TRAINING, PREVENTION, AND REHABILITATION

Update on Rehabilitation of Patellofemoral Pain

Rebecca A. Dutton, MD; Michael J. Khadavi, MD; and Michael Fredericson, MD, FACSM
and dynamic alignment of the lower
extremity, patellar orientation and tracking, lower extremity strength and flexibility, as well as gait analysis (15).
Thus effective rehabilitation must
incorporate a multimodal approach that
addresses all of the underlying contributors identified on an individuals physical examination. Broadly these factors
may be considered in three categories:
local joint impairments, altered lower
extremity biomechanics, and overuse.
Here, we review the current evidence
supporting rehabilitation strategies for
PFPS as they apply to specific etiological factors (Table 2).

Abstract
Patellofemoral pain syndrome (PFPS) is a multifactorial disorder with a
variety of treatment options. The assortment of components that contribute to its pathophysiology can be categorized into local joint impairments, altered lower extremity biomechanics, and overuse. A detailed
physical examination permits identification of the unique contributors for
a given individual and permits the formation of a precise, customized
treatment plan. This review aims to describe the latest evidence and
recommendations regarding rehabilitation of PFPS. We address the utility of quadriceps strengthening, soft tissue flexibility, patellar taping,
patellar bracing, hip strengthening, foot orthoses, gait reeducation, and
training modification in the treatment of PFPS.

Introduction
Patellofemoral pain syndrome (PFPS) is a condition
characterized by insidious onset anterior knee pain that is
magnified in the setting of increased compressive forces to
the patellofemoral joint, such as squatting, ascending or descending stairs, and prolonged sitting (47). PFPS is remarkably common, accounting for up to 25% of all knee injuries
presenting to sports medicine clinics (23). The precise etiology, however, remains poorly defined. Current understanding supports a multifactorial basis in which a diverse array
of contributing factors result in excessive patellofemoral
joint stress (Table 1).
Mounting evidence suggests that PFPS is not self-limiting,
with persistent symptoms observed in as many as 91% of
individuals after extended follow-up (72). Moreover individual responses to specific conservative strategies in isolation are unpredictable (17). The chronicity and variability of
response to treatment likely reflects the diversity of causes
and underscores the importance of recognizing and addressing the unique contributing factors for a given individual.
This tailored approach to rehabilitation necessitates a focused history and examination, including assessment of static
Division of Physical Medicine and Rehabilitation, Department of
Orthopedic Surgery, Stanford University, Redwood City, CA.
Address for correspondence: Michael Fredericson, MD, FACSM, Division
of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery,
Stanford University, 450 Broadway Street, MC 6342, Redwood City,
CA 94063-6342; E-mail: mfred2@stanford.edu.
1537-890X/1303/172Y178
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Volume 13 & Number 3 & May/June 2014

Local Joint Impairments

Traditionally rehabilitation strategies have emphasized correction of abnormal patellofemoral kinematics and alignment
by addressing structures at or crossing the knee joint, as these
local structures have a direct effect on patellofemoral function,
especially patellar tracking. Maltracking is defined classically
by excessive lateral alignment of the patella within the trochlear groove and is thought to play a pivotal role in the development of PFPS. Strategies to address maltracking include
quadriceps strengthening and improved flexibility of regional
soft tissues (namely, the quadriceps, hamstrings, and iliotibial
band). External methods, including taping and bracing, to resolve patellar maltracking have been investigated also.
Quadriceps strength
Strengthening of the quadriceps femoris has been the prevailing method of rehabilitation for PFPS, based on a strong
association between PFPS and knee extension weakness.
There is recent prospective evidence to suggest that healthy
individuals with weak knee extensors are at increased risk of
developing PFPS (9). Furthermore isolated strengthening of
the quadriceps femoris complex consistently has shown success in treatment of PFPS (2,74,84).
The ideal approach to quadriceps strengthening may incorporate both open and closed kinetic chain exercises. In
open kinetic chain exercises such as knee extensions, quadriceps muscle force and patellofemoral joint stress are greatest near full extension (31,73). Conversely in closed kinetic
chain exercises such as lunges and leg presses, quadriceps
muscle force and patellofemoral joint stress are highest near
full flexion (31,73). Therefore integration of both forms of
Rehabilitation of Patellofemoral Pain

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Table 1.
Etiologic contributors to PFPS.

