I have pain at the front of my knee when running or going down stairs — is this patellofemoral pain syndrome?

Anterior knee pain that appears with running, climbing stairs, going down stairs, or after prolonged sitting or squatting is a typical presentation of patellofemoral pain syndrome. It usually develops gradually rather than from a single trauma, but assessment by a physician is still advised to rule out other structural problems.

Do I always need an X-ray or MRI for this condition?

Not necessarily. The article notes that most radiological findings are normal, and X-ray, CT, or MRI is usually arranged only when another condition is suspected or when basic conservative treatment has not led to improvement, in order to rule out structural abnormalities. Whether imaging is needed still depends on individual assessment.

Why is this condition more common in women?

This condition occurs more often in women than in men. The article notes that this relates to factors such as the Q angle of the patella, malalignment, knock-knees or bow-legs, and an imbalance in the strength of the quadriceps, gluteus medius, and hip external rotators, all of which can affect how the kneecap tracks.

Can it really get better with exercise instead of surgery?

The article notes that about 80 percent of patients show some degree of response to conservative treatment, and that quadriceps strengthening has a marked effect on symptom improvement. A Cochrane review also found that exercise therapy helps relieve pain and improve function, though the quality of evidence is low, and the best form of exercise still needs individual assessment.

When should surgery be considered?

The article suggests that surgery may be considered only if symptoms have not improved after more than six months of appropriate conservative treatment. If there is recurrent dislocation or an associated medial ligament tear, a physician's assessment is also needed to decide whether surgical management is required.

What Is Patellofemoral Pain Syndrome? A Detailed Overview

Pain around or behind the kneecap is an overuse injury that can arise from many factors. These include biomechanical changes, lower-limb malalignment, and muscle imbalance. Many people call it chondromalacia patellae. To help avoid this condition, you can take up lower-impact activities such as swimming and yoga. Wearing suitable insoles and using appropriate supportive devices can also help improve malalignment.

Epidemiology

Anterior knee pain accounts for 20 to 40 percent of all knee problems, and patellofemoral syndrome is one of the most common running injuries in sports medicine. It can occur in all age groups, with a prevalence of about 22.7 percent in the general adult population and 28.9 percent in adolescents. Women are more likely than men to develop it. Anterior knee pain can be caused by trauma (such as landing on the knee, which injures the cartilage or the subchondral bone), but in most cases it develops gradually.

Risk factors

A recent increase or change in training or activity volume: joint loading during exercise that exceeds the load capacity of the muscles (for example running, squatting, or lunging)
Patella-related problems and an increased patellar angle (Q angle)
Malalignment problems (for example increased femoral anteversion, inward-pointing patellae, patellar tilt, external tibial rotation, and pes varus)
Knock-knees or bow-legs
Family history
Imbalance in surrounding strength (for example the medial muscles being weaker relative to the lateral ones, an overly tight quadriceps, anterior pelvic tilt, and an overly tight lateral iliotibial band)
Dysfunction of the gluteus medius and hip external rotators; this leads to reduced hip control and increased femoral adduction and/or internal rotation

History

Anterior knee pain after recent changes in activity frequency, exercise type, and intensity, longer wear time or a change of current athletic shoes, prolonged sitting (such as in a cinema, driving, or on a flight), or squatting
Anterior knee pain with running, climbing stairs, or going down stairs
A history of the kneecap catching or dislocating, and/or a history of direct trauma
The presence or absence of joint crepitus is not helpful for diagnosis, because most healthy women and nearly half of healthy men may also have crepitus on examination

Diagnostic tools

If another condition is suspected, or if the patient has not improved with basic conservative treatment, imaging studies are advised. Most radiological findings will be normal, but structural abnormalities need to be ruled out.

Routine X-ray radiological examinations include:

An anteroposterior standing bilateral weight-bearing view, which can show valgus or varus alignment of the femur, knee, or tibia
A lateral X-ray of the affected knee, on which patellar height can be assessed with the Insall-Salvati ratio (the ratio of patellar tendon length to patellar length)
A Merchant view of both patellofemoral joints, which can assess the trochlear sulcus angle, the degree of patellar tilt, and the appearance of the femoral condyles
A tunnel view, when an osteochondral defect lesion is suspected

CT scan: useful for assessing the relationship of the patellofemoral joint (such as tilt and subluxation), especially when a patellar subluxation cannot be clearly seen on routine X-ray.

