Patellofemoral pain (PFP), also known as patellofemoral pain syndrome is used to describe general pain within the front of the knee, particularly around the kneecap, or patella. The pain, discomfort, or sometimes feelings of clicking, typically occurs with running, squatting, stairs, or sitting for prolonged amounts of time.
The patella lies on top of the femur (thigh bone) within a groove called the trochlea which allows for bony stability of the patellofemoral joint. As we flex or extend our knee, the patella will slide up or down along the trochlear groove where both surfaces are covered with articular cartilage allowing for smooth movement. A number of structures attach to the patella to allow for further stability. These structures include the quadricep tendon, iliotibial (IT) band, patellar tendon, and medial and lateral patellar retinaculum. If there is an increased or decreased pull from any of the structures that help with stability, the patella will not slide smoothly through the trochlear groove causing pain or discomfort.
The patella is most commonly pulled laterally due to the number of structures that contribute to this pull and cause irritation between the patella and femur. With increased maltracking, this irritation can turn into Chondromalacia Patellae which are degenerative changes to the cartilage that lies under the patella.
What are the common Causes of PFP?
Incorporating or changing physical activity can cause irritation or pain between the patella and femur. This can occur by increasing the frequency, intensity, or duration of a specific activity like running.
Abnormal patellar tracking can occur due to several structural differences between individuals. An increased Quadriceps angle (Q angle) or a pes planus abnormality (flat foot) can both contribute to a lateral pull of the patella.
Tight or weak muscles tend to have the biggest impact on the amount of pull on the patella. If some muscles are weak, our bodies will compensate and overwork other muscles leading to tightness. Some of these factors include:
Weak vastus medialis oblique (VMO)
Weak gluteus medius and minimus
Tight tensor fascia latae (TFL)
Tight IT Band
How Can Physiotherapy Help?
Physiotherapy has been found to be an effective way to treat PFP. A physiotherapist can assess the number of factors that contribute to PFP. The physiotherapist will assess several functional activities including walking, squatting, lunges, stairs, jumps, etc. to determine any factors that could contribute to malalignment of the patella. The physiotherapist can also assess the strength and length of different muscles within the lower extremity to determine other factors that could contribute to knee pain or discomfort. The physiotherapist will also have a feel for how the patella and knee joints move to help determine a treatment plan.
A physiotherapist will provide education on the above findings to determine a solution. On top of therapy within the clinic, most of the effects will be seen by strengthening weak muscles and releasing or stretching tight muscles.
A physiotherapist can work to release tight muscles through several different techniques including soft tissue release, trigger point release, cupping, dry needling, and modalities. A physiotherapist can also mobilize the patellofemoral and knee joint to help improve proper tracking.
External support through taping or braces has been shown to have both structural effects towards patellar tracking as well as biofeedback which helped decrease PFP symptoms. The external support can act as a barrier for the patellar so it can remain within the femoral trochlear groove.
Different types of tape can be used depending on the patient’s goals and the amount of stability needed. A brace will provide the most external support and control or restrict the movement of the patella allowing for decreased pain or discomfort. As there are a number of different types of braces, the physiotherapist can help guide which one is best.
Orthotics can also be an option if there is overpronation of the foot (flat-footed). They can help by adding support to the arch and improving the rotation of the tibia. Improving the rotation of the lower leg can improve upstream and the tracking of the patella.
Easing back into activities
Since overuse is a common cause of PFP, it is critical to not jump right back into normal activities when the pain or discomfort starts to improve. It is important to ease back into your activities by increasing frequency, intensity, and duration over time. The experienced physiotherapists at K-TOWN Physiotherapy can help determine a specific return to activity protocol.
Three PFP Strength Exercises
Clamshell with a Band
Lie on your side with your affected side up with a band around your thighs, just above your knees. Hips should be flexed slightly, and knees should be flexed around 90 degrees. Stack both legs on top of each other and while keeping your feet together, lift your top knee away from the bottom knee and slowly lower back to the starting position.
Banded Side Steps
Wrap a band around your legs, just above the knees. Turn your feet out slightly and place a slight bend in the knee ensuring that the knees are over your toes. While keeping this position, slowly take a small sidestep while always keeping tension on the band and repeat.
Straight Leg Raise with External Rotation
Lie on your back with the unaffected knee bent. Straighten the affected leg with slight external rotation (pointing your knee laterally). While keeping your leg in this position, lift the leg to about 45 degrees then lower slowly back down to the starting position.
Three PFP Stretches/Releases
TFL Release on Foam Roller or Ball
Place a foam roller or lacrosse ball on the floor. Take a side position with your affected side down. Place the side of the hip over the foam roller or the ball with the other leg bent to support you. The TFL muscle sits behind the bone at the front of your hip and just in front of the greater trochanter (a large bone you can feel on the side of the hip). If using a foam roller, roll back and forth. If using a lacrosse ball, find a tight spot and hold each spot for 30 seconds.
Sit on the edge of a sturdy chair with the unaffected leg bent and the affected leg extended out in front of you. Stick your hips back while keeping your back straight. Slowly bend forward until you feel a stretch behind your straight leg.
Stand in front of a wall with your legs staggered. Place the affected leg behind. Keep the back knee extended and straight with the heel remaining on the ground. While keeping the back leg in this position, slowly bend the front knee closer to the wall until you feel a stretch in the calf of the back leg.
Lauren Ianni, Queen's Student PT.
Magee D. Orthopedic Physical Assessment. 6th Edition. St. Louis, MO: Saunders; 2-14. Redrawn from Neumann DA. Kinesiology of the musculoskeletal system – foundations for physical rehabilitation. St. Louis, 2002, Mosby, p. 463.
Nunes, G. S., Stapait, E. L., Kirsten, M. H., de Noronha, M., & Santos, G. M. (2013). Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine, 14(1), 54–59. https://doi.org/10.1016/j.ptsp.2012.11.003
Crossley, K., Bennell, K., Green, S., Cowan, S., & McConnell, J. (2002). Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. The American journal of sports medicine, 30(6), 857–865. https://doi.org/10.1177/03635465020300061701