Patellofemoral Syndrome Assestment and Management

Assessment and Management
of Patellofemoral pain
syndrome
Dr. Venus Pagare (PT)

MPT, KMC Mangalore
SEHA EMIRATES HOSPITAL
Abu Dhabi, UAE
ASSESSMENT AND MANAGEMENT OF PFPS 1
CONTENTS
 Introduction
 Anatomy of Patellofemoral Complex
 Epidemiology
 Aetiological Risk factors
 Pathogenesis
 Clinical Features
 Assessment
 Differential Diagnosis
 Management
 The Patellofemoral Foundation
INTRODUCTION
Anterior knee pain (AKP)- most common

musculoskeletal complaint
Common overuse injury in sports

medicine
More prevalent in the athletic population

specially runners
The Black Hole of Orthopaedics

IT Band Syndrome Symptomatic
Articular Patellar
cartilage injury bipartite patella Tendinopathy
Bone Tumors
Chondromalacia Patellar instability Quadriceps
Hoffa’s patellae subluxation Tendinopathy
disease
Plica
Osgood-schlatter synovialis
Neuromas
Patellofemoral
arthritis Osteochondritis
Referred pain Dissecans
from hip
Pre –patellar Loose- Sinding-Larsen-
bursitis Bodies Johannson- Syndrome
Pes anserine
bursitis
An overuse injury, a syndrome
Idiopathic AKP, runner’s knee, retropatellar pain

syndrome, lateral facet compression syndrome.
Accounts for 20%-40% of patients presenting

with AKP
25% of knee injuries in athletes in a sports medicine

clinic
Frequently becomes chronic
Pain may limit physical activities
May lead to patellofemoral osteoarthritis
Diagnosis by Clinical and by Exclusion

Anatomy and Biomechanics of
Patellofemoral Complex
Interface between articular surface

of the patella and trochlear groove
Modified plane joint
3 degrees of freedom

Passive structures / Static Active structures /
stabilizers Dynamic stabilizers
Anteriorly: patellar
tendon limits the Quadriceps Muscle
excursion of patella from
the tibia.
Resultant pull of the
The superficial and deep 4 muscles that
lateral retinaculum on the constitute the
lateral side Quadriceps &
patellar tendon
Medially: medial
patellofemoral ligament,
Clinicaly: Q
aided by menisco-patellar
angle
ligament.
PFJ reaction
force
Influenced by quadriceps angle

and angle of the knee joint
Knee in full extension: minimum

compressive force on patella
As knee flexion ↑, compressive

forces ↑
Beyond 90 ̊, only odd and lateral

facet
Patellofemoral joint reaction forces depend upon the knee
flexion angle and as the knee is flexed, the patellofemoral
compressive load is increased.
Activity Patellofemoral compressive
force
Stance phase of walking 25 - 50% body weight
(peak knee flexion is about
20°)
Ascending stairs 2 – 3 times body weight
Running 5 – 6 times body weight
Flexion greater than 90° 8 times the body weight
Squatting 20 times the body weight

Factors affecting Patellar Tracking
Local Factors
Tight ITB, Lateral Lax medial structures

retinaculum
Lax medial patellar
retinaculum
Trochlear dysplasia
Weakness of
quadriceps Flat Trochlea
Global
Factors
Excessive Subtalar
Excess genu Pronation
valgum
Ext. rotation of
tibia
Excess femoral
anteversion
Asso. with foot
pronation

INCIDENCE
Common in young adults; high socioeconomic

importance
More common in Militiary recruits and athletes
Female : Male :: 2 : 1

ETIOLOGY
1. Intrinsic factors 2. Extrinsic
3. Others
Factors
Alterd Biomechanics of leg
Altered biomechanics of foot
Anatomic Anomalies
Med-Lat. patellar Mobility
Soft-tissue tightness
Muscle Imbalance
1. Altered Biomechanics of leg
Increase in Q angle = ↑ lateral

patellofemoral contact pressure
Excessive laterally tilted patella
Other malalignments: femoral

anteversion, genu valgum and
varum, genu recurvatum, external
tibial torsion
2. Altered Biomechanics
of the foot
Subtalar joint pronation  alters

tibial rotation
During terminal knee extension 

tibia remains internally rotated
To compensate: femur rotates

externally  ↑ Q angle
Flat foot → internal rotation of tibia

→ ↑ Q angle
3. Anatomic Anomalies
Dysplasia or hypoplasia
of patella or trochlea
Patella Alta / Baja →

