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Patellofemoral Pain Syndrome (PFPS): Causes, Symptoms, Treatment, Recovery, Exercises, Surgery

What is Patellofemoral Pain Syndrome (PFPS)?

Patellofemoral Pain Syndrome (PFPS) is a medical condition in which a person experiences pain in the anterior part of the knee from the kneecap. Patellofemoral Pain Syndrome (PFPS) is the name given to pain located in the front portion of knee. It begins gradually and then the symptom increase with time and is also called as anterior knee pain.

Patellofemoral Pain Syndrome (PFPS)

PFPS is short form for patellofemoral pain syndrome, which refers to pain experienced on the anterior part of the knee area, usually because the cartilage under the kneecap has softened, worn out, or handled roughly.[1] It is mostly experienced by manual laborers, athletes, and teenagers.

Patellofemoral Pain Syndrome (PFPS) is very common among athletes and non-athletes alike. Physicians have to deal with this kind of complaint almost on a daily basis.

What is Patellofemoral Joint Dysfunction?

Patellofemoral joint dysfunction is the inability of the patella and the femur beneath it to properly work together as they should. The patella is a bone located in front of the femur and shaped similar a diamond. It cannot function properly on its own without the femur, and once there is a disjointment, the patellofemoral pain syndrome (PFPS) occurs.[2]

Relationship Between the Patellofemoral Pain Syndrome (PFPS) and Chondromalacia Patellae

The chondromalacia patellae are the softening of the cartilage under the kneecap. It is often treated alongside patellofemoral pain syndrome (PFPS). In other words, people with patellofemoral pain syndrome (PFPS) may also be affected by chondromalacia patellae, but sometimes, some individuals are not get affected by it, and those not affected by chondromalacia patellae are known to have patellofemoral pain syndrome (PFPS).

The academic distinction above is not often considered when diagnosing patellofemoral pain syndrome (PFPS). Results are mostly based on history and physical assessment. It is therefore not often revealed if people diagnosed of patellofemoral pain syndrome (PFPS) also have cartilage damage. The difference is only made theoretical and not practical. Some people assume that chondromalacia affects only those who have pain in front of their knee.

Causes of Patellofemoral Pain Syndrome (PFPS)

Patellofemoral pain syndrome (PFPS) generally develops when the patella stops moving in an appropriate manner during flexion or extension of the knee. This maltracking of patella results in damage to the adjoining tissues producing pain. Sportsmen and young adults are mostly affected by this injury.

When the knee is bent and straightened, there are many different structures present in the joint working together so as to make the patella move straight in the intercondylar groove. Any sort of tightness or weakness in the structures affects the balance resulting in patellar maltracking. Patellofemoral pain syndrome (PFPS) may also be caused because of a knee injury, if the quadriceps (especially VMO) becomes restrained or severely weakened.[3]

Factors that Can Cause Patellofemoral Pain Syndrome (PFPS) are:

  • Patellofemoral Pain Syndrome (PFPS) Caused Due to Overloading: Flexion of the knee causes pressure to increase between the kneecap and femur. Individuals involved in sports where repeated weight bearing is required like athletics often have patellofemoral pain syndrome (PFPS).
  • Patellofemoral Pain Syndrome (PFPS) Caused Due to Pronated Feet: Biomechanical stress is increased in the joint in case of pronated or ‘flat’ feet. This in turn may influence the patellar alignment, especially with any sort of motion.
  • Patellofemoral Pain Syndrome (PFPS) Caused Due to Q Angle: Individuals with larger than normal Q-angle develop genu valgum. If the person straightens the leg with weight bearing, the patella is pushed to the outer part of the knee. Repeated bending and putting stress may lead to injury of the structures underlying it and result in pain. Q-angle is larger in females as they have a wider pelvis and this is why women are more prone to develop this condition. If a wide Q-angle is felt to be root cause, then strengthening the abductors and lateral rotators of the hip helps.[4]

Patellofemoral Pain Syndrome (PFPS) needs to be differentiated from chondromalacia patellae (CMP). In patellofemoral pain syndrome (PFPS), the lining of the cartilage gets damaged on the under part of the kneecap. Patellofemoral pain syndrome (PFPS) may cause CMP, although it may also occur separately, commonly because of injury due to any impact. The various causes of patellofemoral pain syndrome (PFPS) include: overuse, injury, overweight, improper alignment of the kneecap (tracking disorder of the patella), changes that occur beneath the kneecap.

