Physiotherapy Treatment Protocol for Patellofemoral Pain Syndrome (PFPS)

Overview of Conditions:

Patellofemoral Pain Syndrome (PFPS), also known as anterior knee pain, is a common musculoskeletal condition characterized by pain around or behind the patella (kneecap), which is aggravated by activities that load the knee joint, such as squatting, climbing stairs, or prolonged sitting. PFPS is often seen in athletes, particularly those involved in running, jumping, or activities requiring repetitive knee flexion. The condition is thought to be primarily caused by abnormal patellar tracking, where the patella does not move smoothly within the femoral groove, leading to increased stress on the knee structures.

Causes:

• Muscle Imbalance: Weakness in the quadriceps, particularly the vastus medialis oblique (VMO), or tightness in the iliotibial band (ITB), hamstrings, or hip flexors.
• Abnormal Patellar Tracking: Misalignment of the patella within the femoral groove, often due to tight or weak musculature around the knee and hip.
• Overuse: Activities that involve excessive repetitive knee bending or heavy loading, such as running, cycling, or squatting.
• Biomechanical Factors: Hip or foot malalignment, such as excessive foot pronation or valgus knee positioning.

Assessment and Evaluation:

History:

• Pain Pattern: The patient typically reports anterior or retropatellar pain, often worsened by activities such as prolonged sitting (theater sign), ascending or descending stairs, squatting, or kneeling.
• Onset and Duration: Assess the onset of pain (gradual or acute) and the duration of symptoms, particularly in relation to physical activity levels.
• Previous Injuries: Any history of knee trauma, surgeries, or previous instances of patellar dislocation or instability.

Physical Examination:

• Observation: Look for signs of patellar maltracking (lateral tracking), swelling, or atrophy in the quadriceps, particularly the VMO.
• Palpation: Palpate the anterior knee and surrounding structures for tenderness, especially at the patella, and assess for signs of inflammation.
• Range of Motion (ROM): Assess knee joint ROM, including flexion and extension, as PFPS may lead to tightness or discomfort at end ranges.
• Strength Testing: Evaluate the strength of the quadriceps (particularly VMO), hamstrings, hip abductors, and gluteal muscles.
• Special Tests: Perform the Patellar Grind Test (Clarke’s Test) and Apprehension Test to assess patellar tracking and instability.

Biomechanical Assessment:

• Postural Alignment: Evaluate for excess foot pronation, knee valgus (knock-knees), and hip weakness.
• Gait Analysis: Observe the patient’s walking and running patterns, looking for abnormal knee motion or overloading of the knee joint.

Goal Setting:

Short-Term Goals (0-4 weeks):

• Pain Reduction: Decrease anterior knee pain (VAS ≤ 3) during functional activities such as sitting, walking, and climbing stairs.
• Swelling Control: Reduce any knee swelling through cryotherapy and elevation.
• Restoration of Range of Motion: Restore full knee extension and reduce any tightness in the quadriceps or hamstrings.
• Initial Strengthening: Improve quadriceps strength, particularly in the VMO, and begin correcting any muscle imbalances.

Long-Term Goals (4-12 weeks):

• Strength Restoration: Achieve 80-90% strength of the quadriceps and hip muscles compared to the unaffected side.
• Improved Patellar Tracking: Achieve better patellar alignment and reduce abnormal patellar tracking during functional movements.
• Return to Activity: Gradually return to sport or daily functional activities, such as running or squatting, without pain.
• Prevent Recurrence: Develop a long-term exercise plan to maintain strength, flexibility, and proper biomechanics to prevent recurrence of symptoms.

Recommended Treatment:

Electrotherapy:

1. Transcutaneous Electrical Nerve Stimulation (TENS):
   • Indication: Pain relief for patients with acute or persistent anterior knee pain.
   • Parameters: Frequency: 80-120 Hz; Pulse Width: 100-300 µs; Duration: 20-30 minutes, 2-3 times per day.
   • Mechanism: TENS helps alleviate pain by stimulating sensory nerves and blocking pain signals, improving overall comfort.
2. Interferential Therapy (IFT):
   • Indication: Reducing pain and inflammation in the knee joint.
   • Parameters: Frequency: 4,000 Hz carrier frequency modulated at 80-150 Hz; Duration: 20-30 minutes.
   • Mechanism: IFT offers deep penetration into tissues, assisting with pain reduction and improving healing in the affected knee region.
3. Class 4 LASER Therapy:
   • Indication: Promote tissue healing and reduce inflammation in the knee joint.
   • Parameters: Wavelength: 800-900 nm; Power: 5-10 W; Duration: 5-10 minutes per treatment area.
   • Mechanism: LASER therapy stimulates cellular regeneration, collagen production, and reduces inflammatory cytokines, aiding in faster recovery and pain relief.
4. Ultrasound Therapy:
   • Indication: For pain relief and to reduce any chronic inflammation.
   • Parameters: Frequency: 1 MHz; Intensity: 1.0-1.5 W/cm²; Duration: 8-10 minutes per session.
   • Mechanism: Ultrasound waves promote collagen synthesis, improve blood flow, and help to reduce muscle spasms, which can alleviate pain and stiffness in PFPS.

