DALLAS, TX – Patellofemoral pain (PFP) is one of the most common but misunderstood knee problems in active individuals seen by Orthopaedic and Sports Medicine practitioners. It is also one of the most challenging conditions to manage due to its complex nature. To support athletic trainers, as well as other healthcare providers, the National Athletic Trainers’ Association (NATA) has published recommendations and a framework for identifying risk factors and managing patients that experience PFP. The position statement, “Management of Individuals With Patellofemoral Pain”, is available online in the most recent edition of the Journal of Athletic Training, NATA’s scientific publication.
“This statement is the culmination of four years of research and over 20 years of clinical work,” said lead author, Lori A. Bolgla, Ph.D., PT, MAcc, ATC. “My hope is that our findings in this statement will provide additional tools for clinicians to achieve even more positive short and long-term outcomes for these patients.”
“Patellofemoral pain affects more than 22% of the population with patients ranging from student athletes to active older adults,” said NATA President, Tory Lindley, MA, ATC. “The research and analysis led by Dr. Bolgla provide additional insight and recommendations that clinicians can use to diagnose, treat and rehabilitate PFP.”
The National Athletic Trainers’ Association (NATA) suggests the following guidelines to identify risk factors and manage patients with PFP.
RISK FACTORS
PFP is particularly prevalent in younger people who are physically active with females reported as a higher risk for development. Early identification of risk factors may allow clinicians to develop and implement programs aimed at reducing the severity and length of this condition. The significance of early detection is highlighted by the fact that as many as 70% to 90% of individuals with this condition have recurrent or chronic symptoms.
- Excessive hip adduction and internal rotation during dynamic tasks such as running and landing from a jump
- Quadriceps weakness and tightness
- Greater vertical peak force to the lateral heel and second and third metatarsals during gait
- Delayed activation of the vastus medialis obliquus (VMO) relative to the vastus lateral (VL), as identified with a patellar tendon tap or voluntary tasks (e.g., rocking back on the heels)
- Increased knee abduction impulses and moments during running and landing activities
- Hip muscle weakness is not a likely risk factor associated with patellofemoral pain onset.
BEST PRACTICES FOR CONSERVATIVE MANAGEMENT
PFP is a multifactor problem that requires a comprehensive plan of care consisting of active interventions (hip and quadriceps strengthening exercise, neuromuscular retraining) and patient education (contributing factors, activity modification, and rehabilitation adherence). Clinicians should consider movement retraining for individuals with PFP who demonstrate altered lower extremity gait mechanics. Nonsurgical treatment continues to be the recommended strategy.
Patient Education
- Identify contributing factors
- Get patient “buy-in” on treatment options
- Share expected rehabilitation outcomes
- Discuss the importance of active interventions
Active Interventions
- Quadriceps and gluteal strengthening exercises
- Ankle and foot exercises if deficits exist
- Calf and hamstrings stretching if deficits exist
- Hip movement retraining if deficits exist
Passive Interventions
- Patellar taping if it provides pain relief
- Foot orthoses in patients with excessive dynamic foot pronation
- Patella, ankle and first-ray joint mobilization if deficits exist
PFP is a complex condition with no single contributory factor. Treatment for PFP should include a multimodal approach addressing impairments not only at the knee but also the hip, foot, and ankle. Continued research is necessary to refine these recommendations and to advance our understanding of this complicated issue.