Patellofemoral pain syndrome (PFPS) is a condition presenting with anterior

knee pain or pain behind the patella (retropatellar pain).1 The term “PFPS” is often

used interchangeably with “anterior knee pain” or “runner’s knee.” PFPS can be

defined as anterior knee pain involving the patella and retinaculum that excludes other

intraarticular and peripatellar pathology2.It is commonly experienced during running,

squatting, stair climbing, prolonged sitting and kneeling.3 In the Patellofemoral joint,

the patella serves as a link to converge the fibers of quadriceps femoris muscle group

to increase its lever arm and maximizing its mechanical advantage.4 To ensure its

functional efficacy, it is necessary to maintain patellar alignment in the trochlear

groove of the femur.5

Knee pain is one of the most commonly reported musculoskeletal disorders

with estimates that it will affect 30-40% of population by age 656. Anterior knee pain

is the most prevalent disorder involving the knee, with its prevalence being as high as

7% at any one time in active young adults7.

Anterior knee pain or patellofemoral pain syndrome is a common symptom

complex characterized by pain in the vicinity of the patella in young adults worsened

by sitting and climbing stairs8.

Among all the causes of anterior knee pain, Patellofemoral pain syndrome

(PFPS) is the most common diagnosis in outpatients presenting with knee pain.

Studies have shown PFPS to be the most common single diagnosis among runners

and in sports medicine centers9. Eleven percent of musculoskeletal complaints in the

office setting are caused by anterior knee pain (which most commonly results from

PFPS), and PFPS constitutes 16 to 25 percent of all injuries in runners 6.

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Patellofemoral pain is common, particularly in active, young patient with

patellofemoral malalignment10.

Patellofemoral pain syndrome (PFPS) is the most common cause of knee pain

in the out patient setting. It is caused by imbalances in the forces controlling patellar

tracking during knee flexion and extension, particularly with overloading of the joint.

Risk factors include overuse, trauma, muscle dysfunction, tight lateral restraints,

patellar hypermobility, and poor quadriceps flexibility. Typical symptoms include pain

behind or around the patella that is increased with running and activities that involve

knee flexion11.

Despite its frequent occurrence, PFPS remains a difficult and often frustrating

condition for all of us to treat, it is not only difficult to treat but also difficult to asses

its gravity of pathology. In PFPS, identification of the underlying pathophysiology is

difficult, though the classic picture in Patellofemoral pain is easily identifiable. The

patient complains of retropatellar or peripatellar pain (mainly medial side)

precipitated by prolong sitting (Movie-Goer’s sign) and the pain is proportional to the

activity, particularly evident when squatting or descending stairs. Generally, onset is

insidious and progression slow. Patellar grind test is positive and patient complains of

discomfort or palpation of medial and lateral border of patella. Giving way and

instability is also common. 12

The patella is an unique structure that plays a central role in the normal

biomechanics of the knee. Unfortunately the patella remains the enigma of sports

medicine and sports physical therapy. Across all sports and all age, it is probably the

single most cause of pain13

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 In patellofemoral joint the patella acts as a lever and also increases the

moment arm of the patellofemoral joint, the quadriceps and patellar tendons. Many

theories have been proposed to explain the etiology of patellofemoral pain. These

include biomechanical, muscular and overuse theories. In general, the literature and

clinical experience suggest that the etiology of patellofemoral pain syndrome is

multifactorial14. Managing patellofemoral pain syndrome is a challenge, in part

because of lack of consensus regarding its cause and treatment14.

Anatomy and Biomechanics

The patellofemoral joint comprises the patella and the femoral trochlea. The

patella acts as a lever and also increases the moment arm of the patellofemoral joint,

the quadriceps and patellar tendons.15 Contact of the patella with the femur is initiated

at 20 degrees of flexion and increases with further knee flexion, reaching a maximum

at 90 degrees.16

Stability of the patellofemoral joint involves dynamic and static stabilizers

(Figure 1.2), which control movement of the patella within the trochlea, referred to as