Signs and Symptoms of Patellofemoral Pain Syndrome (PFPS)

A patient diagnosed of patellofemoral pain syndrome (PFPS) will experience the following signs and symptoms:

  • Pain in the knee joint that is throbbing in nature, mostly in the front portion, about, and below the patella.
  • Presence of tenderness in the inner border of the patella.
  • In some cases, any sort of activity leads to development of swelling.
  • One of the symptoms of Patellofemoral Pain Syndrome (PFPS) is increased pain with stair climbing or walking up a hill.
  • Yet another symptoms of Patellofemoral Pain Syndrome (PFPS) is that bending the knee produces an audible click or a crack.
  • An uncomfortable feeling in the knee when sitting for long period of time, also known as “Theatre Sign” or “Movie-Goers Knee.”
  • In chronic cases of Patellofemoral Pain Syndrome (PFPS), there is presence of quadriceps muscle atrophy.
  • The Q-angle is more than 18 degrees.
  • Symptoms of stiffness is present in the muscles, especially the muscles of the calf, hamstrings, quadriceps, and the IT (Iliotibial) band.
  • Pain on the knee, usually as a result of jumping, bent knees, climbing down the stairs, or squatting can also be a sign of Patellofemoral Pain Syndrome (PFPS).
  • Sudden shift of the knee (knee buckle.)
  • The person experiences some cracking sounds when walking.[5]

Treatment for Patellofemoral Pain Syndrome (PFPS)

The treatment of patellofemoral pain syndrome (PFPS) is mostly done without any surgery. What is required is to relieve the pain, heal any wounds and to fix any damage to movement and restore strength to the bones and soft tissues. Treatments are classified into nonsurgical and surgical treatments.

Non-Surgical Treatment for Patellofemoral Pain Syndrome (PFPS)

Most of the treatments for patellofemoral pain syndrome (PFPS) that do not require any surgery include:

  • Medicines to Treat Patellofemoral Pain Syndrome (PFPS): Patients will be given non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen and ibuprofen that will help to relieve the pain and the swelling for patellofemoral pain syndrome (PFPS). If the pain persists or worsens, go back to your doctor for further evaluation.
  • Physical Therapeutic Exercises to Treat Patellofemoral Pain Syndrome (PFPS): Specific exercises that are meant to strengthen and straighten your quadriceps and hamstrings may be should be recommended alongside other treatments for patellofemoral pain syndrome (PFPS). These exercises will help to improve your endurance, mobility, and strength of other parts of your body, such as the lower back and abdomen.
  • Orthotics to Treat Patellofemoral Pain Syndrome (PFPS): Orthotics such as braces or splint can also be recommended for patellofemoral pain syndrome (PFPS) to help realign your patellar and relieve you of stressing your legs.[6]

Surgical Treatment for Patellofemoral Pain Syndrome (PFPS)

It is only in a very severe case of patellofemoral pain syndrome (PFPS) that the surgical treatment is used. If after undergoing a complete program of rehabilitation (for 6 months to 1 year) and the symptoms persist, then the surgical treatment can be introduced. Available surgical treatments for patellofemoral pain syndrome (PFPS) include:

Arthroscopy for Patellofemoral Pain Syndrome (PFPS)

Arthroscopy for patellofemoral pain syndrome (PFPS) involves a small camera that is inserted into the knee joint that can show images of the position and structure of the joint on a screen. The surgeon now uses these images to guide him or her during the course of the surgery. This method of surgery can be carried out in two ways.

  • Debridement for patellofemoral pain syndrome (PFPS) is a method of relieving pain by removing any damaged cartilage from the patella surface.
  • Lateral release for patellofemoral pain syndrome (PFPS) is done to loosen the tissues and better align the patellar in case of when the lateral reticulum tendon is too tight and can remove the patella from the trochlear grove.[7]

Tibial Tubercle Transfer for Patellofemoral Pain Syndrome (PFPS)

Tibial tubercle for patellofemoral pain syndrome (PFPS) is the realignment of the kneecap by placing the patella tendon to align with the tibia tubercle. This method is less often needed, but can be employed in a very serious case. To carry out this surgery, it is necessary to do an open surgery incision. The tibial tubercle will be removed and both the bone and the tendon will be taken to the interior part of the knee. This is then moved back into the tibia with the aid of screws.