Maltracking

4. Medial- Lateral
Mobility
Increased medial-
lateral movement
Rapid translation of the

patella
Repeated blows by the

medial facet on trochlea

5. Soft Tissue Tightness
Gastro- Hamstrings Iliotibial Band

soleus
↓dorsiflexio Knee flexion at Increased
n ↑ subtalar heel strike → lateral tracking
pronation increased and lateral tilt
quadriceps of the patella
activity
↑ valgus ↑ PFJ
force= ↑ Q compression
angle ↑ PFJ
compression

Quadriceps Lateral Retinaculum
Restrictes full
excursion of Predisposes to
patella in ELPS
trochlear groove
Causes lateral
tracking along Laterally tilted
with TFL patella

6. Muscle Imbalance
Hip muscles Quadriceps
weakness weakness
Abductors & ↓ activity of

External VMO
Rotators
Excessive VL activates
adduction & before VMO
Internal Rotation
Maltracking
↑ Q angle of the patella
Extrinsic Factors
Excessive duration or frequency of physical
Errors in training such as sudden increase in

mileage
Activities change of training surface
Inappropriate foot wear such as high heels

Others
Female Generalised
Gender ligamentous
laxity
Greater knee
valgus moment ↑ Total
patellar
mobility
Greater internal
rotation
Alters
patellar
tracking
↑ Q angle
A study has identified 4 factors that have predictive
values for the development of patellofemoral pain,
which included:
 Tightness of the gastrocnemius and quadriceps
 Delayed reflex of vastus medialis obliquus
 Hypermobility of patella
 Decreased power of the quadriceps muscle.

PATHOGENESIS
Varied theories for cause and

source of pain
3 types : Hypoxic, mechanical,

inflammatory

Factors inducing patellofemoral nociceptive output

1. Theory of Homeostasis
Single loading event Series of repetitive

of sufficient loading events of a
magnitude or lesser magnitude
Theory of
Homeostatis
Beyond a certain
Differential loading of
level, loss of tissue
PFJ
homeostasis
Certain activities highly load the PFJ
Climbing up or down stairs, hills or inclines,

kneeling, squatting
Stress = load applied + surface area
High loading beyond the safe acceptance

capacity of the joint
Length testing in neck and trunk and upper
extremity
Mosaic of pathophysiologic process
Patellofemoral pain
The “Envelope of
Function”
Torque that can be safely

withstood and transmitted
Zone of subphysiologic underload
Zone of homeostatic loading
Zone of supraphysiologic overload
Zone of macrostructural failure

3. Raised Intra-
2. Ischaemia osseous pressure
Limited
Low levels of
pulsatile blood venous
flow outflow
When knees
are flexed
Hypoxia-
release of
neural growth
factors and SP ASSESSMENT AND MANAGEMENT OF PFPS 32
Pain
Popping or
Giving
catching
way
sensation
CLINICAL
FEATURES
Pseudo- Swelling
locking
Crepitus Stiffness
Source of pain: Unclear
Any structure with sensory

nerve endings
Except Articular cartilage
Subchondral bone,
synovium, retinaculum,
fat pad
ASSESSMENT
DEMOGRAPHIC CHIEF
DATA COMPLAINT
Age: 10- 40 yrs Pain
Gender : F : M Crepitus
:: 2 : 1
Giving way /
Athletes &
Locking
Militiary
recruits
Swelling &
stiffness
Pain History
Onset : Insidious or Gradual, can be precipitated by

Trauma
Area: peri-patellar, retro-patellar, ‘circle sign’
Behind,underneath, around the patella
Diffuse dull ache, sometimes sharp

