Rehabilitation Protocol for Patellofemoral Pain Syndrome

This guideline is intended to provide the clinician with a guideline of the non-operative course of care for Patellofemoral
Pain Syndrome. Specific intervention should be based on the needs of the individual and should consider exam findings
and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary. If a
clinician requires assistance in the progression of a patient, they should consult with the referring provider.

The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should
be included and modified based on the progress of the patient and under the discretion of the clinician.

Patellofemoral Pain Syndrome (PFPS) is a general category of anterior knee pain that is characterized as pain behind or
around the patella, as a result of patella malalignment, altered patellofemoral (PF) joint forces and/or repetitive stress
to the area. Also known as Runner’s Knee, chondromalacia patella, retropatellar pain syndrome, anterior knee pain
syndrome, patellar malalignment, and patellofemoral arthralgia. Patellofemoral syndrome can have a collection of
signs and symptoms which may encompass body regions throughout the kinetic chain, from the lumbar spine to the
feet.

Diagnosis  Pain: typically reported anywhere circumferential to the anterior knee or retropatellar region.
Considerations  Common Aggravating Factors: prolonged sitting, squatting, climbing/descending stairs, running,
and jumping.
 Increased tibiofemoral varum/valgum or tibial varum: normal subjects with hypermobility
exhibit larger Q angles than normal subjects with normal mobility. Patients with greater
amounts of medial rotation of the femur with respect to the tibia, typically produce larger
amounts of contact area at the patellofemoral joint.
 Foot position/footwear. Excessive or late pronation during gait can increase tibial internal
rotation, thus altering patellofemoral forces.
 Higher-level activities which include landing with excessive hip internal rotation and/or knee
valgus may contribute to abnormal PF joint loading.
 Strength deficits (including balance and eccentric control) may be noticeable throughout the
lower extremity and lumbopelvic region.
 Special tests: Vastus Medialis Coordination Test, Patellar Apprehension Test, Clarke’s Test,
Eccentric Step Test, McConnell’s Test, Patellar Tilt Test, Tibial Angulation Test
Differential  Articular cartilage injury  Osgood-Schlatter disease
Diagnosis  Bone tumor  Osteochondritis dessicans
 Chondromalacia patella  Patellar stress fracture
 Referred pain from low back or hip  Patellofemoral arthritis
 Hoffa’s Disease  Pes Anserine Bursitis
 Iliotibial Band Friction Syndrome  Prepatellar Bursitis
 Inflammatory joint disease  Quadriceps/Patellar tendinopathy
 Loose Bodies  Sinding-Larsen-Johansson Syndrome
 Meniscal pathology  Symptomatic Bipartite Patella
 Neuromas  Synovial plica

PHASE I: IMMEDIATE/ACUTE (0-2 WEEKS)

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Rehabilitation  Reduce any swelling, minimize pain
Goals  Restore patellar, lower extremity mobility (including hip and ankle)
 Restore tolerance to full motion
 Minimize arthrogenic muscle inhibition and re-establish quadriceps, hip control
 Patient education

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 o Minimize aggravating factors as much as possible, such as descending stairs,
prolonged sitting, running, jumping
o Initial self-symptom management and joint protection
o Independent with initial home exercise program
Interventions During this early phase, numerous manual interventions may be utilized to reduce the patient’s pain,
restriction to movement, and joint loading:
 Soft Tissue Mobilization/Instrument-Assisted Soft Tissue Mobilization
 Patellar Taping (McConnell, Kinesiotaping)
 Ischemic compression/Bloodflow Restrictive Training
 Dry Needling
 Nerve mobilization
 Joint mobilization/manipulation
 Strengthening
 Stretching

Mobility
 Stationary biking for tolerable mobility (minimal resistance)
 Stretching/Foam rolling
o Hip flexors
o Hamstrings
o Quadriceps
o Iliotibial band
o Adductors
o Hip extensors/rotators
o Gastroc-soleus complex

Strengthening
 Quadriceps isometrics at 0, 45, 90 degrees of flexion
 Straight leg raise
 Bridge/unilateral bridging
 Sidelying clamshells
 Sidelying hip abduction
 Core/lumbopelvic stabilization (transverse abdominus, multifidus lifts, front/side planks)
Criteria to  Full knee motion, compared to uninvolved side
Progress  Appropriate quad contraction with superior patella glide and full active extension
 Able to perform straight leg raise without lag or pain
 Full tolerance to weightbearing with relative knee extension

PHASE II: INTERMEDIATE/SUB-ACUTE (2-4 WEEKS)

Rehabilitation  Progress to closed-chain/weightbearing activities without loading of knee flexion
Goals  Maintain full ROM
 Tolerance to closed chain strengthening without loading of knee joint in flexion
 Independent with progressed home exercise program, all daily activities
Additional Strengthening
Interventions  Sumo walks
*Continue with  Monster walks
Phase I  4-way hip drills
interventions as
indicated Balance/proprioception
 Single-leg stance
 Clock taps
 Ball toss

Correction of movement abnormalities with functional tasks

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 Criteria to  Tolerance to weightbearing activities
Progress  Maintenance of full ROM
 Normalize muscle length or achieve muscle length goals

PHASE III: LATE/CHRONIC (4-6 WEEKS)

Rehabilitation  Maintain full ROM
Goals  Promote proper movement patterns
 Avoid post exercise pain/swelling
 Achieve all muscle strength goals
 Negotiating stairs unlimited
 Full tolerance to closed chain knee joint loading with flexion, with appropriate eccentric control
 Achieve all muscle strength goals
 Achieve daily/functional goals
Additional Strengthening
Interventions  Partial squat, squat to chair, wall slide, progressing to functional squat pattern
*Continue with  Lunge/reverse lunge
Phase I-II  Step ups
Interventions as  Step downs, eccentric loading
indicated
Correction of movement abnormalities with sport-related tasks

Return to Running Program

Criteria for  Independent self-management of symptoms
Discharge  Demonstrate appropriate understanding of condition and maintenance to prevent risk
of recurrence

Revised 6/2021

Contact Please email [email protected] with questions specific to this protocol

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