Other Treatments for Patellofemoral Pain Syndrome (PFPS)

There are other treatments that can be administered to a patient with patellofemoral pain syndrome (PFPS), some of these include:

  • Bracing can help patients with patellofemoral pain syndrome (PFPS). Braces are orthopedic apparatus that are used to support and align the body to correct any broken part. This can be used to help the knee to be able to carry the whole body while moving and it will also help to align the kneecap after sometime. Bracing should be used while other treatments are being administered. Although results from random studies show that there were no significant change recorded from using bracing.
  • Analgesics can aid in the recovery from patellofemoral pain syndrome (PFPS). Analgesics can be administered alongside with non-steroidal anti-inflammatory drugs to ensure better healing progress.
  • Patellar Taping for patellofemoral pain syndrome (PFPS) is a physiotherapy taping of the knee to alleviate the pain of patellofemoral pain syndrome (PFPS). It can also help to realign the knee and can help the quadriceps parts to function properly. Many studies have shown significant change in reducing pain when patellar taping was used, but it is not certain of the long-term treatment.
  • Occupational therapy can be useful for the victims of patellofemoral pain syndrome (PFPS). The therapy administered should be changed occasionally, considering other human factors that may discourage or encourage their use in administering therapy. There are occupational therapists concerned with this and they will know the kind of therapy that will be required at any point in time. It is necessary to avoid repetitive exercises such as squatting.
  • Recreational therapy for patellofemoral pain syndrome (PFPS) and other fitness activities that can be enjoyed while helping regain the ability to coordinate movement. Recreational activities may include concentrated body part movements and dance, games, cycling, etc. This treatment measure is most often employed when other therapeutic methods do not work as expected.
  • Foot orthoses can relieve the pain caused by patellofemoral pain syndrome (PFPS). These are braces that which are placed inside a shore to be worn on the foot. Foot orthoses has been confirmed to yield good results in symptoms of patellofemoral pain syndrome (PFPS). They provide a good alignment of the kneecap.

Treatment Summary for Patellofemoral Pain Syndrome (PFPS)

The following is the treatment summary for patellofemoral pain syndrome (PFPS):

  • Rest, Ice Compression and Elevation after being physically active is beneficial in reduction of pain along with swelling.
  • Patient should take adequate rest till the time the pain resolves.
  • Knee support and a heat retainer are helpful.
  • Consulting a sports injury physician for advice for treating this condition and the rehab required.
  • Anti-inflammatory drugs are beneficial.
  • A comprehensive rehab program should be done religiously.
  • The possibility of a synovial plica should be ruled out.
  • Massage can be done to loosen the tight structures.
  • Exercises to build up strength of the VMO along with stretches of other muscles that may be tight.
  • Gait analysis should be done to find out if there is over-pronation.
  • Orthotics can also be helpful.
  • In cases where the syndrome has become chronic and conservative measures fail, surgery for release of the lateral structure becomes necessary.
  • Athletes should use appropriate and comfortable shoes while running.

Home Remedies and Changes in Lifestyle for Patellofemoral Pain Syndrome (PFPS)

To ensure better healing, the patient should be given some home remedies for patellofemoral pain syndrome (PFPS). These treatments should be administered, bearing in mind that some of the lifestyle changes which are needed. The kinds of home remedies and lifestyle changes that may be suggested include:

  • Changes in activities for patellofemoral pain syndrome (PFPS) can help the victim. The patients’ lifestyle activities should be changed, especially those that can hurt the knee. More subtle activities like swimming and cycling can be administered. Also, if the patient is overweight, there is need to first lose some weight before going ahead with the exercises.
  • The RICE Method for patellofemoral pain syndrome (PFPS) includes Rest, Ice, Compression, and Elevation. Rest- The patient should relax the knee often. Ice- he or she should apply some ice on the knee every 20 minutes in a day. Compression- Elastic bandage should be used to compress the knee to prevent it from more swelling. The bandage should fit and loosely tied around the knee area, leaving a little space on the kneecap. Elevation – You should often try to raise your knee above your heart to allow it to relax.
  • Complete knowledge about patellofemoral pain syndrome (PFPS) can help in the patient. The patient should be educated to understand the kind of activities he or she should engage in, that will not cause more pain. He or she should be given a thorough understanding of the home treatment program and should be told the repercussion of failure to adhere to the program activities.

