Evidence-Based Treatment for Patellofemoral Pain Syndrome $0.00

Evidence-Based Treatment for Patellofemoral Pain Syndrome

By: Rebecca Moore |
Patellofemoral Pain Syndrome

Patellofemoral pain is a popular chronic pain; not in the sense that patients love experiencing it, but more in the sense that hands-on healthcare professionals see countless patients suffering from this pain syndrome. Usually presenting as discomfort at the front of the knee and in the kneecap, this condition occurs when friction interferes with the kneecap’s ability to glide smoothly on the femur in the femoral groove during movement.1 While patellofemoral pain is often found in highly active individuals, plenty of older adults or anyone looking to quickly establish a more active lifestyle are also highly at risk

Robert Manske PT, DPT, MEd, SCS, ATC, CSCS, an author, professor and the Chair and Program Director in the Department of Physical Therapy at Wichita State University, is an expert in orthopaedic physical therapy and rehabilitation. We took some time to pick his brain about patellofemoral pain and get to the bottom of best practices for treating this common but dynamic injury. You know what that means; it’s time for another installment of the Injury Management Series!

Causes of Patellofemoral Pain


The first causes of patellofemoral pain are external factors, like acute trauma, overuse or long bouts of high performance training. According to Dr. Manske, failing to prepare your body for a sudden increase in activity is one of the main culprits of patellofemoral pain.

“There are many external causes. Those could be things like overuse, maybe someone who starts training too hard or at too high of a level,” said Manske. “It could also be someone who’s already training now, but they’re ramping up their training … that causes a significant type of overuse. It could be lack of flexibility, it could be lack of conditioning; there’s a lot of external reasons for having patellofemoral pain.”

External Knee Pain


Internal causes of patellofemoral pain can be difficult to identify and, unfortunately, are also plenty in number. “There are multiple types of internal causes of patellofemoral pain; the list could really go on for quite some time,” said Dr. Manske.

Some common internal causes of patellofemoral pain syndrome he notes are:

  • Patellar tracking issues
  • Tightness of different structures within the knee
  • Decreased strength in the quadriceps
  • Lack of dynamic control of muscles in and around the knee
  • Proximal influences at the hip
    • “When someone is in a closed kinetic chain type of a pattern, if their hip is not maintaining proper control, they may have a valgus collapse or they may have some additional internal rotation of the femur on the tibia, creating a relative lateral translation of the patellofemoral joint,” explains Manske.

Get Hip to the Core of Patellofemoral Pain Management

If you look at any traditional patellofemoral pain play book, you’ll see that decreasing tightness to increase range of motion is one of the first plays called by physical therapists, athletic trainers and other musculoskeletal rehabilitation professionals. Which is great; don’t scrap these fundamentals when building your program. However, recent research regarding this pain syndrome has started to explore the relationship between the hip, core and knee pain, with admittedly unsurprising results (stability/mobility continuum, anyone?!). Let’s take a look at three different studies that have explored this theory:

Study #1: “The Effect of Hip and Knee Exercises on Pain, Function and Strength in Patients with Patellofemoral Pain Syndrome: A Randomized Controlled Trial”

Goal of the Study: Compare the efficiencies of hip exercises alongside knee exercises versus only knee exercises on pain, function and isokinetic muscle strength in patients with this syndrome

Goal of the Study: Compare the efficiencies of hip exercises alongside knee exercises versus only knee exercises on pain, function and isokinetic muscle strength in patients with this syndrome

Conclusion: “We suggest additional hip-strengthening exercises to patients with patellofemoral pain syndrome in order to decrease pain and increase functional status.” 2

Study #2: "Pain, Function, and Strength Outcomes for Males and Females with Patellofemoral Pain Who Participate in Either a Hip/Core- or Knee-Based Rehabilitation Program”

Goal of the Study: Compare improvements in pain, function and strength between males and females with patellofemoral pain who participated in either a hip/core or knee rehabilitation program

Results: Visual analog scale and anterior knee pain scale scores improved for all participants, regardless of sex or rehabilitation group. All patients exhibited improved hip abductor, hip extensor and knee extensor strength; however, males saw a 15.4% increase in hip internal rotator strength, compared to only a 5.0% increase in females.

Conclusion: “On average, males and females with patellofemoral pain benefitted from either a hip/core or knee rehabilitation program. Subjects with successful outcomes likely had hip and knee weakness that responded well to the intervention. These males and females had similar and meaningful improvements in hip extensor and knee extensor strength. Only males had relevant changes in hip external rotator strength. Clinicians should consider a subgroup of males who may benefit from hip extensor and external rotator exercise and females who may benefit from hip extensor exercise.”3

Study #3: “Strengthening of the Hip and Core Versus Knee Muscles for the Treatment of Patellofemoral Pain: A Multicenter Randomized Controlled Trial”

Goal of the Study: Compare patellofemoral pain, function, hip- and knee- muscle strength and core endurance between knee and hip protocols after 6 weeks of rehabilitation

Results: While the visual analog scale and the anterior knee pain scale improved for patients participating in both protocols, the visual analog scale scores for those in the hip protocol were reduced one week earlier than in the knee group. Also, while both groups yielded gains in strength, participants in the hip-focused group gained more hip-abductor and -extensor strength and posterior core endurance than those in the knee group.

Conclusion: “Both the hip and knee rehabilitation protocols produced improvements in patellofemoral pain, function and strength over six weeks. Although outcomes were similar, the hip protocol resulted in earlier resolution of pain and greater overall gains in strength compared with the knee protocol.” 4

Knee Injury Treatment

Evidence + Fundamentals = An Easy Recipe to Follow

According to the American Physical Therapy Association,1 here are the recommended treatments for patellofemoral pain:

  1. Strengthening exercises
  2. Stretching exercises
  3. Positional training
  4. Cross-training guidance
  5. Taping or bracing
  6. Electrical stimulation
  7. Activity-based exercises

Based on the evidence we covered in the last section, we know that adding hip- and core- focused exercises to these rehabilitation recommendations can help improve and accelerate patient outcomes. But what does this look like in practice?

Dr. Robert Manske has the answer. Below, he shares his top five recommended exercises that you can easily replicate in the clinic or in home programs with four simple tools from TheraBand:

  1. TheraBand CLX Bands
  2. TheraBand Tubing with Cuffs
  3. TheraBand Stability Trainers
  4. TheraBand Rocker Board

Watch the videos below for an instructive demo of each exercise.

Download the printable exercise guides to easily share the protocol with patients and colleagues!

Exercises for Patellofemoral Pain



2. Sahin M et al. 2016. The effect of hip and knee exercises on pain, function, and strength in patients with patellofemoral pain syndrome: a randomized controlled trial Turk J Med Sci 46:265-77

3. Bolgla et al. 2016. Pain, function, and strength outcomes for males and females with patellofemoral pain who participate in either a hip/core- or knee-based rehabilitation program. Int J Sports Phys Ther. 11(6):926-935.

4. Ferber R, et al. 2015. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. Journal of Athletic Training 50(4):366-77.