Aggravating Factors
Relieving Factors
Descending stairs > Extension of
Ascending
the knee
Going uphill or walking
on incline Rest
Standing up from
squatting
Movie goer’s / theatre’s

sign

Functional status, Activity Level, Sports
Specific Questions
Recent changes in activity
Any changes in the frequency,

duration, and intensity of training
A history of injuries, including patellar subluxation

or dislocation, trauma

Objective Examination
Observation: Posture- Standing Anterior View
Malalignment: genu-varum (bowleg) or genu-

valgum (knock-knee)
Tibial Torsion: Medial →Genu varum

Lateral→Genu valgum
Size, shape, position of the patella:
grasshopper/ squinting/ patellar alta
Subtalar joint Pronation: antero-superior view

Lateral View
Patellar alta, camel

sign
The longitudinal
arches
Genu recurvatum

Posterior View Sitting: Anterior
and Lateral View
↑ Genu-varum :
Intercondylar space
Patella faces
↑ Genu valgum : forward
Distance between the
malleoli Patella alta:
more aligned
with anterior
Subtalar joint Pronation
surface of femur
“Grasshopper eye”
Level of popliteal crease appearance

GAIT ASSESSMENT
Tight ITB or hip Tight Hamstrings
abductor
weakness PF tightness Need for↑
Dorsiflexion
↑ Internal
rotation of hip If DF range is not
Prevents full available
Opposite side knee
pelvis drops extension Subtalar pronation
↑ Q angle ↑ Q angle
Local Palpation
Observation
In PFPS: Lateral
Wasting of retinacular
quadriceps tenderness
Echymosis IT band
tightness
Palpate scars or
Swelling arthroscopy
portals
Surgical Note: Warmth/ Cold,

Scars Edema, Tenderness
EXAMINATION
Movement testing
Active & Passive ROM of Hip,

knee and Ankle
Pain with rotations of Hip

→Hip Pathology
Full ROM of knee
Crepitus: asymptomatic
Patellar tracking while knee
Flexion-Extension
Abrupt lateral deviation of

patella during terminal knee
extension (J-sign)
Can be due to VMO

defeciency, patellar alta,
trochlear dysplasia
During knee Extension,

palpate VL & VMO: delay in
onset of VMO contraction
Observe Movement
Patterns
Hip Abduction & Hip

Extension
Alteration reveals hip

abductor and gluteus
maximus weakness

Muscle Strength Flexibility
Testing Testing
Quadriceps ITB
Hip
abductors Rectus Femoris
Hip Internal
Rotators Hamstrings
Hip Flexors
Gastrocnemius
Limb Length Limb Girth
Measurement Measurement
Externally rotated Quadriceps atrophy

hip: Lengthened
Athletes have near

Subtalar joint same bilateral
pronation: Shortened symmetry

Functional Performance
Testing Vertical Jump Performance
PFPS patients: Antero-medial Lunge

lower strength
capacity
Decreased
performance in:

Step Down
Single Leg Press

Balance and Reach Test
Bilateral Squatting

Special Tests
1. Patellar Tilt Test
Compare height of
medial and lateral
patellar border
Laterally tilted: medial

border is more anterior
Compress medial
border→lateral border
cannot be raised = tight
lateral retinaculum
2. Patellar Glide
Test
Passive translation of
the patella,
measured as % of
patellar width
25%: Normal, >50 :

laxity of medial
constraints

3. Vastus Medialis Co-ordination
Test
Terminal Knee
extension
Lack of co-ordinated
full extension:
Positive Test

4. Patellar Apprehension Test
Knee flexed to 30°
Push the patella as lateral

as possible
Positive Test: Pain /

Apprehension
Less sensitive for PFPS

5. Waldron’s Test
Phase I- Press the patella against

femus while flexing the knee
passively
Phase II- slow, full squat while

pressing the patlla against femur
Presence of Pain and Crepitus

6. Patellar Grind /
Clark’s Test
Knee is in slight
flexion
Press the patella distally (with

the hand on the superior
border of the patella)
Contraction of Quadriceps
muscle
Pain, However specificity is

low
7. Eccentric Step Test 9. Sustained Flexion
Test
Stands on 15 cm (6
inches) stool
Sustained
Steps down. First passive flexion
with uninvolved and
then involved leg
Pain at the Pain in the knee
knee
Highly specific Ischaemia of patella

and sensitive on prolonged
Test flexion
In patients presenting with knee pain, a
positive outcome on either the vastus
medialis coordination test, the patellar
apprehension test, or the eccentric step test
increases the probability of PFPS.

