Patellofemoral pain (PFP), one of the most common knee problems in active people, is also one of the most challenging conditions to manage, due to its complex nature. To support athletic trainers and other healthcare providers who treat the problem, the National Athletic Trainers’ Association (NATA) has published recommendations and a framework for identifying risk factors and managing patients who experience PFP. The Association’s position statement, “Management of Individuals with Patellofemoral Pain”, is available online in the September issue of NATA’s Journal of Athletic Training (http://natajournals.org).
“This statement is the culmination of 4 years of research and over 20 years of clinical work,” said lead author, Lori A. Bolgla, PhD, PT, MAcc, ATC. “My hope is that our findings in this statement will provide additional tools for clinicians to achieve even more positive short and long-term outcomes for these patients.”
“Patellofemoral pain affects more than 22% of the population, with patients ranging from student athletes to active older adults,” said NATA President, Tory Lindley, MA, ATC. “The research and analysis led by Dr. Bolgla provide additional insight and recommendations that clinicians can use to diagnose, treat and rehabilitate PFP.” (See Guest Editorial on page 9.)
The National Athletic Trainers’ Association (NATA) suggests the following guidelines to identify risk factors and manage patients with PFP.
About the National Athletic Trainers’ Association
Athletic trainers are healthcare professionals who specialize in the prevention, diagnosis, treatment, and rehabilitation of injury and sport-related illness. They prevent and treat chronic musculoskeletal injuries from sports and physical and occupational activity and provide immediate care for acute injury. Athletic trainers offer a continuum of care that is unparalleled in healthcare. The National Athletic Trainers’ Association represents and supports 45,000 members of the athletic training profession. For more information, visit www.nata.org.
Patellofemoral pain is particularly prevalent in younger people who are physically active, with females reported as being at higher risk. Early identification of risk factors might allow clinicians to develop and implement programs aimed at reducing the severity and duration of this condition. The significance of early detection is highlighted by the fact that as many as 70% to 90% of people with this condition have recurrent or chronic symptoms.
Key risk factors include:
- excessive hip adduction and internal rotation during dynamic tasks, such as running and landing from a jump
- quadriceps weakness and tightness
- greater vertical peak force to the lateral heel and the second and third metatarsals during gait
- delayed activation of the vastus medialis obliquus relative to the vastus lateral, as identified with a patellar tendon tap or voluntary tasks (eg, rocking back on the heels)
- increased knee abduction impulses and moments during running and landing activities.
Hip muscle weakness is not a likely risk factor associated with patellofemoral pain onset.
Best Practices for Conservative Management
Patellofemoral pain is a multifactorial problem that requires a comprehensive plan of care comprising active interventions (hip and quadriceps strengthening exercise, neuromuscular retraining), passive interventions, and patient education (contributing factors, activity modification, and rehabilitation adherence). Clinicians should consider movement retraining for patients with PFP who demonstrate altered lower-extremity gait mechanics. Nonsurgical treatment continues to be the recommended strategy.
Active interventions are:
- quadriceps and gluteal strengthening exercises
- ankle and foot exercises (if a deficit exists)
- calf and hamstrings stretching (if a deficit exists)
- hip movement retraining (if a deficit exists)
Passive interventions are:
- patellar taping (if it provides pain relief)
- foot orthoses in patients with excessive dynamic foot pronation
- patella, ankle, and first-ray joint mobilization (if a deficit exists)
Patient education comprises:
- identifying contributing factors
- getting patients’ buy-in on treatment options
- sharing expected rehabilitation outcomes
- discuss the importance of active interventions.
Patellofemoral pain is a complex condition, with no single contributory factor. Treatment should be multimodal, addressing impairments not only at the knee but also at the hip, foot, and ankle. NATA plans to continue supporting research to refine these recommendations and to advance the understanding of this complicated issue.