Patellofemoral joint pain

Demographic

Common in adolescents / young adults; seen across active & general populations

Questionably more frequently found in women

(Barton et al 2015, Crossley, K.M. et al. 2016)

Diagnosis and presentation

Diffuse anterior / peripatellar pain, worse with squatting, stairs, prolonged sitting

Additional criteria- not essential:

Crepitus during knee flexion movements

Tenderness on facet palpation

Small effusion

Pain on sitting, rising from siting or straightening knee following sitting

Crossley, K.M. et al. (2016)

Clinical Examination

No definitive clinical test

Best available test= anterior knee pain on a squatting movement- 80% sensitivity

Provocative PFJ loading (e.g. squats, step down), movement quality, hip/knee strength, use PROMs

Other tests (limited evidence):

Tenderness on palpation of patellar edges

(note patellar grinding and Clarke’s test have low sensitivity and limited diagnostic accuracy) Crossley, K.M. et al. (2016)

Patellar compression (Gilchrist, 2004) (Video link)

Can also be known as Clarke’s sign and patellofemoral grind test. The patient is positioned in long-sitting with their knee fully extended and quadriceps relaxed. The clinician places the web space of their hand on the superior aspect of the patella. A caudad movement is applied. The patient is asked to contract their quadriceps. A positive result is reproduction of symptoms

Possible Contributors

Structural:

Hip/knee muscle weakness, abnormal biomechanics (valgus, foot pronation), training load changes, psychosocial factors

Proximal mechanics such as excessive hip adduction and/ or internal rotation may be relevant (reported consistently in women with PFP)

Trunk mechanics including contralateral pelvic drop may be relevant ,

Hip muscle weakness (especially gluts) relevant in PFP and possible PF OA

Barton et al 2015, Crossley et al 2016,

Differential Diagnosis

Patellar tendinopathy

PFJ Subluxations & Dislocations

PFJ OA

Osgood Schlatters Disease

Sinding Larsen Johansson Syndrome (SLJS)

(NICE Guidelines 2022)

Red Flags

Trauma/Fracture

Infection

Auto-Immune Condition

Tumour

DVT

Spontaneous Osteonecrosis of the Knee

Slipped Capital Femoral Epiphysis

(NICE Guidelines 2022)

Intervention

Education

Education in load management, self-management, expectations, activity modification

Exercise

Combined hip + knee strengthening outperforms knee alone; progressive loading, functional strengthening

Other Interventions

Taping, orthoses, gait retraining, manual therapy as adjuncts

Not Recommended

Routine imaging to “diagnose” PFP

passive modalities alone;

surgery without clear indication

(Nice Guidelines, Barton et al 2015)

Prognostic influences

Factors that might predict better outcome

Adherence, shorter symptom duration, lower baseline pain/disability → better outcomes

(Lack et al., 2014)

Factors that might predict poor outcome

Longer duration of symptoms (>12 months)

Greater pain severity

Lower self-reported function

Greater height

Positive patella apprehension test

Crepitation during physical examination

Lankhorst et al., 2016; Lack et al., 2014)

Imaging

Indications for Imaging

Emphasises imaging to rule out other pathology rather than routinely for PFPS.

Imaging may be considered when:

Symptoms are atypical

Persistent pain not improving after ≥3 months of appropriate rehabilitation

Older patients where degenerative changes are suspected

Pre-surgical planning (rare in PFPS alone)

Crossley et al., 2016; Lack et al., 2014

Escalation

As per normal pathway discuss at case review and/ or request second opinion with MSK APP if need for escalation

Evidence

Relevant local links/ resources/Masterclasses etc:

Patellofemoral pain syndrome | NHS inform

Patellofemoral Pain Syndrome - Physiopedia (physio-pedia.com)

Patellofemoral Pain Syndrome Masterclass | Physiotutors Podcast ep.037 | Claire Robertson

https eXcK6zMmeKA328Wg ://youtu.be/I10l-ANhHiE?si=

Understanding Red Flags in Patellofemoral Pain - Physiopedia (physio-pedia.com)

References:

Barton, C.J., Lack, S., Hemmings, S., Tufail, S. & Morrissey, D. (2015) ‘The “Best Practice Guide to Conservative Management of Patellofemoral Pain”: incorporating level 1 evidence with expert clinical reasoning’, British Journal of Sports Medicine, 49(14), pp. 923–934. doi:10.1136/bjsports-2014-093637. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning | British Journal of Sports Medicine
Crossley, K.M. et al. (2016) ‘2016 Patellofemoral Pain Consensus Statement … Part 2: Physical interventions’, British Journal of Sports Medicine, 50(14), pp. 844–852. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome … | British Journal of Sports Medicine
Crossley, K.M. et al. (2016) ‘2016 Patellofemoral Pain Consensus Statement … Part 1: Terminology, definitions, clinical examination …’, British Journal of Sports Medicine, 50(14), pp. 839–843. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions) | British Journal of Sports Medicine
Willy, R.W. et al. (2019) ‘Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health’, Journal of Orthopaedic & Sports Physical Therapy. Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association: Journal of Orthopaedic & Sports Physical Therapy: Vol 49, No 9
Non-traumatic causes | Diagnosis | Knee pain - assessment | CKS | NICE Available at: https://cks.nice.org.uk/topics/knee-pain-assessment/diagnosis/non-traumatic-causes/
Lack, S., Barton, C., Vicenzino, B. & Morrissey, D. (2014) ‘Outcome Predictors for Conservative Patellofemoral Pain Management: a systematic review and meta-analysis’, Sports Medicine, 44, pp. 1703–1716. doi:10.1007/s40279-014-0231-5. Outcome predictors for conservative patellofemoral pain management: a systematic review and meta-analysis - PubMed
Neal, B.S., Barton, C.J., Gallie, R., O’Halloran, P. & Morrissey, D. (2024) ‘Best practice for patellofemoral pain should include delivering knee-targeted exercise therapy, with supportive interventions as required’, British Journal of Sports Medicine, 58(24), p.1486. Neal, B.S., et al. https://bjsm.bmj.com/content/58/24/1486
Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013 - PubMed (nih.gov)
Spontaneous Osteonecrosis of the Knee - StatPearls - NCBI Bookshelf (Di Li et al 2024)
Patient Education for Patellofemoral Pain: A Systematic Review - PubMed (nih.gov) Danilo de Oliveira Silva, 2020
Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning | British Journal of Sports Medicine
Lankhorst, N.E. et al. (2016) Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis - PubMed