Last updated: March 2019

Patellofemoral pain

1. What is patellofemoral pain?

The patellofemoral joint (PFJ) is formed by contact of the knee cap (patella) and the thigh bone (femur). The patella normally sits in a groove at the end of the femur. It’s made up of three bones and has many muscles which control its function. The patella acts as a lever for some muscles of the knee and together help to control knee movement and keep it running smoothly in the groove.

2. What causes patellofemoral pain?

There are many potential causes that contribute to Patello-femoral pain (PFP) and often vary from person to person. Some examples are:

Reduced “load tolerance”
Depending on usual activity levels you will have a level of activity your knee is comfortable with. Excessive activity or varied and rapid increases in activity can increase sensitivity in your knee which can make the knee painful without causing any physical injury or damage.

Movement biomechanics
It’s important that the muscles around your knee work effectively to control movement including muscles and joints above (hip) and below (foot). Reduced control can irritate the PFJ.

Strength
Pain in the knee can affect how well your quadriceps (thigh muscles) work and overtime can become weaker. This can have an effect on your load tolerance as well as biomechanics.

Tight muscles
Tightness or other causes of restricted movement can affect joint range of movement and can have an effect on load tolerance. Common areas of tightness include your quadriceps, hamstrings, calf muscles and iliotibial band (outside of your thigh).

Natural shape
Some people are predisposed to PFP due to the natural position of their hips, knees and feet.

3. What are the symptoms of PFP?

PFP is pain in or around the kneecap. Activities that commonly aggravate PFP are bending the knee, prolonged sitting, squatting, kneeling, walking, running and climbing stairs. You may also notice a feeling of stiffness as well as sensations of catching, clicking or grinding. While disconcerting they are often not a cause for concern.

4. How is PFP treated?

There is a strong body of evidence finding that conservative treatment is very effective at managing this condition. This will involve medication, activity modification and specific exercises. More details on this can be found below. Alternative treatment options may include local injections and in some circumstances when a conservative approach has failed surgical options can be considered.

Rest from painful activities
It is always important to keep moving, however resting from painful activities in the short term can ease strain on the knee allowing it to recover. Once pain has settled and/or stable we can gradually return to normal activities. The typical advice for this problem is to follow the “soreness rule”. This means it’s okay to do activity that makes your knee hurt so long as the pain level is acceptable to you and reduces or remains acceptable 24 hours later. If this is not the case then consider reducing this activity.

Pain relief
Paracetamol and ibuprofen are the first choice of pain medication. They can be taken together although it is recommended you stagger dosing. It is important to take these according to the packet information to gain the most benefit safely. Other pain medications can be prescribed by your health care provider and these should be used following their guidance.

You should only take medicines if it is safe for you – if concerned speak with your prescriber or pharmacist first.

Heat or cold application can also help to reduce pain but ensure you apply either safely. Many methods are available such as cold/heat packs, gels and creams. If applying heat or cold packs a maximum of 10 minutes per use is advised to be used up to five times daily. If using gels or creams supplied by a pharmacy follow the pharmacist advice or packet guidelines.

Exercises increasing in difficulty

1.
Lying on your back push the back of your knee into the floor/bed by tightening your thigh muscles as hard as you can for 10 seconds. Take 1-2 seconds to rest short rest then repeat as many rounds as you possibly can.

2.
Stand with feet shoulder width apart and toes slightly turned out. Keeping your torso as upright as you can push your hips back and knees forwards to perform a squat. Try not to let your heels lift off the floor. If this happens some simple calf stretches may help. Perform 15-20 repetitions for 3-5 sets.

3.
Stand with your back against a smooth wall or door with your feet in front of you away from the door. (To get the position right try to imagine if the door was to disappear you would fall through it!) Slide down the wall/door as far as is comfortable – hold for 3-5 seconds then slide back up. Repeat 10-12 repetitions for 3-5 sets.

4. 
Stand with plenty of space around you and feet together. Take a big step forwards and perform a lunge by bending your knee keeping your torso upright and avoiding swaying from side to side. Push through your leg to bring your feet back together again. Repeat on the opposite side. Perform as many as you can – if you can do more than 10 on each side consider holding on to some weights.

Depending on how easily your pain is aggravated start doing these exercises every other day or daily. If this is having little to no effect either way try using weights or increasing the weight you are using or doing the exercises twice a day.

Other useful exercises

Other exercises that might help are quadricep, hamstring and calf stretching exercises (see below) – three lots of 20-30 second holds for each exercise.

Quadricep
On your side bring one knee to your chest. Hold the ankle and pull to your buttock.

Hamstring
Stand with your feet hip width apart and one foot in front. Keep your front leg straight and bend the back knee pushing your pelvis backwardly.

Calf
Stand one foot in front of the other. Bend the front knee keeping the back knee straight. Push your hips forward – support yourself with a chair if needed.

5. What to do if your condition continues

Following the above advice symptoms should gradually settle over 6-12 weeks allowing a full return to function. If symptoms fail to improve in this time or become more painful further treatment or investigation may be required. If symptoms are persisting you should discuss further management with your health care provider.