Guideline sources The following summarized guidelines for the evaluation and management of patellofemoral pain syndrome (PFPS) are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2020; 2018) and the American Physical Therapy Association (APTA 2019). 1 2 3 Guidelines 1. Screening and diagnosis Diagnostic criteria: reproduce retropatellar or peripatellar pain during squatting as a diagnostic test for PFPS. Perform other functional activities loading the patellofemoral joint in a flexed position, such as stair climbing or descent, as diagnostic tests for PFPS. A Show 2 more 2. Classification and risk stratification Classification: Consider using the proposed impairment/function-based PFPS classification system to guide management: Situation Guidance https://web.pathway.md/diseases/recgAtwMyYspdhAoa 1/4 6/29/23, 10:55 PM Patellofemoral pain syndrome Pathway Overuse/overload without other impairment Patients presenting with a history suggesting an increase in magnitude and/or frequency of patellofemoral joint loading at a rate surpassesing the ability of patellofemoral joint tissues to recovery Patients presenting with lower extremity muscle performance deficits in the hip and quadriceps Muscle performance deficits Patients may respond favorably to hip and knee resistance exercises Patients presenting with excessive or poorly controlled knee valgus during a dynamic task, but not necessarily due to weakness of the lower extremity musculature Movement coordination deficits Patients may respond favorably to gait retraining and movement re-education interventions leading to improvements in lower extremity kinematics and pain, suggesting the importance of assessing dynamic knee valgus during movement Patients presenting with higher than normal foot mobility and/or flexibility deficits of 1 of the following structures C Mobility impairments 3. Diagnostic investigations Clinical assessment: use the AKPS, the KOOS-PF, or the VAS for activity or EPQ to measure pain and function in patients with PFPS. A Show 2 more Diagnostic imaging (acute knee pain): obtain knee X-ray for the evaluation of a fall or acute twisting trauma to the knee in 5 years old patients with focal tenderness, effusion, or inability to bear weight. B Show 4 more Diagnostic imaging (chronic knee pain): obtain knee X-ray as the initial imaging of chronic knee pain in patients aged 5 years. B Show 2 more 4. Nonpharmacologic interventions Physical therapy: offer exercise therapy with combined hip-targeted (targeting posterolateral hip musculature) and knee-targeted exercises (either weight-bearing exercises, such as https://web.pathway.md/diseases/recgAtwMyYspdhAoa 2/4 6/29/23, 10:55 PM Patellofemoral pain syndrome Pathway resisted squats, or non-weight-bearing exercises, such as resisted knee extension; as both exercise techniques target the knee musculature) to reduce pain and improve patient-reported outcomes and functional performance in the short, medium, and long term. Prefer a combination of hip- and knee-targeted exercises over solely knee-targeted exercises to optimize outcomes. Consider preferring hip-targeted exercise over knee-targeted exercise in the early stages of treatment. A Show 3 more Orthoses and taping: do not offer patellofemoral knee orthoses, including braces, sleeves, or straps, in patients with PFPS. D Show 2 more Alternative and complementary therapies (manual therapy): do not offer manual therapy in isolation, including lumbar, knee, or patellofemoral manipulation/mobilization, in patients with PFPS. D Alternative and complementary therapies (biophysical therapies): do not offer biophysical therapies, including ultrasound, cryotherapy, phonophoresis, iontophoresis, electrical stimulation, and therapeutic laser, for the treatment of patients with PFPS. D Alternative and complementary therapies (biofeedback): Do not offer EMG-based biofeedback on medial vastii activity to augment knee-targeted (quadriceps) exercise therapy for the treatment of PFPS. D Do not offer visual biofeedback on lower extremity alignment during hip- and knee-targeted exercises for the treatment of patients with PFPS. D Alternative and complementary therapies (acupuncture and dry needling): Do not offer dry needling for the treatment of patients with PFPS. D Consider offering acupuncture (in the setting where acupuncture is within the scope of practice of physical therapy) to reduce pain in patients with PFPS. C 5. Patient education General counseling: consider providing specific patient education on load management, body- weight management when appropriate, the importance of adherence to active treatments like exercise therapy, biomechanics contributing to relative overload of the patellofemoral joint, the evidence for various treatment options, and kinesiophobia, to improve compliance and adherence to active management and self-management strategies. C Clinical findings Symptoms Triggers Knee pain Climbing stairs Knee stiffness Jumping Patellar pain Running Squatting Social history Standing after prolonged sitting https://web.pathway.md/diseases/recgAtwMyYspdhAoa 3/4 6/29/23, 10:55 PM Patellofemoral pain syndrome Pathway Long-distance runner Musculoskeletal exam Sports participation Knee crepitus Knee instability Patellar maltracking Patellar tenderness References 1. Expert Panel on Musculoskeletal Imaging, Mihra S Taljanovic, Eric Y Chang et al. ACR Appropriateness Criteria Acute Trauma to the Knee. J Am Coll Radiol. 2020 May;17 5S S12 S25. Open 2. Richard W Willy, Lisa T Hoglund, Christian J Barton et al. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019 Sep;49 9 CPG1 CPG95. Open 3. Expert Panel on Musculoskeletal Imaging:, Michael G Fox, Eric Y Chang et al. ACR Appropriateness Criteria Chronic Knee Pain. J Am Coll Radiol. 2018 Nov;15 11S S302 S312. Open https://web.pathway.md/diseases/recgAtwMyYspdhAoa 4/4