Local Joint Impairments

Altered Lower Extremity Biomechanics

Training Errors/Overuse

Quadriceps weakness

Hip abductor weakness

Increasing exercise too quickly

Impaired VM function

Hip external rotator weakness

Inadequate time for recovery

Excessive foot pronation

Excessive hill work

Soft tissue inflexibility

Quadriceps

Pes planus

Gastrocnemius

Excessive impact shock with heel strike

Iliotibial band
Hamstring

exercise promotes strengthening throughout the arc of motion. Moreover open kinetic chain exercises (especially in the
range of 90-Y45-) may be better tolerated in the acute phases
of PFPS when there is significant weakness or pain with
weight bearing (31). In the long run, however, closed kinetic
chain exercises with an emphasis on cocontraction of the
hamstring and quadriceps muscles have proven overall superior to open kinetic chain exercises in improving function
(2,84). Thus closed kinetic chain exercises should be incorporated to the rehabilitation program as early as a patient is
able to tolerate (15).

Vastus medialis strength

Much attention has been given to the role of the vastus
medialis (VM), and particularly the VM oblique (VMO),
based on observations of reduced VMO volume and strength
in individuals postsurgery, following injury, or with PFPS.
The VMO fibers insert more distally and horizontally on the
patella and are critical to providing dynamic medial patellar
stability (30,32,44). Studies have found a significant correlation between VMO abnormalities (insertion level, fiber angle,
and VMO volume) and patellofemoral pain (39,57). However
three randomized controlled trials have compared attempts

Table 2.
Approach to PFPS management.

Local factors

Causative Element

Physical Examination Correlate

Management Considerations

Patellar malposition/maltracking

Patella alta

Patellar taping

Lateral patellar tilt

Patellar bracing

Lateral patellar displacement

Correction of vasti activation imbalance

Tight iliotibial band

Stretching and foam roll

Soft tissue inflexibility

Tight quadriceps
Tight hamstring
Lower extremity
biomechanics

Hip muscle weakness

Foot malposition
Gait

Tight gastrocnemius
Static hip abductor weakness,
Dynamic knee valgum,
Excessive hip adduction with
SLS, and Contralateral pelvic
drop with single leg squat
Excessive pronation contributing
to increased femoral rotation
Ipsilateral hip adduction

Hip strengthening progressing to

functional movement patterns

Foot orthosis
Gait retraining

Contralateral pelvic drop

Excessive impact shock with
heel strike
Training errors

Overly rapid
exercise progression

NA

Relative rest
Correct training errors

Overly intense exercise

intensity for level of fitness
Inadequate recovery
NA, not applicable.