"patellar tracking." Patellar tracking can be altered by imbalances in these stabilizing

forces affecting the distribution of forces along the patellofemoral articular surface,

the patellar and quadriceps tendons, and the adjacent soft tissues. Forces on the patella

range from between one third and one half of a person's body weight during walking

to three times body weight during stair climbing and up to seven times body weight

during squatting.17Abnormalities of patellar tracking must be understood to appreciate

the possible causes of PFPS and to determine the focus of treatment

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 Figure 1.2 Schematic of the right knee, anterior view. Dynamic stability of the

patellofemoral joint is provided by the quadriceps tendon, patellar tendon, vastus

medialis obliqus (VMO), vastus lateralis, and iliotibial band. The VMO is the only

muscle that provides a medial force and is therefore of particular importance in

stabilizing the patella. Static stability is provided via the articular capsule, the femoral

trochlea, the medial and lateral retinaculum, and the patellofemoral ligaments.

Palpation of the bony and soft tissue structures should be performed in an attempt to

identify the anatomic site of the pain.

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 Pathophysiology and Etiology

The patella articulates with the patellofemoral groove in the femur. Several

forces act on the patella to provide stability and keep it tracking properly .18

A common misconception is that the patella only moves in an up-and-down

direction. In undersurface of the patella and the femur.19-20 Repetitive contact at any of

these areas, sometimes combined with maltracking of the patella that is often not

detectable by the naked eye, is the likely mechanism of patellofemoral pain syndrome.

The result is the classic presentation of retropatellar and peripatellar pain. This pain

should not be confused with pain that occurs directly on the patellar tendon (patellar

tendonitis).

Many theories have been proposed to explain the etiology of patellofemoral

pain. These include biomechanical, muscular and overuse theories. In general, the

literature and clinical experience suggest that the etiology of patellofemoral pain

syndrome is multifactorial.18

Overuse and Overload

Because bending the knee increases the pressure between the patella and its

various points of contact with the femur, patellofemoral pain syndrome is often

classified as an overuse injury.21-23 However, a more appropriate term may be

"overload," because the syndrome can also affect inactive patients. Repeated weight-

bearing impact may be a contributing factor, particularly in runners.20 Steps, hills and

uneven surfaces tend to exacerbate patellofemoral pain. Once the syndrome has

developed, even prolonged sitting can be painful ("movie-goer's sign") because of the

extra pressure between the patella and the femur during knee flexion.18

Overload is common with sports that require a lot of running or weight

bearing activity. This is why ilotibial band is commonly a runner's injury. When the

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tensor fasciae latae muscle and iliotibial band become fatigued and overloaded, they

lose their ability to adequately stabilize the entire leg. This in-turn places stress on the

knee joint, which results in pain and damage to the structures that make up the knee

joint.24

Overload on the ITB can be caused by a number of things. They include:

• Exercising on hard surfaces, like concrete;

• Exercising on uneven ground;

• Beginning an exercise program after a long lay-off period;

• Increasing exercise intensity or duration too quickly;

• Exercising in worn out or ill fitting shoes; and

• Excessive uphill or downhill running.

Biomechanical errors include:

• Leg length differences;

• Tight, stiff muscles in the leg;

• Muscle imbalances;

• Foot structure problems such as flat feet; and

• Gait, or running style problems such as pronation.25

Risk Factors

Several factors may create a predisposition for the development of PFPS via

alterations in patellar tracking, increased patellofemoral joint forces, or combinations

of these biomechanical features. Overuse, trauma, and anatomic factors appear to be

the main contributors.

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• Anatomic anomalies (e.g., hypoplasia of the medial patellar facet, patella alta).

• Malalignment and altered biomechanics of the lower extremity (static or dynamic)

• Muscle dysfunction (e.g., quadriceps weakness, improper firing pattern).

• Poor quadriceps, hamstring, or iliotibial band flexibility

• Tight lateral structures (i.e., lateral retinaculum and iliotibial band)

• Training errors or overuse trauma.26

CLINICAL PICTURE

The characteristic complaint is a diffuse aching pain over the front or

anterioromedial aspect of knee and made worse when the knee functions under load in

flexion, such as prolonged sitting with knee flexion.27

OTHER SYMPTOMS

• Pain on ascending and descending stairs

• Crepitus

• Giving way

• Pseudolocking

• Swelling

Patellofemoral pain syndrome (PFPS) is a common problem and has an impact on

many aspects of daily life. The possibly multifactorial etiology of PFPS is partially

unknown and a wide range of conservative procedures has been used to treat patients

with the syndrome. There are evidences that shows exercise therapy reduces anterior

knee pain in patients with PFPS28.