Recovery Period for Patellofemoral Pain Syndrome (PFPS)

The period for full recovery for patellofemoral pain syndrome (PFPS) usually spans between six weeks to six months, and in extreme cases, the physical therapy (PT) may extend for a lifetime. There are usually successful records of full recovery and about eighty to ninety percent of patients treated of patellofemoral pain syndrome (PFPS) have gained full recovery within a short time.

The rehabilitation program will be thoroughly supervised within the period given for the program, to ensure speedy healing/ recovery. Programs that extend until lifetime are often menial exercises that are meant to strengthen and stretch the knees, muscles and the hamstring, even after healing is achieved.[8]

Exercises for Patellofemoral Pain Syndrome (PFPS)

Stretching Exercises for Patellofemoral Pain Syndrome (PFPS)

Stretching exercises can help the patients of patellofemoral pain syndrome (PFPS). Tightening of the kneecap can lead to stress beneath the patella, and proper movement will be constricted. The following exercises can aid in stretching them. The following are some of the stretching exercises for patellofemoral pain syndrome (PFPS):

Quad Exercise for Patellofemoral Pain Syndrome (PFPS)

Quad exercise for patellofemoral pain syndrome (PFPS) is done while standing. With your right hand holding a stool, use your left hand to hold your ankle from the front, so that your leg goes back and your knee is bent. Hold it like that for a few minutes and then release it. Do the same for the other foot.

Hamstring Exercise for Patellofemoral Pain Syndrome (PFPS)

Using the hamstring exercise for patellofemoral pain syndrome (PFPS) the muscles beneath the kneecap can be stretched. This is done while sitting on a bench. Carry one foot on the bench and stretch it out on it while the other is foot on the floor. Try to touch the tip of the toes of the outstretched foot with the tips of your finger and hold it like that for 30 seconds. Do the same for the other foot.

Iliotibial Band Exercise for Patellofemoral Pain Syndrome (PFPS)

The iliotibial band exercise for patellofemoral pain syndrome (PFPS) is the kind of exercise meant to straighten from the hip to the knee. The impact is felt most at the back of your lap. What you need to do is to sit straight up on the floor with both legs lying flat on the floor, then fold the leg that needs straightening over the other leg while the foot is firmly planted on the floor. With the hand opposite the folded leg, hold up the folded leg to make sure its foot remains planted on the floor while pulling your body up, supported with the other hand planted firmly on the floor.

Strengthening Exercises for Patellofemoral Pain Syndrome (PFPS)

To help reduce the pain on the kneecap caused by patellofemoral pain syndrome (PFPS) and allow it to relax, you should also carry out some strengthening of the muscles around the affected knee for patellofemoral pain syndrome (PFPS). The kinds of exercises that are needed to strengthen the muscles include:

Straight Leg Raise Exercise for Patellofemoral Pain Syndrome (PFPS)

To do straight leg raise for patellofemoral pain syndrome (PFPS) exercise lie on your back, bend the knee that is not affected, and straighten the affected knee, with its toes raised to a 30 degree level of the bent knee. Hold it up this way for a few seconds and then drop back to relax. This should be repeated 15 times.

Hip Abduction Exercise for Patellofemoral Pain Syndrome (PFPS)

For hip abduction exercise for patellofemoral pain syndrome (PFPS) lye on your side, making sure your body is very straight, and with the affected leg place on top of the unaffected leg, bend the unaffected leg backwards while keeping the affected leg straight. Then, gently lift the straight leg up and drop back to the table after a few seconds. While doing it, make sure your body does not lie with your stomach or with your back. Repeat 15 times, three at a time.

Hip Adduction Exercise for Patellofemoral Pain Syndrome (PFPS)

Hip adduction exercise for patellofemoral pain syndrome (PFPS) will also be done while lying on your side. Lie with your affected leg on the chair while the unaffected leg is kept on top of it. Then bend the unaffected leg to cross over the affected leg, while the affected leg is raised up for a few seconds and later placed back to the table. Also, repeat for 15 times, taking it three at a time.

