The Complete Guide to Patellofemoral Pain Syndrome

PFPS affects the kneecap & surrounding area. Don’t confuse it with iliotibial band syndrome (ITBS) which definitely affects primarily the outside of the knee (the lateral or outward-facing side of the knee). This picture is of a right knee.

Patellofemoral syndrome is a problem with pain that feels like it is mainly on the front of the knee, specifically on the underside of or somewhere around the edges of the kneecap. One or both knees can be affected. Patellofemoral pain is usually worse when climbing stairs or hills, or after sitting for a long time.

I’ll cover the basics in the form of answers to the most common questions. There will be much more detail about all of this later in the tutorial.

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Knee pain may be common, but it’s surprisingly hard to find good self-help information for it. Patellofemoral pain is one of the most misunderstood of all knee pain problems. There are countless shallow webpages about it, which all just repeat the same useless conventional wisdom.6 And not many doctors and therapists are prepared to treat tough cases. Sports medicine in general is amazingly primitive considering how much potential funding it has. You’d think anything affecting elite athletes with huge audiences would be getting more attention! The situation is improving, but only recently and it still has a long way to go.7

And so, many popular treatments for PFPS are of dubious value:

• Correcting muscle imbalances is by far the most common prescription for PFPS. The idea is to teach muscles to pull more evenly on your kneecap — which good science has shown to be difficult at best, possibly impossible, and quite likely irrelevant.8

• Quadriceps massage is a popular alternative treatment, but massage — while good medicine for many painful conditions — is really not very helpful for kneecap pain, which is a very “jointy” problem.
• “Stay active” is one of the most common recommendations — but it can be the worst therapy of all for patellofemoral pain. It’s knee jerk advice, given by professionals unfamiliar with the nature of PFPS. While exercise can be useful, “staying active” is overly simplistic advice, and it can backfire.
• Treating PFPS like arthritis is a basic misunderstanding of the condition. Family doctors usually do this, but they are poorly informed about PFPS.9 It’s an understandable mistake — the distinction between PFPS and arthritis is complex — but it’s bad news for the patient with serious chronic pain!
• Knee surgery is rarely a good option and often prescribed prematurely. Specialists10 and orthopaedic surgeons cannot be counted upon to provide good advice for PFPS.11 Experts believe surgery to be quite risky,12 and the research is very discouraging.

You should try to find good professional help, but that can be difficult — so it’s always a great idea to be as well informed as possible when you do it, or you can easily waste a lot of time and money on dubious therapies — even if this tutorial can’t give you “the answer,” I hope it can at least help you avoid wasting time and money on ineffective treatments.

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“Patellofemoral pain syndrome” is a surprisingly meaningless name. It basically means “strange kneecap pain,” but in Latin. “Anterior knee pain syndrome” is another common name with an even broader meaning, and it’s a little more direct and honest: it’s pain, and it’s on the front of your knee, ‘nuff said.

Sometimes the “pain” part is dropped and it is just called “patellofemoral syndrome” or PFS. Sometimes syndrome is swapped out for “disorder.” And sometimes pain is replaced with “stress,” emphasizing that it’s usually a repetitive strain injury: “patellofemoral stress syndrome.” Sometimes the femur is shunned, and people just talk about patellar pain — and indeed sometimes it probably is the kneecap itself, and not really the joint under it.

And the misspellings! No musculoskeletal condition is trickier. The number of poorly spelled Google searches for this condition is off the charts.13

“Patellofemoral pain syndrome” is the most common term. A syndrome is never a “diagnosis,” or not a good one anyway: it’s an unexplained distinctive pattern of symptoms. In the case of pain on the front of the knee, especially where overuse is a factor, we assume that those problems are coming from the patellofemoral joint, and the odds do favour that — but it’s hardly guaranteed. The patellofemoral joint is the prime suspect in most cases, but it’s not the only one. I will get into much more detail about other possibilities later in the guide.

Do you live in a chair?

“Chair warriors” who spend more than 4–6 hours per day suffer as much from knee pain as many runners. Woe to runners who also work all day in a chair.

“Runner’s knee” is a popular description among runners, of course, and they do get it more often than anyone else. But it is not a good term to use, because there are at least a half dozen other conditions that term could refer to, especially iliotibial band syndrome. And of course it excludes other people who get the condition — all those people with cyclist’s knees and hiker’s knees, for instance!

Calling it “runner’s knee” particularly leaves out people whose knees hurt while sitting and because of sitting. Office workers and other chair-bound workers really do suffer from PFPS in droves. In fact, another name for this condition is moviegoer’s knee because of the tendency of the condition to cause pain after sitting for a long time. This also explains the use of the term “theatre sign” among professionals, as in, “He’s got theatre sign — must be a case of movie-goer’s knee.” In my professional experience, however, you could just as well say, “He’s got desk job sign — must be a case of office worker’s knee.”