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173

at VMO strengthening to overall quadriceps strengthening

using electromyographic feedback techniques, with unanimous results that negate any difference in short-term outcomes (26,74,88). Another study examined nine commonly
used strengthening exercises and found that electromyographic activity was no different between the VMO and
other muscles comprising the quadriceps complex (49).
Therefore specific exercises to isolate the VMO for
strengthening are not indicated. A well-rounded quadriceps strengthening program should correct any imbalance in
strength between the quadriceps muscles.
VM activation and timing
In addition to strength of the VMO, the timing of VM
activation in relation to that of vastus lateralis (VL) has been
implicated in multiple studies of PFPS (12,18,78,85). However this finding has not been consistent across all studies
(11,64). Fortunately more recent research has helped to clarify
the role of delayed VM activation in patellar maltracking.
Vasti muscle activation may be quantified by either delay in
VM activation when compared to the VL or the ratio of the
magnitudes of normalized activations of the VL and VM muscles (VL/VM) (69). A novel diagnostic method by Pal et al.
(55,56) has provided important breakthroughs in understanding
the relationship between vasti muscle imbalance and patellar
maltracking in patellofemoral pain patients. They defined a
subset of individuals with patellar maltracking based on patellar tilt and bisect offset as measured from weight-bearing
magnetic resonance imaging, and they found that within this
group, the degree of maltracking was correlated with delay in
VM activation. Furthermore when they combined their patients with and without patellar maltracking, no relationship between maltracking and vasti muscle imbalance was
detected (55,56). In so doing, Pal et al. demonstrated the
importance of accurate classification of individuals with
PFPS into maltracking and normal tracking groups. One
reason for the discrepancies observed in prior studies likely
relates to the percentage of maltracking and normal tracking patients included in these studies; a study with a large
number of maltrackers would conclude vasti muscle imbalance in patellofemoral pain patients, while a study with a
large number of normal trackers would likely find no vasti
muscle imbalance in patellofemoral pain patients. Indeed in a
recent review article, Wong (86) hypothesized that the discrepancies between previous studies were due to lack of
standardized methods for quantifying vasti muscle imbalance. Thus while controlled trials are lacking, it is logical to
address deficits in VM activation delay and patellar maltracking within this subgroup of patellofemoral pain subjects
with documented maltracking (abnormal tilt and/or abnormal bisect offset).
Pal et al. (56) have developed a cost-effective method for
determination of vasti activation imbalance, based on the
discovery of a strong correlation between the two vasti
activation imbalance measures. Measurement of VM activation delay during functional tasks requires synchronization
of EMG data with joint kinematics and ground reaction
forces; VL/VM activation ratios can be obtained by simply
placing surface electrodes on a patient while performing a
functional task and is feasible in clinical settings.
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Once vasti activation imbalance is recognized, several techniques may be effective to modify VM discrepancies. EMG
biofeedback measures neuromuscular contractions and provides auditory or visual feedback signals designed to increase
awareness and voluntary control of muscle activation. When
combined with therapeutic exercise, EMG biofeedback aimed
at increasing VMO activation while maintaining constant VL
activity has been shown to improve VMO/VL activation ratios (53). Patellar taping, discussed in greater detail below,
may likewise represent a useful adjuvant to augment temporal activation of the VMO (14,19).
Soft tissue flexibility
Stretching the muscles that surround the knee is another
commonly employed technique in the management of PFPS.
Inflexibility of both the rectus femoris and the gastrocnemius has been prospectively associated with development of
PFPS (84). Cross-sectional studies likewise have observed a
relationship of hamstring and iliotibial band tightness to the
presence of PFPS (37,65). The iliotibial band, in particular,
appears to play an essential role in patellar maltracking, with
its derivative fibers comprising the strongest and most substantial layer of the lateral retinaculum. The transverse orientation of these fibers serves to resist medial displacement of
the patella; however, when excessively tight, it may result in
disproportionate lateral translation. Cadaveric studies support this notion, demonstrating increased lateral patellar shift
and tilt with augmented iliotibial band loads (42,46). Furthermore among a small sample of patients, surgical release
of iliotibial tract contracture has been shown to result in reduced lateral patellar subluxation and patellar tilt (87).
Generalized stretching protocols that encompass the
quadriceps, hamstring, gastrocnemius, and iliotibial band
have established benefit, especially when combined with an
exercise program. In a randomized, controlled, single-blind
trial, Moyano et al. (50) demonstrated significant reductions
in pain among individuals managed with a stretching routine
combined with strengthening or aerobic exercise. Proprioceptive neuromuscular facilitation stretching, in particular, a
technique combining passive and isometric stretching, may
yield enhanced pain control and function. However there is
currently a paucity of research addressing isolated stretching
protocols. Of the two controlled studies examining the role of
isolated rectus femoris stretching in PFPS (45,58), only one
showed significant clinical improvement (45). There are no
randomized clinical trials that assess directed hamstring or
iliotibial band stretching in the management of PFPS.
Although further investigation is necessary to identify
whether specific muscles or stretches contribute more significantly to clinical improvement in PFPS, a stretching
protocol aimed to reverse identified inflexibility of the quadriceps, gastrocnemius, hamstring, and/or iliotibial band is a
valuable component of PFPS rehabilitation. Given the role of
the iliotibial tract on patellar tracking, an emphasis on relieving iliotibial band tightness may prove particularly high yield,
especially in individuals with concurrent maltracking and
iliotibial band tightness on examination.
Patellar taping
A variety of taping methods have been proposed with the
tailored McConnell taping technique representing the standard
Rehabilitation of Patellofemoral Pain