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 Patellofemoral pain syndrome (PFPS) remains one of the most common and

challenging musculoskeletal entities encountered by physiotherapists and sports

medicine practitioners29.

The management and prevention of PFPS begin with an understanding of the

risk factors that predispose to this injury. Excessive pressure of the patella against the

underlying femur generally results from excessively tight quadriceps muscle which is

best addressed through appropriate stretching exercises. There are several risk factors

that can cause the patella to ride excessively on the side of the groove, invariably

along the lateral (outside) side of the groove. There are three primary causes of

improper patellar tracking: 1) weakness of the vastus medialis obliqus (VMO) -- the

large quadriceps muscle in the inside/front of the thigh, 2) tightness of the iliotibial

band, and 3) improper lower extremity biomechanics. When this is caused by

weakness of the VMO, the medial pull of the medial pull of the VMO is overwhelmed

by the lateral pull of the vastus lateralis (the quadriceps muscle on the outside front of

the thigh) and the iliotibial band, resulting in lateral tracking of the patella. Tightness

of the iliotibial band will also cause an excessive lateral pulling of the patella, again

by overwhelming the medial pull of the VMO. 30

Medial patellar instability can be assessed by displacing the patella medially

with the knee extended, then flexing the knee and releasing the patella. Pain indicates

medial subluxation.31 Finally, flexibility of the iliotibial band (ITB), quadriceps,

hamstrings, hip flexors, and the gastrocnemius should be evaluated. Tightness of the

ITB and tightness of the quadriceps have been shown to be risk factors for PFPS.

Poor flexibility in these areas may contribute to stress across the patellofemoral joint,

and attention should be directed to this in therapy.32-33

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 Non-operative management includes patellar taping; stretching of the lower

extremity muscles, including the quadriceps, hamstrings, gastrocnemius, anterior

tibialis, iliotibial band, and gluteal muscles; stretching of tight structures such as the

lateral retinaculum; strengthening of the VMO; activity modification; biofeedback;

neuromuscular electric stimulation; ultrasound; thermotherapy; bracing; and foot

orthotics.34-37

Physical therapy interventions for PFPS often are intended to alleviate pain by

correcting or improving proper patellar tracking within the patellofemoral groove.

The lack of understanding of the etiology and pathology associated with

patellofemoral pain and dysfunction is reflected in the vast number of treatment

options for PFPS. Nonoperative treatments are usually used (especially in the first

instance), and physiotherapy is a commonly used conservative physical intervention.

Manual therapy techniques including mobilisation, stretching, and soft tissue

massage are used in the treatment of anterior knee pain with the aim of decreasing

tightness of the lateral structures38, results in significantly greater improvement in

active knee flexion and the ability to step up/down a step in people with anterior knee

pain39, but the participants in these trials were relatively old and it may be possible

that there would be a better response to this intervention in younger patients, so there

is a need to assess the efficacy of manual therapy for Patellofemoral pain syndrome

(PFPS) in younger patient.

Physiotherapy treatments often include vastus medialis obliqus (VMO) strengthening

to promote active medial stabilization of the patella within the femoral trochlea and/or

patellar realignment procedures (taping, bracing, stretching) 40,41.

Need of the study:

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 It has been demonstrated that physiotherapy intervention is effective in

reducing pain and improving activity in people with anterior knee pain42-43. These

studies have included combinations of patellofemoral taping, muscle stretching,

strengthening and co-ordination exercises, along with techniques aimed at decreasing

tightness of the lateral structures such as patellofemoral mobilisation and deep friction

massage to the lateral soft tissues of the knee. It is not yet known; however, which

components may be individually responsible for the improvement. Manual therapy

techniques including mobilisation, stretching, and soft tissue massage are used in the

treatment of anterior knee pain with the aim of decreasing tightness of the lateral

structures44, results in significantly greater improvement in active knee flexion and the

ability to step up/down a step in people with anterior knee pain45, but the participants

in these trials were relatively old and it may be possible that there would be a better

response to this intervention in younger patients, so there is a need to assess the

efficacy of manual therapy for Patellofemoral pain syndrome (PFPS) in younger

patient.

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