Patellofemoral Pain Syndrome
Pathophysiology and Etiology
“Patellofemoral pain is one of the most common lower extremity conditions seen in orthopedic practice.”1 This condition typically affects physically active adolescents and young adults under the age of 50. “The condition typically develops insidiously and can be defined by the presence of pain in the retropatellar or peripatellar region.”2 Even though this is a very common condition, the root causes and associated risk factors of this condition are poorly understood. “It has been proposed that abnormal neuromuscular and biomechanical factors alter patellar tracking and contribute to increased patellofemoral joint contract pressures that ultimately lead to pain and dysfunction.”3 Additionally, Powers et al. claim that “The structures that may be the possible source of PFPS are the synovium, lateral retinaculum, subchondral bone, and the infrapatellar fat pad.”1 Because of the poorly understood etiology of patellofemoral pain syndrome, diagnosing the condition is somewhat difficult. “The diagnosis of PFPS is typically made based on the presence of anterior of retropatellar knee pain associated with prolonged sitting or with weight-bearing activities that load the patellofemoral joint, such as squatting, kneeling, running, and ascending and descending steps.”4 Additionally, this tends to be a nagging injury as “70% to 90% of individuals with this condition have recurrent or chronic pain.”1
Diagnostic Tools
In general, Patellofemoral Pain Syndrome is a diagnosis of exclusion meaning that “once the standard sources of pain are ruled out, a large percentage of patients remain with what can only be termed as having “chronic idiopathic PFPS.”1 A typical examination may include the following:
While the above listed examination techniques are important, “there currently exists no gold standard for diagnosis of PFPS. Inclusion of the step down test may increase the likelihood of diagnosis of PFPS from 40% to 65%.”4
- Postural Examination – Subtalar joint, calcaneal varus/valgus, external tibial torsion, pelvic rotation, and symmetrical weight bearing.
- Neurologic Examination to screen for pain of spinal origin.
- Muscle Length Examination – Hamstring length, gastrocnemius and soleus length, piriformis length, and iliopsoas length
- ROM – AROM and PROM of the knee and hip
- MMT – Gluteal musculature, quadriceps, hamstrings, and hip rotators
- Patellar compression test
- Assessment of passive accessory mobility – Lumbopelvic spine, hip, patellofemoral, and tibiofemoral joints.
- Assessment of functional movements including a step down test, functional squat, and stair navigation
While the above listed examination techniques are important, “there currently exists no gold standard for diagnosis of PFPS. Inclusion of the step down test may increase the likelihood of diagnosis of PFPS from 40% to 65%.”4
Signs and Symptoms
The most common symptom in patellofemoral pain syndrome is pain in or around the patella. This pain most commonly presents as a dull ache that is exacerbated by movements that stress the quadriceps muscle including prolonged sitting, squatting, kneeling, and stair climbing. Additionally, “the vast majority of patients with PFPS have no history of trauma. A brief period of overuse of the patellofemoral joint or an increase in physical activity is reported in almost all patients with PFPS.”5 It is important to note that “foot pronation, femoral anteversion, poor gluteal control, or the delay in the onset timing of vastus medialis obliquus are not in themselves the source of PFPS, even though their presence has been associated with pain.”1
Prognosis
Most patients can be successfully treated with conservative management including physical therapy. The patient will typically undergo physical therapy for 4-6 weeks, following which it is expected that he or she will be able to experience a full return to function.
References
1. Powers CM, Bolgla LA, Callaghan M, Collins N, Sheehan F. Patellofemoral pain: proximal, distal, and local factors, 2nd international research retreat. J Orthop Sports Phys Ther. 2012;42(6):A1-A54. Epub 2012 Jun 2011.
2. Barton CJ, Bonanno D, Levinger P, Menz HB. Foot and ankle characteristics in patellofemoral pain syndrome: a case control and reliability study. J Orthop Sports Phys Ther. 2010;40(5):286-296.
3. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008;38(6):297-309; discussion 309-212. Epub 2008 Jan 2022.
4. Lowry CD, Cleland JA, Dyke K. Management of patients with patellofemoral pain syndrome using a multimodal approach: a case series. J Orthop Sports Phys Ther. 2008;38(11):691-702.
5. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012;42(2):81-94. Epub 2011 Oct 2025.
2. Barton CJ, Bonanno D, Levinger P, Menz HB. Foot and ankle characteristics in patellofemoral pain syndrome: a case control and reliability study. J Orthop Sports Phys Ther. 2010;40(5):286-296.
3. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008;38(6):297-309; discussion 309-212. Epub 2008 Jan 2022.
4. Lowry CD, Cleland JA, Dyke K. Management of patients with patellofemoral pain syndrome using a multimodal approach: a case series. J Orthop Sports Phys Ther. 2008;38(11):691-702.
5. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012;42(2):81-94. Epub 2011 Oct 2025.