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Patellofemoral Pain: What Works

Patellofemoral pain (PFP) proves to be a pervasive and recalcitrant challenge for healthcare professionals.

The condition involves retropatellar and/or peripatellar pain associated with lower limb loading. It affects 23% of adults and 29% of adolescents.1 For roughly half of those people, symptoms persist into the long term, sometimes for decades.2-5 In addition to limiting athletic participation and occupational tasks,2,6 the condition may be associated with the development of patellofemoral osteoarthritis.7

A recent PFP consensus statement recommends exercise therapy as the cornerstone of treatment.8 However, varied exercise approaches are numerous, and comparative studies to identify the most effective approaches did not exist at the time of the recommendation.

Enter Ji Yu-Xiu  and colleagues with a first-of-its-kind metaanalysis comparing wait-and-see and various exercise therapy approaches.9 Their analysis includes 45 randomised, controlled trials with 42,319 patients. It covers therapeutic approaches such as proprioceptive neuromuscular facilitation, whole body exercise, hip-and-knee focused exercise, foot orthoses plus exercise, hip exercise, knee brace plus exercise, gait retraining, knee exercise, knee arthroscopy plus exercise, biofeedback, and more.

Every exercise approach proved effective, but some were more effective than others.

Key Findings:

  • Wait-and-see is the least effective clinical approach and should be avoided.
  • The combination of knee and hip strength training is highly effective in pain relief and function improvement.
  • General exercise therapy can be improved by devices such as elastic therapeutic taping, braces, and foot orthoses.
  • Education improves the effects of exercise therapy.
  • Targeted therapeutic exercise based on individual evaluation is superior to general exercise for knee function.


1. Smith BE, Selfe J, Thacker D, Hendrick P, Bateman M, Moffatt F, Rathleff MS, Smith TO, Logan P. Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis. PloS One. 2018 Jan 11;13(1):e0190892.

2. Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Is knee pain during adolescence a self-limiting condition? Prognosis of patellofemoral pain and other types of knee pain. The American Journal of Sports Medicine. 2016 May;44(5):1165-71.

3. Lankhorst NE, van Middelkoop M, Crossley KM, Bierma-Zeinstra SM, Oei EH, Vicenzino B, Collins NJ. Factors that predict a poor outcome 5–8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2015 Oct 13:bjsports-2015.

4. Nimon G, Murray D, Sandow M, Goodfellow J. Natural history of anterior knee pain: a 14-to 20-year follow-up of nonoperative management. Journal of Pediatric Orthopaedics. 1998 Jan 1;18(1):118-22.

5. Collins NJ, Bierma-Zeinstra SM, Crossley KM, van Linschoten RL, Vicenzino B, van Middelkoop M. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2012 Dec 1:bjsports-2012.

6. Hall R, Foss KB, Hewett TE, Myer GD. Sport specialization’s association with an increased risk of developing anterior knee pain in adolescent female athletes. Journal of Sport Rehabilitation. 2015 Feb;24(1):31-5.

7. Crossley KM. Is patellofemoral osteoarthritis a common sequela of patellofemoral pain? Br J Sports Med. 2014;48:409–10.

8. Doyle E. Appraisal of clinical practice guideline: 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 Physiotherapy. 2020 Apr;66(2):134.

9. Ji Y, Xie Y, Zhou X, Wang S, Li L, Akira M, Zhang C. Comparative efficacy of exercise therapy for patellofemoral pain: A network meta-analysis of randomized controlled trials. MedRxiv. 2023:2023-01.

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