Patellofemoral Pain Patellofemoral pain (PFP) is a common musculoskeletal related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retro patellar and/or peripatellar region of the knee. An overuse injury in sports medicine. Commonly known as “runner’s knee.

1. PATELLOFEMORAL PAIN
DR HARLEEN KAUR NAGI (PT)
MPT (SPORTS)

2. INTRODUCTION
• Patellofemoral pain (PFP) is a
common musculoskeletal
related condition that is
characterized by insidious
onset of poorly defined pain,
localized to the anterior retro
patellar and/or peripatellar
region of the knee.
• An overuse injury in sports
medicine.
• Commonly known as
“runner’s knee.

3. PREVALENCE AND INCIDENCE
• Prevalence ranges from 3% to 85% for idiopathic
anterior knee pain (AKP) or PFP and its associated
diagnoses.
• Patellofemoral pain occurs across the life span, from
young children to older sedentary individuals.
• More common in Military recruits and athletes
• Female : Male :: 2 : 1

4. Anatomy and Biomechanics of
Patellofemoral Complex
• Interface between
articular surface of the
patella and trochlear
groove.
• Modified plane joint
• 3 degrees of freedom

5. .
• Anteriorly: Patellar tendon limits the
excursion of patella from the tibia.
.
• The superficial and deep lateral retinaculum
on the lateral side
.
• Medially: medial patellofemoral ligament.
PASSIVE STRUCTURES/ DYNAMIC STABILIZERS

6. .
• Quadriceps Muscle
.
• Resultant pull of the 4 muscles that
constitute the Quadriceps & patellar tendon
.
• Clinicaly: Q angle
ACTIVE STRUCTURES/STATIC STABILIZERS

7. Patellofemoral joint reaction forces depend upon the knee
flexion angle and as the knee is flexed, the patellofemoral
compressive load is increased.

8. Activity Patellofemoral compressive
force
Stance phase of walking
(knee flexion is about 20°)
25 - 50% body weight
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

9. ETIOLOGY
Intrinsic factors:
• Altered Biomechanics of leg
• Altered biomechanics of foot
• Anatomic Anomalies
• Medial-Lateral patellar Mobility
• Soft-tissue tightness
• Muscle Imbalance

10. Altered Biomechanics
of leg
• Increase in Q angle =
↑ lateral patellofemoral contact
pressure.
• Excessive laterally tilted patella
• Other malalignments: femoral
ante version, genu valgum and
external tibial torsion.

11. Subtalar joint pronation 
alters tibial rotation
During terminal knee
extension tibia remains
internally rotated
To compensate: internal
rotation of femur- ↑ Q angle
→ internal rotation of tibia
→ ↑ Q angle
Altered Biomechanics of the foot

12. Anatomic Anomalies
• Dysplasia or hypoplasia
of patella or trochlea.
• Patella Alta

13. Gastrosoleus
↓dorsiflexio
n ↑ subtalar
pronation
↑ valgus
force= ↑ Q
angle
Hamstrings
Knee flexion at
heel strike →
increased
quadriceps
activity
↑ PFJ
compression
Iliotibial Band
Increased
lateral tracking
and lateral tilt
of the patella
↑ PFJ
compression
Soft Tissue Tightness

14. Restricts full excursion
of patella in Trochlear
groove
Causes lateral tracking
along with TFL
Quadriceps

15. Muscle Imbalance
Hip muscles
weakness
Abductors &
External
Rotators
Excessive
adduction &
Internal Rotation
↑ Q angle
Quadriceps
weakness
↓ activity of
VMO
vastus lateralis
activates before
VMO
Maltracking of
the patella

16. Extrinsic Factors
• Excessive duration or
frequency of physical
activities
• Errors in training such as
sudden increase in
mileage.
• Change of training
surface.
• Inappropriate foot wear
such as high heels.