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in management of PFPS. The McConnell method aims to

control patellar tilt, glide, and/or spin based on physical
examination findings (20). Studies have found increased
tolerance to knee joint loading, increased VMO activity,
and improved onset of the VMO in relation to the VL
muscles utilizing this method (14,19,63,68). Alterations in
patellofemoral kinematics have been demonstrated also
(22). Taping performed under dynamic magnetic resonance
imaging reveals inferior shift of the patella, thereby increasing the patellofemoral contact area within the trochlea
(22). Taping also may lateralize the patella partially in individuals with baseline medial displacement and medialize the
patella in individuals with baseline lateral displacement, again
improving patellofemoral contact area (22). This increase in
contact area is theorized to contribute to pain reduction in
PFPS by producing a wider distribution of forces across the
patella and possibly relieving contact in sensitive areas (62).
McConnell taping shows promise in providing enhanced
pain relief and function particularly when combined with
exercise (45,79). Whittingham et al. (79) investigated pain
and functional outcomes among three treatment groups:
McConnell taping combined with exercise, placebo taping
combined with exercise, and exercise alone. While pain improved across all groups by 4 wk, both pain and function
scores were significantly better in the group managed with a
combination of McConnell taping and exercise. In an effort
to further delineate the impact of taping, Mason et al. (45)
evaluated the effect of quadriceps strengthening, quadriceps
stretching, and McConnell taping in isolation and in combination. Improvements in pain and strength were demonstrated for all intervention groups in isolation, but more
significant and pervasive improvements were observed when
the three modalities were combined. A recent meta-analysis
further concluded that there is moderate evidence to support
incorporation of tailored taping into a rehabilitation program for PFPS, particularly for early pain reduction (7).
Patellar bracing
Bracing has been explored similarly for its role in patellar stabilization and management of PFPS. As with taping,
bracing has been shown to modify patellofemoral kinematics
(27,62). Medially directed patellofemoral stabilization braces,
and to a lesser degree, simple knee support sleeves, contribute
to reduced lateral translation of the patella (27). Medially directed braces also may reduce patellar tilt (27). These alterations are more apparent in a subset of individuals who have
baseline abnormal kinematics when compared to controls (27).
However it is recognized that the impact of braces on patellar
lateralization and tilt is limited, and alignment is not restored
to normal with bracing alone (27,62). Patellofemoral contact
area, on the other hand, does appear to increase substantially
with the application of a medially directed brace and may
be a driving factor in associated pain reduction (62).
The clinical effect of knee braces on patellofemoral pain
has been investigated with varying results. There are few
prospective randomized clinical trials evaluating the impact
of bracing. Immediate pain reduction following application
of a brace has been reported (62). Longer-term benefits in a
small population also have been demonstrated (1). Arazpour
et al. (1) found a nearly 60% reduction in pain with the
use of bracing and additionally ascertained gains in walking
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speed and step length. Despite this, others have failed to

uncover a therapeutic benefit to bracing (48). This may represent inappropriate patient selection (normal patellar kinematics) or variability in the type of brace employed. Although
further studies are needed to clarify the outcomes and most
appropriate subpopulations for brace utilization, a properly
fitted patellar stabilization brace represents a potential adjuvant to a physical therapy program, particularly in those
patients with documented patellar maltracking, and is a reasonable alternative to patellar taping.
Altered Lower Extremity Biomechanics
While addressing local joint impairments remains an integral component of PFPS rehabilitation, there is expanding
evidence to support the influence of lower extremity kinematics in the development of PFPS. Aberrations that result
in excessive internal rotation of the femur in particular
appear to increase patellofemoral stress. Studies utilizing
dynamic magnetic resonance imaging suggest excessive internal femoral rotation, rather than patellar rotation, as
giving rise to lateral patellar tracking and increased patellofemoral joint stress (59,70). These kinematic changes more
likely are to be seen during more demanding tasks such as
single-limb squat, running, single-limb jumping, and singlelimb drop landing (24,71,80,81).

