Patellofemoral Syndrome
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Patellofemoral syndrome (PFS) is characterized by a group of symptoms that contribute to anterior knee pain and that often respond to conservative management. The pain is associated with positions of the knee that result in increased or misdirected mechanical forces between the patella and femur. [1, 2] Lack of consensus regarding the cause of PFS remains, likely because several factors associated with the syndrome present differently in each patient.
PFS is a clinical diagnosis based on history and physical examination. Plain film radiographs can assess the patella (kneecap) position. The anterior-posterior (AP) view shows the patella over the sulcus; the lateral view is imaged at 45º of knee flexion and in full extension to determine the height of the patella (ie, whether it is baja [low] or alta [high]). The sunrise view visualizes the patellofemoral articulation in the femoral condylar groove and can determine the tilt or angle of the patella, as well as demonstrate the depth of the intercondylar groove.
Advanced imaging studies such as computed tomography (CT) scanning or magnetic resonance imaging (MRI) are rarely needed but can be part of the diagnostic workup for refractory cases to ensure that there is no concurrent intra-articular disease or other contributing pathology. In addition, arthroscopic evaluation can provide assessment of joint structures that may cause symptoms that mimic PFS when they are impaired and allows for the direct visualization of the cartilage surface.
PFS responds well to a rehabilitation program. The initial treatment stage is designed to decrease pain, using modalities such as ice, analgesic medication, nonsteroidal anti-inflammatory drugs (NSAIDs), and activity modification. Patellar taping techniques are used in patients with PFS to reduce friction on the patella. A neoprene knee sleeve with the patella cut out is also helpful, as it provides proprioceptive feedback.
The rehabilitation treatment stage uses therapeutic exercise to restore flexibility, strength, and proprioception to the lower limb kinetic chain. Orthotics or appropriate footwear are sometimes recommended.
If PFS presents concurrently with knee pain secondary to degenerative changes and conservative measures fail, aspiration of effusion, along with injection of the knee joint with steroid or hyaluronic acid, may be tried. Surgical intervention for patellofemoral syndrome usually is in the form of arthroscopic evaluation followed by release of the lateral attachments of the patella. Most authors agree that surgical treatment rarely is indicated.
While theories regarding the pathophysiology of patellofemoral syndrome vary, identification of the resultant forces involved in dynamic and static knee positions has been fundamental to the research on this syndrome. Factors believed to contribute to production of retropatellar pain include impairments affecting the patellofemoral joint interface. Such impairments may result from an imbalance of ligamentous and muscle forces, malalignment between the joint surfaces, excessive knee valgus (ie, increased Q-angle) resulting in increased lateral forces, and quadriceps contractures causing production of excessive leverage forces on the patellofemoral joint surface. Excessive use of the joint, either in frequency of loading or excessive loading, also contributes to the symptoms.
Patellofemoral syndrome is estimated to be the most common cause of anterior knee pain in athletic and nonathletic populations.
United States
Patellofemoral syndrome is common in the United States, especially among physically active persons.
International
Patellofemoral syndrome has an estimated prevalence rate of 20% in student populations.
Morbidity associated with patellofemoral syndrome is directly proportional to the activity level of the patient. Curtailing physical activities that place unnecessarily stressful demands upon the patellofemoral articulation may be necessary (preferably while substituting other activities into the exercise program).
No racial predilection has been identified for patellofemoral syndrome.
Patellofemoral syndrome more frequently affects females than males.
Patellofemoral syndrome occurs most frequently in adolescents and young adults.
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Noel F So, MD, FAAPMR Amputee Medical Director, PMRS Attending Physician, Department of Physical Medicine and Rehabilitation, VA Eastern Colorado Health Care System; Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital
Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.
Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.
Keith Aj Sequeira, MD, FRCPC Associate Professor, Director of Education, Department of Physical Medicine and Rehabilitation, Parkwood Hospistal, University of Western Ontario
Disclosure: Nothing to disclose.
Patrick J Potter, MD, FRCSC Associate Professor, Department of Physical Medicine and Rehabilitation, University of Western Ontario School of Medicine; Consulting Staff, Department of Physical Medicine and Rehabilitation, St Joseph’s Health Care Centre
Patrick J Potter, MD, FRCSC is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, College of Physicians and Surgeons of Ontario, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Texas Medical Association
Disclosure: Nothing to disclose.
Patellofemoral Syndrome
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