Tubercle
Q Angle
sulcus angle
Patient is supine
Line Perpendicular to:
with knees
extended
The line from the center of
Line from ASIS to patella and tibial tubercle
centre of patella
Line through femoral
condyles
Center of patella Normal: 0°
to tibial tuberosity
> 10° : lateralization of
tibial tubercle
Sitting or Standing
(more reliable)
External Tibial Torsion Femoral Anteversion
Angle between: bimalleolar
plane and longitudinal axis of Prone, knee
femur flexed to 90°
IR > ER = ↑
Femoral
anteversion

VAS & NPRS for pain
Functional Independence Questionnaire (FIQ)
Anterior knee pain- specific questionnaire
Patellofemoral Function Scale (PFS)
PFPS severity scale
The Activity of Daily Living Scale (ADLS) of the Knee

Outcome Survey
Investigations
Axial view with knee flexed AP View: varus, valgus

to 30°-40° angulation, patella height
and tibial tubercle location.
Radiographs
Lateral view: rotational &

Skyline view at 30-45° knee
vertical malalignment,
flexion: morphology of the
morphological
PFJ
characteristics
• 0°, 15°, 30°, • Articular
45° Knee cartilage
flexion • Lateral
• Precise mid- retinaculum
patellar
transverse CT MRI
images
Radio- CT Hip,
nuclide patella
• Activity of and • Q angle
bone scans • incongruenc
tibial
remodelling ies
tubercle
in patella/
trochlea

Pinhole
Scintigraphy collimator and
SPECT
Pathological
Increased osseous
scintigraphic uptake
metabolic activity
pattern,
localization and
Abnormal joint intensity in
homeostasis patellofemoral joint
can be detected

DIFFERENTIAL DIAGNOSIS
Chondromalacia Pes anserine bursitis Ilio- tibial Tenonitis
Patallae
Patellar subluxation/ Plica syndrome Osteochondritis
dislocation dissecans
Patellar tendinitis Sinding-larsen- Patellofemoral

Johannson syndrome osteoarthritis
Osgood- schlatter Symptomatic bipartite Prepatellar bursiis
lesion patella
Hoffa’s Disease Quadriceps Patellar stress fracture
tendinopathy
Referred pain from hip Loose bodies Saphenous neuritis
and lumbar pathology
MANAGEMENT OF PFPS
No Two Rehabilitation programs are same
Underlying mosaic of patho-physiology and

tissue healing responses are unique
Depends on the findings of the assessment
The aim of non-operative management is to

alleviate pain and correct the mal-alignment
Clinical Classification of

1. Relative Rest
PFPS is an overuse/ overload syndrome
Runners: reduce mileage
Cyclists: lower gear, high pedal revolutions per

minute
Breast stroke to be avoided
For those engaged in high impact activities: swimming,

elliptical trainer
2. ICE, NSAID’S, Electrotherapy
Ice particularly after exercise
Ice-massage at tender areas
NSAID’s if pain is during ADL’s or not

controlled by ice application
Ultrasound, Electrical stimulation
Gentle mobilization of patella
Dry needling
3. Strengthening : Quadriceps/ VMO
Current evidence suggests that the VMO cannot be

exercised in isolation
The first step for the patient to learn to contract the

muscle.
Determine which position gives the best contraction
The patient should palpate the VMO while contracting

their quadriceps in various degrees of knee flexion and
/ or in different activities
Starting in sitting with knees bent to 90
Emphasis on weight bearing and functional

activities
Bio-feedback or Neuro-muscular electrical

stimulation to enhance the contraction.
Minimal pain before these exercises, else muscle

action may be inhibited.
Taping can be applied before exercise

Open v/s Closed Kinetic Chain Exercises
Open kinetic chain (OKC) exercises have been
reported to exacerbate symptoms in PFPS patients
Closed kinetic chain exercises are a more

functional way of rehabilitation
CKC place less stress on PFJ
CKC: last 30° of knee extension
OPC: 90° - 40° Of knee flexion