Hip strength
Deficits in hip muscle performance, particularly the external rotators and abductors including gluteus maximus and
medius, could result in internal rotation of the femur during
dynamic lower limb functions and consequent increased patellofemoral compressive forces. Multiple studies have established a correlation between hip external rotator and abductor
weakness in women with PFPS (8,38). Altered neuromuscular
activity of gluteus medius and maximus also has been associated with PFPS (51).
Recent experience corroborates the incorporation of hip
strengthening in the management of PFPS, especially for the
female population. In 2008, Nakagawa et al. (51) published
the first randomized controlled trial investigating the utility
of a hip strengthening protocol. This study demonstrated that
the addition of hip abduction and external rotation strengthening exercises to a traditional rehabilitation program of patellar mobilization and quadriceps strengthening results in less
pain and improved gluteus medius neuromuscular activation
(51). Since that time, four additional randomized controlled
trials investigating female patients with PFPS have supported
hip strengthening further in reducing patellofemoral pain and
optimizing function (25,34,35,41). Importantly when compared to knee stretching and strengthening alone, the addition
of targeted hip exercise appears to provide significantly more
lasting benefits at 1 year and minimize risk of pain relapse
(35). Thus targeted hip muscle strengthening is encouraged for
PFPS rehabilitation, particularly in women who demonstrate
static or dynamic evidence of hip weakness and medial femoral
collapse on physical examination. Exercises should address the
gluteus medius and maximus specifically. Gluteus medius may
be targeted with side-lying abduction and single-limb squats.
Gluteus maximus is best recruited using front planks with hip
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175

extension and gluteal squeezes. Side planks effectively target

both gluteus maximus and medius (10).
Foot position
Observational studies have demonstrated an association
between excessive foot pronation and PFPS (3,67). The precise manner by which excessive pronation may result in increased patellofemoral stress has not been elucidated; however
Tiberio (76) theorized one possible mechanism through compensatory internal rotation of the femur. In normal gait, the
subtalar joint is supinated at heel strike. During early contact,
the foot pronates and the tibia internally rotates. Once the
foot reaches midstance and the foot is in full contact with the
ground, the subtalar joint again supinates and the tibia follows, externally rotating, in order to move the knee into extension. However in situations of excessive pronation, the
subtalar joint remains in a pronated position at midstance,
preventing the tibia from externally rotating. Tiberio proposed that to compensate and promote knee extension, the
femur internally rotates on the tibia (the so-called compensatory internal rotation of the femur). This then results in
lateral tracking of the patella, thereby increasing patellofemoral strain. Although not proven, this model has become
accepted widely and provides a plausible rationale for the
apparent relation between overpronation and PFPS. However Reischl et al. (66) have reported that the magnitude of
foot pronation does not predict the magnitude of tibia or
femur rotation. As such, patients need be evaluated on an
individual basis to determine whether abnormal foot mechanics are contributing to a kinematic pattern that could
explain the presence of patellofemoral symptoms.
Historically results utilizing foot orthoses to correct excessive pronation in the management of PFPS have been
mixed; however there is a growing body of literature to support the use of foot orthoses. The predominance of recent
studies implement semirigid orthoses. Instead of rigid materials, semifirm materials that absorb shock and provide medial longitudinal arch support without hindering the natural
pronation mechanism of the foot are recommended (61).
Positive effects in both pain reduction and functional
performance have been reported immediately following use
(6) and over a period of time up to 3 months (5,40). In a
recent randomized clinical trial comparing the efficacy of
foot orthoses to flat inserts or physical therapy, prefabricated orthoses did appear superior to flat inserts according
to participants perception in the short-term management of
PFPS (16). Outcomes were no different between the orthosis
group and physical therapy. Furthermore the combined use
of a foot orthosis with physical therapy did not portend any
additional gains in pain or function at follow-up. It is worth
noting that participants of this study were not screened for
lower extremity mechanics including foot posture. The
failure to detect an advantage, particularly in the combined
group, may reflect inclusion of individuals for whom an
orthosis would be less likely beneficial. Several predictors
for response to foot orthoses have been identified including lower baseline pain levels, increased midfoot mobility
(change in midfoot width between non-weight bearing and
weight bearing), reduced ankle dorsiflexion, and use of less
supportive shoes (4,77). In addition it has been suggested
that those who report immediate pain reduction with an
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orthosis when performing a single-leg squat are more likely