17. CLINICAL
FEATURES
Pain
Swelling
Stiffness
Crepitus
Pseudo-
locking
Giving
away
Popping
sensation

18. PAIN HISTORY:
Onset : Insidious or
Gradual, can be
precipitated by
Trauma
Area: peri-patellar,
retro-patellar,
‘circle sign’
Type: Diffuse dull
ache, sometimes
sharp.

19. Aggravating Factors
• Descending stairs >
Ascending
• Going uphill or
walking on incline
• Standing up from
squatting

20. • 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
Observation: Posture- Standing
Anterior View

21. Lateral view:
• Patellar alta,
camel sign
• Genu
recurvatum

22. Local Observation:
• Wasting of
quadriceps
• Echymosis
• Swelling
Palpation:
• Warmth, Edema,
Tenderness
• In PFPS: Lateral
retinacular tenderness

23. EXAMINATION
• Active & Passive ROM of
Hip, knee and Ankle.
• Patellar tracking while
knee Flexion-Extension.
• Abrupt lateral deviation of
patella during terminal
knee extension (J-sign).

24. Muscle Strength
Testing
Quadriceps
Hip
abductors
Hip Internal
Rotators
Flexibility
Testing
ITB
Rectus Femoris
Hamstrings
Hip Flexors
Gastrocnemius

25. Single Leg Press
Step Down
Functional Performance Testing

26. Balance and Reach Test
Bilateral Squatting

27. Special Tests
1.Patellar tilt test:

28. 2. Patellar Glide
Test
•Passive translation
of the patella,
measured as % of
patellar width
•25%: Normal, >50
: laxity of medial
constraints

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

30. 4. Patellar Apprehension
Test:
•Knee flexed to 30°
•Push the patella as
lateral as possible.
•Positive Test: Pain /
Apprehension

31. 5. Waldron’s Test
•Phase I-
Press the patella against femus while
flexing the knee passively.
•Phase II-
slow, full squat while pressing the
patella against femur.
Presence of Pain and Crepitus

32. 6. Patellar Grind Test:
• Knee is in slight flexion
• Press the patella distally (with the hand on the
superior border of the patella)

33. 7. Eccentric Step Test:
• Patient stands on 15
cm (6 inches) stool
• Steps down. First
with uninvolved and
then involved leg

34. MANAGEMENT
• 1. RELATIVE REST!!
• PFPS is an overuse/
overload syndrome
• Runners: reduce mileage
• Cyclists: lower gear, high
pedal revolutions per
minute.
• Swimming: Breast stroke
to be avoided.

35. 2.ICE:
• Ice particularly after
exercise
3. Electrotherapy:
• TENS, ultrasonic therapy,
Electrical stimulation
4. Gentle mobilization of
patella

36. Strengthening exercises
Start from non-weight bearing → weight
bearing
Particularly hip abductors and external
rotators
Stabilizes pelvis and controls hip internal
rotation
Pelvic and hip-stabilizing muscles:
Transverse abdominus, Gluteus medius,
and Gluteus minimus

37. Open v/s Closed Kinetic Chain Exercises:
• Open kinetic chain (OKC) exercises have been
reported to exacerbate symptoms in PFPS
patients.
• CKC place less stress on PFJ

38. 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

39. • Correcting Lateral
Glide:
• Correcting External
Rotation:

40. 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.

41. Knee braces and sleeves
• 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.

42. Orthoses
• Reducing excessive pronation
in individuals with PFPS will
result in reduced internal
rotation of the lower limb.
• Greater than 15 mm: -
foot orthoses in runners.

43. MEDICAL
MANAGEMENT
• NSAID’s
• Intra-articular hyaluronic acid
(HA) injections:
It forms viscous synovial
fluid that lubricates joints,
absorbs mechanical shock
and protects the articular
cartilage.

44. SURGICAL INTERVENTION
• If symptoms persist despite completing 6 – 12 months of
rehabilitation

45. Lateral Retinacular
Release
Proximal Realignment
of extensor
mechanism
Repair or reconstruction
of patellofemoral
ligament
Repair of patello- femoral articular
cartilage lesion eg. Mosaic plasty
Interposition
trochleoplasty