ISOKINETIC TRAINING
Provides optimal loading of the muscles
Allows muscular performance at different

angular velocities
Less compressive forces on the joint surfaces

during high angular velocity.
Isokinetic training at high angular velocity

(120°/s) is preferred
Eccentric contraction is more difficult

Isokinetic eccentric training should initially at 90°/s or
lower angular velocities
Patients with maltracking of the patella should
avoid isokinetic training at high angular velocities
during eccentric actions
Risk for possible patellar subluxation or
dislocation..
Isokinetic training at high angular velocity

(120°/s) is preferred
Isokinetic training improves proprioception as well as

muscular strength.
Strengthening exercise : Hip Muscles
Particularly hip abductors and external rotators
Stabilizes pelvis and controls hip internal rotation
Start from non-weight bearing → weight

bearing
Activation with VMO
Pelvic and hip-stabilizing muscles: Transverse

abdominus, Gluteus medius, and Gluteus minimus.
4. Flexibility Exercises
Hamstrings
Rectus Femoris
Gastro-soleus
IT Band
Hip Flexors
5. Taping
To maintain the patella correctly within the femoral
trochlea during full knee range of motion.
McConnell Technique is most commonly used
McConnell’s Rehabilitation Program: Patellar taping +

stretching of lateral tight structures + VMO strengthening
Aim of taping: to medialize the patella, to improve

patellar tracking
Correction is made on individual mal-alignment

Correcting
Lateral Glide
Knee in
extension
Tape started at
mid-lateral
border
It is brought across
the face of the
patella
Centering Effect

Correcting
Correcting External Rotation
Lateral Tilt
Tape started at
middle of the
inferior border of
patella
Tape started in the

middle of patella
The inferior pole of the
patella is manually rotated
internally.
Secured to the medial Secured to medial soft

tissues in superior and
border of medial hamstring medial direction while
tendons, lifting the lateral the manual correction
is maintained.
border of the patella.

The effect of taping should be assessed
immediately using a pain provoking activity
Acute cases may initially need tape applied

24hrs a day until the pain reduces
The tape time is then gradually reduced.
Kinesiotaping method
Clinical Prediction Rule to identify those patients who
would immediately receive a 50% reduction in
patellofemoral pain with a medial patellar taping, four
variables were identified:
Degree of tibial angulation
Soleus muscle length
Patellar tilt test
Relaxed calcaneal stance
 Positive patellar tilt test and tibial angulation greater
than 5° of varus: best predicted success with taping.

6. Knee braces and sleeves
Coumans bandage technique:

influences tracking of the
patella + massaging effects to
the peripatellar structures
during motion.
Protonics orthosis: patella’s

tracking pattern by improving the
pelvic position via an active
resistance mechanism

The Palumbo dynamic patellar brace consists of a
lateral pad that ’floats’ over the patella, maintaining
effective position during knee motion.
Cho-Pat knee strap functions dynamically , improves

patellar tracking and spreads pressure uniformly over
the surface area.
Over prolonged periods, bracing can lead to atrophy

in the quadriceps, and should be avoided.

7. Orthotics
Control excessive foot

pronation
Reducing excessive pronation in individuals with PFPS will

result in reduced internal rotation of the lower limb
Reduced Q angle
Navicular drop test is a convenient clinical method for estimating

the amount of foot pronation. 10 mm is considered to be a
normal amount of navicular drop, whereas values greater than 15
mm indicate excessive motion and reason to consider the use of
foot orthoses in runners.
The Clinical Prediction Rule for use of off-the –shelf
orthotic insert for patients with PFPS:
Forefoot valgus alignment (2° of valgus)
Limited passive extension of the first MTP joint (78°)
Minimal motion on the navicular drop test (3 mm)
Evidence indicates that combining physiotherapy with

prefabricated foot orthoses may be superior to
prefabricated foot orthoses used alone.