Hip Flexion Exercise for Patellofemoral Pain Syndrome (PFPS)

In hip flexion exercise for patellofemoral pain syndrome (PFPS), sit at the tip of a chair or table and make sure your back is straight with both knees bent while lifting the affected knee higher up. At this point, place your hands on both sides of the chair and make sure your body is very straight and does not lean back or front. Be like this for a few seconds and then return to previous position, repeating this 15 times.[9]

Yoga Poses/Asanas for Patellofemoral Pain Syndrome (PFPS)

Doing some yoga can help you straighten and strengthen the muscles around the thigh and at the back of the lower leg. Yoga should only be started after you are completely relieved of the pains and you must be guided and supervised by an expert. Some of these yoga asanas/ poses for patellofemoral pain syndrome (PFPS) include:

  1. Balasana (The child’s pose)
  2. Utkatasana (The supported chair pose)
  3. Setu Bandha Sarvangasana ( The bridge pose)
  4. Veerasana
  5. Padahastasana (The standing forward bend)
  6. Vrikashana (The tree pose)
  7. Sukhasan (The easy pose)
  8. Tadasana
  9. Reclined raises of the leg.
  10. Trikonasana (The triangular pose)
  11. Utthita Trikonasana (The extended triangle pose)

Make sure you are well relaxed for at least 20 minutes before starting yoga and your doctor must certify you fit to go into yoga.

Risk Factors for Patellofemoral Pain Syndrome (PFPS)

The following are the risk factors for patellofemoral pain syndrome (PFPS):

  • People having a relatively smaller kneecap or a kneecap that comes out when the feet pronates are prone to develop patellofemoral pain syndrome (PFPS).
  • Individuals having tight muscles generally develop patellofemoral pain syndrome (PFPS).
  • If the quadriceps is weak, it can also result in development of patellofemoral pain syndrome (PFPS).
  • Athletes who participate in marathons or long distance races are more likely to develop this syndrome.
  • People with a history of prior knee dislocations are more prone to develop this syndrome.
  • Gender, Females than males most often experience the patellofemoral pain syndrome (PFPS).
  • Age, the pain is mostly experienced during teenage years and early years of adulthood.
  • Older adults usually experience arthritis and not patellofemoral pain syndrome (PFPS).

Complications for Patellofemoral Pain Syndrome (PFPS)

Below mentioned are the complications for patellofemoral pain syndrome (PFPS)

  • The patient may develop some difficulty in performing daily chores and activities.
  • It may result to the patient having to be subjected to using Non-steroidal anti-inflammatory drugs (NSAIDs).
  • It may result to the person experiencing infrequent dermatological effects.
  • Most exercises prescribed do not often worsen the symptoms. In case of any activity increasing the pain, there is need to adjust the force, regularity and the length of time of the exercise.[10]

Tests to Diagnose Patellofemoral Pain Syndrome (PFPS)

Once you detect any significant and constant pain on your kneecap for patellofemoral pain syndrome (PFPS), it is important you consult a physician to carry out a thorough examination of your leg and asking questions that will provide the reason for the pain. You may be X-rayed or a go through Magnetic Resonance Imaging (MRI) to exam your knee tissues in order to determine the extent of damage to your knee and other tissues.

Physical Examination to Diagnose Patellofemoral Pain Syndrome (PFPS)

The physician will carry out some physical test of your body parts connected to your knee for patellofemoral pain syndrome (PFPS) such as the legs, hip, kneecap, and total body support with your knee. This will help determine the gravity of the pain, where it is coming from and the extent of damage caused.

In the course of the examination, the physician will inquire about your general health condition and the kind of pain you feel. He would want to know when you started feeling the pains, how it started and if the pain is severe or not. If the pain has worsened, the doctor would like to know what caused it.

The doctor may have to press your knee gently to find out the place where you feel the pain. You may be asked to jump or squat in order to know the strength of your knees.

