30 Seconds Of Therapy: Knee Patellofemoral Pain Syndrome (PFPS)

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Patellofemoral pain syndrome (PFPS), also known as runner's knee, is a condition characterized by pain in the front of the knee, specifically around the kneecap (patella). The pain is often described as a dull ache and may worsen with activities that load the knee, such as bending, climbing stairs, squatting, or prolonged sitting. — ***Patellofemoral pain syndrome (PFPS)***, also known as runner's knee, is a condition characterized by pain in the front of the knee, specifically around the kneecap (patella). The pain is often described as a dull ache and may worsen with activities that load the knee, such as bending, climbing stairs, squatting, or prolonged sitting.

START

Hip Strengthening
a. Hip-focused rehab should precede knee-centric work for better early outcomes:
1. 25% strength deficit in glute medius/maximus in PFPS patients.
2. 4-week hip protocol led to faster pain reduction and functional improvements vs. quadriceps-focused alone.
3. Exercises:
  - Sidelying hip abduction
  - Monster walks with resistance bands
  - Prone hip extension Download Exercises PDF
4. Clinical Application Protocols by PFPS Category
Use Both Open and Closed Chain Exercises
1. Combining OC and CC exercises enhances both isolated strength and kinetic chain function:
  1. Open Chain (OC): Ideal for maximizing quadriceps recruitment (especially VM).
  2. Closed Chain (CC): Facilitates kinetic chain integration and real-life movement patterns.
  3. Useful pairings:
    - Short arc quad in hip external rotation (best VMO activation)
    - Step-downs for proximal chain reinforcement.
    - Lunges and single-leg squats for neuromotor re-education.
Integrate Multi-Joint Exercise Programs
1. Multi-joint strengthening programs significantly reduced pain in women with PFPS.
  1. These programs are more effective in improving pain and function compared to isolated single-joint exercises, especially in the short term.
  2. Exercises:
    - Step-ups, squats, bridges, and split squats
    - Start low load, progress to functional resistance over 10–12 weeks

STOP

Avoid Isolated Quadriceps Protocols
1. Hip + knee strengthening is more effective than knee-only programs in reducing pain and improving activity levels.
2. Solely targeting the quads may ignore the proximal weakness and neuromotor deficits that commonly contribute to PFPS.
Early High-Speed Isokinetics
1. High-speed loading can overload compromised tissue structures, especially in tension-type and friction-type PFPS.
2. Such exercises should be reserved for later rehab stages, after tissue tolerance is restored through eccentric loading and controlled functional work.
  1. Early-phase:
    - Partial ROM
    - Submaximal isometrics
    - Controlled eccentric work

Avoid Full ROM Closed-Chain Loading in Pain
1. In compression-type PFPS (e.g., OA or articular cartilage damage), deep loaded flexion increases joint stress.
  1. Use:
    - Partial ROM, pain-free reps
    - Open chain VM activation
    - Isometrics at multiple angles

WHY

PFPS Often Has a Proximal Origin
1. 25% strength deficit in the hip muscles (glute max and medius) of PFPS patients.
  1. EMG data shows:
    1. Glute Max: ~100% MVIC during plank extensions.
    2. Glute Med: ~60% MVIC during single-limb squats.
Proximal Focus = Quicker and More Predictable Results
1. 88% sensitivity for patients responding to hip/core interventions.
2. Start with hip → progress to integrated chain → monitor at 10–12 weeks.

