Exercise therapy prescribed by a physiotherapist is the best approach for achieving recovery in people with patellofemoral pain (PFP, or runner’s knee), and there is no evidence to support any benefit from non-active treatments alone, although some are helpful as part of a combined strategy, according to new US guidelines. The team behind the updated clinical practice guidelines, published in the Journal of Orthopaedic & Sports Physical Therapy, said the best way to prevent PFP is to do a variety of sports and build up intensity, and in some cases to improve muscle strength, especially in the thighs.
The research team, led from the University of Montana in the US, noted that PFP, which presents at the front of the knee, under and around the kneecap, affects a quarter of the general US population every year, and is reported twice as often by women as by men. Key recommendations of their clinical practice guideline include:
- An exercise programme that gradually increases activities such as running, exercise classes, sports or walking, is the best way to prevent PFP.
- Adolescent athletes who specialise in a single sport are at 28% greater risk of PFP than athletes who participate in a variety of sports.
- An important way to reduce the risk of PFP in military populations is maximising leg strength, particularly the thigh muscles.
- Pain does not always mean there is damage to the knee.
The guideline authors recommended that clinicians should include exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve patient-reported outcomes and functional performance in the short-, medium-, and long-term. Hip-targeted exercise therapy should target the posterolateral hip musculature; knee-targeted exercise therapy includes either weight-bearing (resisted squats) or non-weight-bearing (resisted knee extension) exercise, as both exercise techniques target the knee musculature; and preference to hip-targeted exercise over knee-targeted exercise may be given in the early stages of treatment of PFP.
Further recommendations with good evidence are that clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only in the short-term (up to six weeks) – and if they are prescribed, foot orthoses should be combined with an exercise therapy programme. There is insufficient evidence to recommend custom foot orthoses over prefabricated foot orthoses.
The guideline authors commented: “Clinicians should combine physical therapy interventions for the treatment of patients with PFP, which results in superior outcomes compared with no treatment, flat shoe inserts, or foot orthoses alone in the short- and medium-term. Exercise therapy is the critical component and should be the focus in any combined intervention approach. Interventions to consider combining with exercise therapy include foot orthoses, patellar taping, patellar mobilisations, and lower-limb stretching.”
They concluded: “While it might be tempting to seek quick fixes for knee pain, there is no evidence that non-active treatments alone, such as electrical stimulation, lumbar manipulations, ultrasound or dry needling, help persons with PFP. Persons with PFP should seek clinicians who use exercise therapy for the treatment of this injury.”
*Willy RW, Hoglund LT, Barton CJ, et al. Patellofemoral pain: Clinical practice guidelines linked to the international classification of functioning, disability and health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 2019 Volume:49 Issue:9 Pages:CPG1–CPG95 DOI: 10.2519/jospt.2019.0302