For thorough examination to test the possibility of patellofemoral pain syndrome (PFPS), the following features will be properly tested for any irregularities:

  • If the leg below the knee is properly aligned and kneecap position is okay.
  • The firmness of the hip and knees.
  • Rotation of the hip and the movement of both hips and knees.
  • How firmly the muscle thighs are attached to the kneecap.
  • How tight is the heel
  • How flexible is the feet.
  • Any sign of tenderness of the kneecap.
  • The flexibility and strength of the muscles in front and back of the thighs.
  • The doctor may also need to determine the way you walk, if you limp, sway or your legs are not able to carry your body well.

The next thing the doctor will do is to do a series of internal assessment of your knee structure and the extent of damage suffered.

Devices Used for Internal Body Examination for Patellofemoral Pain Syndrome (PFPS)

  • X-Ray for Patellofemoral Pain Syndrome (PFPS): The doctor will need to X-ray the internal structure of the kneecap and other tissues around it to determine the extent of damage caused because of patellofemoral pain syndrome (PFPS).
  • Magnetic Resonance Imaging (MRI) for Patellofemoral Pain Syndrome (PFPS): This is an alternative scan to X-ray or CT scan, which uses strong magnetic fields and radio waves to give clearer images of the bones and tissues. The MRI gives a better idea of what is happening inside the knee for patellofemoral pain syndrome (PFPS). They are more expensive than X-ray and CT scan.
  • CAT Scan for Patellofemoral Pain Syndrome (PFPS): Short for Computerized Tomography scan. It has more radiation than X-rays and can produce clearer pictures of the soft tissues and bones, section by section, when combined with X-rays, enabled by computers.[11]

Prognosis for Patellofemoral Pain Syndrome (PFPS)

Recent studies carried out have revealed successful results recorded on patients who have passed through the home exercises. Success rate was between 75 to 85% of patients affected by patellofemoral pain syndrome (PFPS). The VMO (Vastus Medialis Oblique) training was administered to a certain number of athletes and results showed that after six years of administration, 54% were either totally relieved of the pains or symptoms were very mild. There has been no real result so far, of arthroscopic treatments. During examination, the factors that were discovered to have hindered successful outcome include old age, the crackle and pain of the patellar, bilateral symptoms, and hypermobile patella.

Preventive Measures for Patellofemoral Pain Syndrome (PFPS)

Physical therapies have proven to relieve patellofemoral pain syndrome (PFPS) symptoms, but if the trainings are not made to suit your present condition, the pain may return. The hamstrings and the quadriceps should be properly conditioned as well.

Once you have been treated of patellofemoral pain syndrome (PFPS), further efforts need to be taken to ensure it does not reoccur. The following will help:

  1. Reduce activities that hurt. Reduce the activities that have caused you to hurt your knee.
  2. Warm up. Always ensure you do proper warm up before starting your exercises.
  3. Gradually introduce more training as time goes.
  4. Maintain healthy lifestyle. Always maintain fitness, so as not to exert so much pressure on your knees.
  5. Wear appropriate shoes. Make sure you put on shoes that suite the exercise you are doing.
  6. Ensure you bring in some stretching and flexible exercises that will help your hamstrings and quadriceps and make sure you stretch after every exercise.[12]


There is usually a regular report of the case of patellofemoral pain syndrome (PFPS). Orthopedics will have to face this problem almost on a daily basis because of the commonality of the problem. The challenging thing will be to ascertain the cause of the problem, given that at first instance; most cases cannot be immediately diagnosed except a surgery is done. Nevertheless, there is need for thorough examination and physical testing to be done to determine the alignment of the kneecap, the strength of the leg beneath knee and the easy movement of the patella.

The alignment of the patella and the articular cartilage can both be assessed using the MRI, radiographs, or X-rays. Treatment of patellofemoral pain syndrome (PFPS) can be better achieved using modification of activities, anti-inflammatory oral medication, physical therapies and in some cases, intraarticular injections. Surgical realignment and straightening of the patella may be introduced if these measures do not yield adequate result.


Also Read:

Pramod Kerkar, M.D., FFARCSI, DA
Pramod Kerkar, M.D., FFARCSI, DA
Written, Edited or Reviewed By: Pramod Kerkar, M.D., FFARCSI, DA Pain Assist Inc. This article does not provide medical advice. See disclaimer
Last Modified On:August 6, 2020

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