8. Biofeedback
Significant improvement in
the vastus medialis oblique
: vastus lateralis EMG ratio
Pain Relief

9. Lumbo-pelvic Manipulation
Sacro-iliac joint (SIJ) or lumbopelvic

region manipulation → ↓ in
quadriceps inhibition in the
involved knees of patients with PFPS.
Clinical Prediction Rule for determining

which patients will exhibit a rapid
response to lumbopelvic manipulation.
The most robust was a side-to-side

difference in hip internal rotation range
of motion of greater than 14°.
10. Activity Modification & Patient Education
Activities requiring flexion-extension

of knee against body weight to be
avoided
Squatting and steps to be avoided

when acute pain is present
Increased body mass index (BMI) correlates with

increased rates of PFPS. Thus, reduction in weight
will significantly diminish the stresses
MEDICAL MANAGEMENT
If no adequate relief from NSAID’s and physical

therapy
Intra-articular hyaluronic acid (HA) injections-

glycosaminoglycan .
It forms viscous synovial fluid that lubricates

joints, absorbs mechanical shock and protects
the articular cartilage.
It is administered as a series of 3-5 intra-articular

injections given 1 week apart.
SURGICAL INTERVENTION
 If symptoms persist despite completing 6 – 12

months of thorough rehabilitation
Proximal
Distal Realignment
Lateral Retinacular Realignment of
of extensor
Release extensor
mechanism
mechanism
Repair or Abrasion
Arthroscopic reconstruction of
debridement arthroplasty /
patellofemoral chondroplasty
ligament
Interposition Replacement Repair of patello-

trochleoplasty arthroplasty of femoral articular
patella or cartilage lesion eg.
patellectomy
ASSESSMENT AND MANAGEMENT OF PFPS
Mosaic plasty 93
PRE & POST OPERATIVE REHABILITATION
Control Pain and inflammation: Protection, Rest, Ice,

compression, Elevate (If acute)
Maintain or improve strength and flexibility of the

quadriceps and the hamstrings
Improve general lower extremity alignment
Patellar bracing and taping to prevent more

damage
Post- op Reahabilitation depends on the type of

surgery
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Patellofemoral Syndrome Assestment and Management

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Assessment and Management

Dr. Venus Pagare (PT)

Anterior knee pain (AKP)- most common

Common overuse injury in sports

More prevalent in the athletic population

The Black Hole of Orthopaedics

Idiopathic AKP, runner’s knee, retropatellar pain

Accounts for 20%-40% of patients presenting

25% of knee injuries in athletes in a sports medicine

Pain may limit physical activities

May lead to patellofemoral osteoarthritis

Diagnosis by Clinical and by Exclusion

Interface between articular surface

Modified plane joint

ASSESSMENT AND MANAGEMENT OF PFPS 7

Influenced by quadriceps angle

Knee in full extension: minimum

As knee flexion ↑, compressive

Beyond 90 ̊, only odd and lateral

ASSESSMENT AND MANAGEMENT OF PFPS 11

Tight ITB, Lateral Lax medial structures

ASSESSMENT AND MANAGEMENT OF PFPS 13

Common in young adults; high socioeconomic

More common in Militiary recruits and athletes

ASSESSMENT AND MANAGEMENT OF PFPS 14

Altered biomechanics of foot

Med-Lat. patellar Mobility

Increase in Q angle = ↑ lateral

Excessive laterally tilted patella

Other malalignments: femoral

Subtalar joint pronation  alters

During terminal knee extension 

To compensate: femur rotates

Flat foot → internal rotation of tibia

Patella Alta / Baja →

ASSESSMENT AND MANAGEMENT OF PFPS 18

Rapid translation of the

Repeated blows by the

ASSESSMENT AND MANAGEMENT OF PFPS 19

Gastro- Hamstrings Iliotibial Band

ASSESSMENT AND MANAGEMENT OF PFPS 20

ASSESSMENT AND MANAGEMENT OF PFPS 21

Abductors & ↓ activity of

Excessive duration or frequency of physical

Errors in training such as sudden increase in

Activities change of training surface

Inappropriate foot wear such as high heels

ASSESSMENT AND MANAGEMENT OF PFPS 25

Varied theories for cause and

3 types : Hypoxic, mechanical,

ASSESSMENT AND MANAGEMENT OF PFPS 26

ASSESSMENT AND MANAGEMENT OF PFPS 27

Single loading event Series of repetitive

Climbing up or down stairs, hills or inclines,

Stress = load applied + surface area

High loading beyond the safe acceptance

Mosaic of pathophysiologic process

Torque that can be safely

Zone of subphysiologic underload

Zone of homeostatic loading

Zone of supraphysiologic overload

Zone of macrostructural failure