Use strategies such as CBT or referrals to address barriers to recovery (e.g., fear-avoidance, stress, anxiety).

    • Maintain activities of daily living: Encourage continued movement and activity as tolerated, avoiding prolonged rest or immobilization.

    • Self-care: Recommend home-based exercise, balanced nutrition, good sleep hygiene, stress management, maintaining a healthy body weight, and avoiding smoking/substance abuse.

    • Engage in social and work activities: Encourage continued engagement in social and work activities as part of rehabilitation.

    • Exercise therapy:

      • Early Phase: Gentle strengthening exercises (e.g., isometric, hip-focused exercises) and knee range of motion (ROM) exercises to prevent stiffness and maintain function.

      • Progression: As symptoms improve, progress to dynamic and functional exercises (e.g., squats, lunges) that engage both the hip and knee muscles.

 

  • Optional Interventions:

    • Manual therapy: Joint mobilization or soft tissue techniques, combined with exercise therapy.

    • Heat/cold therapy: Cold for reducing inflammation, heat for relieving stiffness; used as an adjunct to exercise.

    • Taping: Kinesiotaping or patellar taping for short-term pain relief during movement.

    • Prefabricated foot orthoses: For short-term relief in patients with biomechanical issues (e.g., pronation).

    • Medications: Consult with a medical provider. Short-term NSAIDs for managing pain and inflammation; avoid long-term use.

10. Prognosis

  • Recovery: Most people improve with conservative treatment (e.g., education, lifestyle modifications, exercise). Recovery time can vary based on symptom severity and treatment adherence.

  • Negative Prognostic Factors: Frequent or severe pain, fear avoidance, pain catastrophizing, limited knee function, high disability level, poor response to initial conservative treatment, poor recovery expectation.

11. Ongoing Follow-up

  • Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgment.

  • Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

  • Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).

  • ​Discuss post-discharge plans, including self-management strategies and potential follow-ups.

References

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Wallis JA, et al. A Systematic Review of Clinical Practice Guidelines for Physical Therapist Management of Patellofemoral Pain. Physical Therapy & Rehabilitation, 2021.

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Willy RW, et al.  Patellofemoral Pain. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health. From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. J Orthop Sports Phys Ther, 2019.

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​​Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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