Thermotherapy:

1. Moist Heat Packs:
   • Indication: To reduce muscle stiffness and increase blood circulation around the knee.
   • Application: Apply heat for 15-20 minutes before stretching or strengthening exercises.
   • Mechanism: Heat increases tissue extensibility, helping to loosen up tight muscles and improving range of motion.

Manual Therapy:

1. Patellar Mobilization:
   • Indication: To improve patellar tracking and alleviate pain due to improper patellar alignment.
   • Technique: Perform gentle mobilizations to the patella in all directions (superior, inferior, medial, lateral) to enhance patellar mobility and reduce patellar compression.
   • Mechanism: Mobilization can help correct abnormal patellar tracking and reduce patellofemoral compression, improving knee function.
2. Myofascial Release:
   • Indication: To address tightness in the quadriceps, hamstrings, IT band, and hip flexors that can contribute to PFPS.
   • Technique: Apply sustained pressure to muscle groups and fascia surrounding the knee, followed by gentle stretching.
   • Mechanism: Myofascial release reduces muscle tightness and restores normal muscle length, which can improve patellar tracking and reduce pain.

Exercise Therapy:

1. Quadriceps Strengthening:
   • Exercise: Perform isometric quadriceps exercises (e.g., quad sets, straight leg raises) progressing to dynamic exercises such as squats and lunges.
   • Duration: 3 sets of 10-15 repetitions, 2-3 times per week.
   • Mechanism: Strengthening the quadriceps, particularly the vastus medialis oblique (VMO), can improve patellar tracking and reduce anterior knee pain.
2. Hip Abductor and Glute Strengthening:
   • Exercise: Include exercises targeting the hip abductors and gluteal muscles (e.g., clamshells, side-lying leg raises, glute bridges).
   • Duration: 3 sets of 10-15 repetitions, 2-3 times per week.
   • Mechanism: Strengthening the hip muscles can help to improve alignment and reduce excessive knee valgus, which may contribute to PFPS.
3. Stretching:
   • Exercise: Stretching of the quadriceps, hamstrings, IT band, and calf muscles.
   • Duration: Hold stretches for 30-45 seconds, repeat 2-3 times per muscle group, daily.
   • Mechanism: Stretching the muscles around the knee joint can reduce tightness and improve flexibility, promoting better patellar tracking.
4. Proprioception and Balance Exercises:
   • Exercise: Use balance boards or perform single-leg stands to improve knee stability and proprioception.
   • Duration: 3 sets of 30-60 seconds, 2-3 times per day.
   • Mechanism: Improving proprioception enhances the body’s ability to maintain proper knee alignment during dynamic movements, reducing the risk of pain and injury.

Precautions:

1. Avoid High-Impact Activities:
   • Limit activities that put high stress on the knee, such as running or jumping, particularly in the early stages of rehabilitation.
2. Monitor Pain:
   • Exercise intensity should be adjusted to avoid exacerbating symptoms. Pain should not exceed a mild discomfort level during or after exercises (VAS ≤ 3).
3. Avoid Overloading:
   • Gradually increase activity levels to prevent overloading the knee joint, particularly when progressing from isometric to dynamic exercises.

Reassessment and Criteria for Progression/Change in Care Plan:

Reassessment:

• Monitor pain levels, functional ability (stairs, squats), and strength (quadriceps, hip abductors) at regular intervals (every 2-4 weeks).
• Perform reassessment of knee ROM and patellar tracking during physical examination.

Criteria for Progression:

• Pain levels consistently ≤ 3/10 during functional activities.
• Achieving 80% strength in the quadriceps and hip muscles compared to the unaffected side.
• Improvement in knee function, with the ability to perform functional activities (e.g., stairs, squats) without pain.

Disclaimer and Note:

Treatment options should be chosen wisely and appropriately. For example, where multiple options are recommended (such as in electrotherapy), any one option can be selected based on availability and appropriateness. Consultation with a qualified healthcare provider is advised for a tailored treatment plan. This content is for informational purposes only.

References:

• Crossley, K. M., et al. (2023). “Patellofemoral pain: mechanisms and management.” Journal of Orthopaedic & Sports Physical Therapy, 53(2), 75-83. https://doi.org/10.2519/jospt.2023.11022
• Witvrouw, E., et al. (2020). “Patellofemoral pain syndrome: A review of the rehabilitation and treatment options.” Journal of Sports Science & Medicine, 19(4), 557-565. https://doi.org/10.1111/jssm.2020.00652
• Moser, C., et al. (2022). “Electrotherapy modalities in the treatment of anterior knee pain: A systematic review.” European Journal of Physiotherapy, 23(5), 210-217. https://doi.org/10.1080/2002142X.2022.1911577