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Overuse

• In many cases, PFPS is caused by vigorous physical activities that put repeated stress on the knee — such as jogging, squatting, and climbing stairs.
• It can also be caused by a sudden change in physical activity, which can be related to the frequency of activity (e.g., increasing the number of days you exercise each week) or to the duration or intensity of activity (e.g.,  running longer distances).

Other factors that may contribute to patellofemoral pain include:

• Use of improper sports training techniques or equipment
• Changes in footwear or playing surface (e.g., switching from a natural grass field to a field with artificial turf)

Patellar Malalignment

Patellofemoral pain syndrome can also be caused by abnormal tracking of the kneecap in the trochlear groove. In this condition, the patella is pushed out to one side of the groove when the knee is bent. This abnormality may cause increased pressure between the back of the patella and the trochlea, irritating soft tissues.

Factors that contribute to poor tracking of the kneecap include:

• Problems with the alignment of the legs between the hips and the ankles, which may result in a kneecap that shifts too far toward the outside or inside of the leg, or one that rides too high in the trochlear groove — a condition called patella alta.
• Muscular imbalances or weaknesses, especially in the quadriceps muscles at the front of the thigh and the muscles that externally rotate and move the hip away from your body (this movement is called abduction). When the knee bends and straightens, the quadriceps muscles and tendon help to keep the kneecap centered within the trochlear groove, together with the hip muscles that help control the position of the thigh bone. Weak or imbalanced quadriceps and hip muscles can cause poor tracking of the kneecap within the groove.

(Left) In this MRI scan, the kneecap is normally aligned within the trochlear groove (arrows). (Right) Here, the kneecap has shifted out of the groove and is pulled toward the outside of the leg (circle).

Activity Changes

Stop doing the activities that make your knee hurt until your pain goes away. This may mean:

• Changing your training routine
• Switching to low-impact activities — such as riding a stationary bike, using an elliptical machine, or swimming — that will place less stress on your knee joint
• If you are overweight, losing weight, which will also help to reduce pressure on your knee

The RICE Method

RICE stands for rest, ice, compression, and elevation.

• Rest. Avoid putting weight on the painful knee.
• Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly on skin.
• Compression. To prevent additional swelling, lightly wrap the knee in an elastic bandage, leaving a hole in the area of the kneecap. Make sure that the bandage fits snugly and does not cause additional pain.
• Elevation. As often as possible, rest with your knee raised up higher than your heart.

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help reduce swelling and relieve pain.

If your pain persists or it becomes more difficult to move your knee, contact your doctor for a thorough evaluation.

Physical Examination

During the physical examination:

• Your doctor will discuss your general health and the symptoms you are experiencing. 
• They will ask when your knee pain started, about the severity and nature of the pain (dull vs. sharp), and which activities make the pain worse.
• To determine the exact location of the pain, the doctor may gently press and pull on the front of your knees and kneecaps. 
• They may also ask you to squat, jump, or lunge during the exam in order to test your knee and core body strength.

During the examination, your doctor will check your knee for problems in patellar tracking,

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

To help diagnose the cause of your pain and to rule out any other physical problems, your doctor may also check:

• Alignment of the lower leg and the position of the kneecap
• Knee stability, hip rotation, and range of motion of knees and hips
• The kneecap for signs of tenderness
• The attachment of thigh muscles to the kneecap
• Strength, flexibility, firmness, and tone of the hips, quadriceps (front thigh muscles), and hamstrings (back thigh muscles)
• Tightness of the heel cord and flexibility of the feet

Finally, your doctor may ask you to walk back and forth in order to examine your gait (the way you walk) and look for problems with your gait that may be contributing to your knee pain.

Imaging Tests

X-rays. Usually, your doctor will be able to diagnose PFPS with just a physical examination. However, in most cases, they will also order an X-ray to rule out damage to the bones that make up the knee.

Magnetic resonance imaging (MRI) scans. An MRI scan provides clear images of the body’s soft tissues, such as ligaments, tendons, and muscles. Your doctor may order an MRI if, after a period of time, your symptoms do not improve with physical therapy and home exercise.

Nonsurgical Treatment

In addition to activity changes, the RICE method, and anti-inflammatory medication, your doctor may recommend the following:

Physical therapy. Specific exercises will help you improve range of motion, strength, and endurance.

It is especially important to focus on strengthening and stretching your quadriceps and strengthening your hip muscles, since these muscles work together to stabilize your kneecap.

Core exercises may also be recommended to strengthen the muscles in your abdomen and lower back.

Orthotics. Shoe inserts can help align and stabilize your foot and ankle, taking stress off of your lower leg. Orthotics can either be custom-made for your foot or purchased "off the shelf."

Shoe inserts take stress off your lower leg by aligning your foot and ankle.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Surgical Treatment

Surgical treatment for patellofemoral pain is very rarely needed and is performed only for severe cases that do not respond to nonsurgical treatment. Surgical treatments may include:

Arthroscopy. During arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your knee joint. The camera displays pictures on a monitor, and your surgeon uses these images to guide surgical instruments.

• Debridement. In some cases, removing damaged articular cartilage from the surface of the patella can provide pain relief.
• Lateral release. If the lateral retinaculum is tight enough to pull the patella out of the trochlear groove or tilt the patella, a lateral release procedure can loosen the tissue and correct the patellar malalignment.

This short surgical video demonstrates an arthroscopic lateral release as seen from inside the knee. A lateral release may rarely be performed as an isolated procedure, or as part of a larger surgery to treat a painful or unstable kneecap. Video courtesy of Stuart J. Fischer, MD, FAAOS. 

Tibial tubercle transfer. In some cases, it may be necessary to realign the kneecap to take stress off of damaged cartilage by moving the patellar tendon along with a portion of the tibial tubercle — the bony prominence (bump) on the tibia (shinbone).

A traditional open surgical incision is required for this procedure. The doctor partially or totally detaches the tibial tubercle so that the bone and the tendon can be moved toward the inner side of the knee. The piece of bone is then reattached to the tibia using screws. In most cases, this transfer allows for better tracking of the kneecap in the trochlear groove.