MRI can be used for soft-tissue assessment, including patellofemoral chondromalacia, other articular cartilage defects, tendinopathy, and tendon rupture.

Medical management

Because patellofemoral syndrome usually arises from multiple factors, appropriate treatment should address most of the problem. About 80 percent of patients show some degree of response to conservative treatment. Ice, medication, injections, and some device-based therapies can help with acute pain control.

Medication focuses on pain control rather than controlling inflammation. For daily activity, acetaminophen (paracetamol) or an NSAID can be used first to relieve pain symptoms. Topical analgesics can be applied at 2 to 4 grams over the painful area, 3 to 4 times a day, for up to 7 days. The effect of corticosteroid injection may be limited or not long-lasting. Options such as hyaluronic acid for intra-articular lubrication, or dextrose prolotherapy and other proliferative injections to increase the stability of surrounding tissue, may be considered; the actual situation should be explained after a physician’s assessment, and no single approach fits all cases.

Assess insoles, watching for problems such as excessive wear and inadequate support; they may be considered for some patients with a collapsed arch. Using an appropriate knee brace can also reduce pain. Taping can help correct the tracking of the kneecap. Compared with no taping, studies found that taping significantly improved pain during three clinical test periods. External-rotation taping was more effective than internal-rotation taping. The degree of pain improvement after taping was positively correlated with the initial level of pain.

Training

An appropriate training program: for example, strength training for muscle weakness, mobility training for reduced joint range of motion, and strength training focused on knee and hip exercises, with particular emphasis on gluteal and hip external rotator training.

Modification: reduce activities that may trigger symptoms, such as resistance training (squats or full squats), increasing running mileage, or plyometric exercise, and encourage other training methods for relative rest (such as pool running, cycling, swimming, or using an elliptical trainer).

Training: strengthening the quadriceps has a strong effect on symptom improvement. Closed-chain strength training with the knee flexed 0 to 30 degrees can strengthen the quadriceps (VMO) while keeping the inward force to a minimum. Isokinetic training (applying variable resistance so that the movement stays at a constant speed) is another option.

For the exercise component, a 2017 Cochrane review analyzed 31 trials including 1,690 patients with PFPS. The evidence for the seven main outcomes was of very low quality, largely due to serious flaws in study design and small participant numbers. Exercise therapy showed some clinically important evidence of reduced pain and improved functional capacity, as well as better long-term recovery. However, there is not yet enough evidence to determine the best form of exercise therapy, and it is unclear whether this result applies to everyone with PFPS. That said, there is some very low quality evidence that hip-plus-knee exercise may reduce pain more effectively than knee exercise alone.

Although online information is now abundant, if practising certain movements makes the pain worse, it is advisable to have a healthcare professional or coach assess and help with basic movement training.

Surgical treatment

If there is no improvement after more than six months of appropriate conservative treatment, surgery may be considered.

If dislocation occurs and keeps recurring, a tear of the medial ligament needs to be ruled out. If the ligament is torn, surgery needs to be considered. For the treatment of patellar instability, some procedures, such as an isolated lateral patellar retinacular release, do not work over the long term on their own, but can be addressed together with injuries elsewhere.

References

Patella Instability https://kneeandshoulderclinic.com.au/knees/surgical-conditions/patella-instability/
Patellar Subluxation (Partially Dislocated Kneecap) https://www.braceability.com/blogs/info/patellar-subluxation?utm\_medium=social&utm\_source=pinterest
https://www.sportsinjuryclinic.net/sport-injuries/knee-pain/q-angle-knee
Tibial internal and external rotation taping for improving pain in patients with patellofemoral pain syndrome. J Sci Med Sport. 2022 Aug;25(8):644-648.
Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial. Br J Sports Med. 2020 Dec;54(23):1416-1422.
Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2015 Jan 20;1:CD010387.