References: 1. MedBridge Treatment of Patellofemoral Joint Disorders Terry Malone, PT, EdD, ATC, FAPTA 2. Bloomer, B. A., & Durall, C. J. (2015). Does the addition of hip strengthening to a knee-focused exercise program improve outcomes in patients with patellofemoral pain syndrome? Journal of Sport Rehabilitation, 24(4), 428–433. https://doi.org/10.1123/jsr.2014-0184 3. Bolgla, L. A., Boling, M. C., Mace, K. L., DiStefano, M. J., Fithian, D. C., & Powers, C. M. (2018). National Athletic Trainers' Association position statement: Management of individuals with patellofemoral pain. Journal of Athletic Training, 53(9), 820–836. https://doi.org/10.4085/1062-6050-231-15 4. Bolgla, L. A., Malone, T. R., Umberger, B. R., & Uhl, T. L. (2008). Hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. The Journal of Orthopaedic and Sports Physical Therapy, 38(1), 12–18. https://doi.org/10.2519/jospt.2008.2462 5. Bolgla, L. A., Malone, T. R., Umberger, B. R., & Uhl, T. L. (2010). Reliability of electromyographic methods used for assessing hip and knee neuromuscular activity in females diagnosed with patellofemoral pain syndrome. Journal of Electromyography and Kinesiology, 20(1), 142–147. https://doi.org/10.1016/j.jelekin.2008.11.008 6. Bolgla, L. A., Malone, T. R., Umberger, B. R., & Uhl, T. L. (2011). Comparison of hip and knee strength and neuromuscular activity in subjects with and without patellofemoral pain syndrome. International Journal of Sports Physical Therapy, 6(4), 285–296. 7. Boling, M. C., Bolgla, L. A., Mattacola, C. G., Uhl, T. L., & Hosey, R. G. (2006). Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome. Archives of Physical Medicine and Rehabilitation, 87(11), 1428–1435. https://doi.org/10.1016/j.apmr.2006.07.264 8. Crossley, K. M., van Middelkoop, M., Barton, C. J., & Culvenor, A. G. (2019). Rethinking patellofemoral pain: Prevention, management and long-term consequences. Best Practice & Research: Clinical Rheumatology, 33(1), 48–65. https://doi.org/10.1016/j.berh.2019.02.004 9. Dolak, K. L., Silkman, C., Medina McKeon, J., Hosey, R. G., Lattermann, C., & Uhl, T. L. (2011). Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: A randomized clinical trial. The Journal of Orthopaedic and Sports Physical Therapy, 41(8), 560–570. https://doi.org/10.2519/jospt.2011.3499 10. Earl-Boehm, J. E., Bolgla, L. A., Emory, C., Hamstra-Wright, K. L., Tarima, S., & Ferber, R. (2018). Treatment success of hip and core or knee strengthening for patellofemoral pain: Development of clinical prediction rules. Journal of Athletic Training, 53(6), 545–552. https://doi.org/10.4085/1062-6050-510-16 11. Lavagnino, M., Arnoczky, S. P., Elvin, N., & Dodds, J. (2008). Patellar tendon strain is increased at the site of the jumper's knee lesion during knee flexion and tendon loading: Results and Treatment of Patellofemoral Joint Disorders 2 cadaveric testing of a computational model. The American Journal of Sports Medicine, 36(11), 2110–2118. https://doi.org/10.1177/0363546508322496 12. Nascimento, L. R., Teixeira-Salmela, L. F., Souza, R. B., & Resende, R. A. (2018). Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in individuals with patellofemoral pain: A systematic review with meta-analysis. The Journal of Orthopaedic and Sports Physical Therapy, 48(1), 19–31. https://doi.org/10.2519/jospt.2018.7365 13. Nicholas, J. A., & Marino, M. (1987). The relationship of injuries of the leg, foot, and ankle to proximal thigh strength in athletes. Foot & Ankle, 7(4), 218–228. https://doi.org/10.1177/107110078700700404 14. Reiman, M. P., Bolgla, L. A., & Lorenz, D. (2009). Hip functions influence on knee dysfunction: A proximal link to a distal problem. Journal of Sport Rehabilitation, 18(1), 33–46. https://doi.org/10.1123/jsr.18.1.33 15. Reiman, M. P., Bolgla, L. A., & Loudon, J. K. (2012). A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiotherapy Theory and Practice, 28(4), 257–268. https://doi.org/10.3109/09593985.2011.604981 16. Saltychev, M., Dutton, R. A., Laimi, K., Beaupré, G. S., Virolainen, P., & Fredericson, M. (2018). Effectiveness of conservative treatment for patellofemoral pain syndrome: A systematic review and meta-analysis. Journal of Rehabilitation Medicine, 50(5), 393– 401. https://doi.org/10.2340/16501977-2295 17. Scali, K., Roberts, J., McFarland, M., Marino, K., & Murray, L. (2018). Is multi-joint or single joint strengthening more effective in reducing pain and improving function in women with patellofemoral pain syndrome? A systematic review and meta-analysis. International Journal of Sports Physical Therapy, 13(3), 321–334. 18. Wilk, K. E., Davies, G. J., Mangine, R. E., & Malone, T. R. (1998). Patellofemoral disorders: A classification system and clinical guidelines for nonoperative rehabilitation. The Journal of Orthopaedic and Sports Physical Therapy, 28(5), 307–322. https://doi.org/10.2519/jospt.1998.28.5.307 19. Willy, R. W., Hoglund, L. T., Barton, C. J., Bolgla, L. A., Scalzitti, D. A., Logerstedt, D. S., Lynch, A. D., Snyder-Mackler, L., & McDonough, C. M. (2019). Patellofemoral pain. The Journal of Orthopaedic and Sports Physical Therapy, 49(9), CPG1–CPG95. https://doi.org/10.2519/jospt.2019.0302