to benefit from one (4).
There are no specific criteria to identify those individuals
who warrant a trial of an orthosis in the management of
PFPS. Nevertheless it is reasonable to trial a foot orthosis
simultaneously, or after an appropriate course of physical
therapy, in individuals with excessive pronation on dynamic
examination. If an over-the-counter orthosis is not sufficient,
a custom orthosis with a stiffer medial heel wedge may be
indicated (33,61).
The majority of research on the foot has focused on the
rearfoot. However due to reported findings of increased
foot mobility in individuals with PFPS, future research may
be better served by focusing more on the midfoot. Prospective evaluation of the foots association with PFPS is
needed also (60).
Gait
Gait patterns that demonstrate excessive hip adduction
(9,52), femoral internal rotation (9,71), and excessive pronation during dynamic activities (67) have been implicated
in the development of PFPS. Souza and Powers (71) also reported that isotonic hip extension endurance was a significant predictor of peak hip rotation during running, suggesting
that impaired hip muscle performance may underlie the abnormal hip kinematics thought to contribute to PFPS. It is
interesting that targeted hip strengthening regimens, while
improving strength, may not affect these associated gait impairments necessarily (29,83). Failure to correct these dynamic patterns may result in suboptimal clinical outcomes.
Several researchers have addressed this problem through case
series incorporating various feedback mechanisms, including
visual feedback from an instrumented treadmill (21), realtime hip adduction measurements (54), adoption of a forefoot strike pattern (13), and direct mirror feedback (82), and
all report both biomechanical and clinical success. Thus
while these methods of gait retraining show great promise,
prospective and controlled studies are needed to evaluate
these techniques further in the prevention and treatment
of PFPS.
Increased peak ground reaction forces also have been implicated also in the development of PFPS in runners (75).
Efforts to reduce forces through gait modification have been
undertaken. Heiderscheit et al. (36) performed biomechanical evaluations in healthy runners through modification of
step rate and demonstrated that a higher step rate is associated with a decreased foot inclination angle, step length,
center of mass vertical excursion, and horizontal distance
from center of mass and heel at initial contact. A subsequent
follow-up study associated a 14% force reduction at the
patellofemoral joint with a 10% increase in step rate (43). It
stands to reason that methods aimed at reducing ground
reaction and transmitted patellofemoral forces, such as reducing step length, are a reasonable approach to managing
PFPS; however additional trials are necessary to confirm
this notion.
Training Errors
The likely role of tissue homeostasis in the development
of patellofemoral pain has been described by Dye (28). He
maintains that altered tissue homeostasis may occur under
Rehabilitation of Patellofemoral Pain

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any circumstance that supersedes the so-called envelope of

function or load acceptance capacity of the joint. This includes not only gross structural abnormalities but also repetitive, lower magnitude loads (supraphysiological overload)
to the patellofemoral joint. While not sufficient to produce
immediately evident structural damage, these repetitive stresses
over time result in loss of osseous and periosseous soft tissue
homeostasis as manifested by peripatellar synovitis and inflammation of the fat pad tissues (28). Thus lack of significant findings on physical examination (i.e., normal patellar
mechanics and normal lower extremity function) may suggest training errors and overuse resulting in supraphysiological overload. This overuse is seen often in an athletic
population. In such cases, the training program should be
evaluated for obvious errors, including increasing exercise
intensity too quickly, inadequate time for recovery, and excessive hill work (33). Initial management should emphasize activity modification to a pain-free level (28).
Conclusion
It is becoming increasingly apparent that PFPS is a multifactorial condition that mandates a comprehensive yet individualized approach to treatment. A rehabilitation program
should incorporate quadriceps strengthening and be tailored
further according to identified deficiencies in patellofemoral
kinematics, lower extremity biomechanics, and training. Based
on an individuals constitution, additional strategies that
may prove valuable include enhanced muscle flexibility, patellar bracing or taping, hip strengthening, foot orthoses, and
gait modification. Training errors and overuse must be addressed also.
The authors declare no conflicts of interest and do not
have any financial disclosures.

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Rehabilitation of Patellofemoral Pain

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