One more naming note: occasionally you’ll hear therapists or doctors call this condition “patellofemoral tracking syndrome” (PFTS) or even chondromalacia patellae (definitions and detail ahead), but these are blatantly in error: these are things that might be causes of the condition, but they are not the condition itself.

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I’m pleased to say that American Family Physician came around. They say that the mystery of PFPS has been solved. (That’s sarcasm.) In a tutorial for physicians published in 2007, they confidently declared the cause of PFPS:

[Patellofemoral pain syndrome] is caused by imbalances in the forces controlling patellar tracking during knee flexion and extension, particularly with overloading of the joint.

Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194–202. PubMed 17263215 ❐ PainSci Bibliography 56699 ❐

Well, thank goodness! That’s nice and clear, isn’t it? The conventional wisdom says that patellofemoral pain syndrome is painful degeneration of the cartilage on the underside of the kneecap, caused by a “mechanical” failure of that joint. What kind of failure? A “tracking” problem, in which the patella doesn’t slide evenly in its groove or “track” on the femur. For this condition, we need yet another multisyllabic name: “patellofemoral tracking syndrome.”

Another syndrome? I’m afraid so. It even has almost the same acronym: PFTS instead of PFPS. The conventional wisdom is so entrenched that many professionals consider the “tracking” syndrome to be virtually synonymous with PFPS itself.

But the idea that tracking problems cause patellar pain has not been proven beyond a reasonable doubt. In fact, as I will show in the sections ahead, it’s incredibly difficult to even prove that these problems even coexist, let alone how much they have anything to do with each other … if anything at all. Even stranger, it turns out that tracking problems are extremely difficult to even identify, let alone blame for anything. And as if this wasn’t enough trouble for the conventional wisdom, it turns out that even the “degeneration” of the kneecap’s cartilage is a scientific myth … a myth that probably has little or nothing to do with patellofemoral pain syndrome!

Wow. That’s a lot of myths.

The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

Teaching people about pain — why do we keep beating around the bush?, by Lorimer Moseley, 2–3

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Joints wear out, right? Comedian Louis CK:17

The doctor shows me an x-ray of my ankle and he’s like, “Yeah, your ankle’s just, uh … worn out.”

“What do you mean? I injured my ankle?”

He’s like, “No, it’s just shitty now.”

And yet! Pain in the patellofemoral joint mostly does not appear to be associated with any identifiable tissue degeneration or damage, dysfunction or malfunction, asymmetry or weakness.1819 Sometimes it just hurts, even though the knee — indeed, the whole leg — seem to be healthy in every way that we can measure knee health. And if that seems a bit odd, you ain’t seen nothing yet!

Even when the joint is degenerating…

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here’s some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

I just finished your e-book about patellofemoral pain syndrome and wanted to say that it was very helpful! As a chronic sufferer of PFPS, I have personally experimented and learned the hard way about almost all of the experiences you mentioned and found most of them to be spot on. I wish I had found this information 15 years ago, but it was helpful to confirm that I'm not alone and reinforce what I learned through personal experience.

Jerry Taylor

Thanks for a well written, humorous and informative piece. Your book helped me understand what I did to my knee running and how to treat (and not treat!) stubborn injury. Might see you jogging through Stanley Park or water front, on one of our visits to daughter, love Vancouver.

Matt Randlett

I wanted to write a short thank you email for all the help you have brought me. Im a recently graduated medicine student from Argentina, and i have been getting knee pain for almost 8 months. I have been to the best traumatologists in the country, none who could explain correctly what was going on with my knee. They did exactly the kind of mistakes you constantly mention all along your book.By reading the tutorial i have at last fully understood what im up against, how to correctly fight it, and hopefully beat the crap out of this horrible pain.Just wanted to write this short thank you email, you should know your amazing work helps people all around the globe.

Petra Fellows

My name is Lexy, I’m a 23-year-old with patellofemoral syndrome. For the past six months. I don’t have any questions really, but I wanted to reach out and let you know how valuable your writing has been to me. I’m just an occasional visitor of painscience.com, but when I get those mental waves of dread that tell me my injury is going to last forever, your writing style has been super helpful in putting things in perspective, and helping me be realistic, yet hopeful about my recovery. I’ve seen PTs, acupuncturists, orthopedic surgeons and doctors, many of which have given me shit advice and left me feeling upset and angry, or like my pain wasn’t being taken seriously. I thank you for creating a forum where I feel a sense of solidarity with other humans/athletes, and most importantly where I don’t feel like I have to pay a ridiculous amount of money to feel like a factory-line patient. I really appreciate that.

Shakil Irvine

I wanted to send you a quick email to deeply thank you for all your work. I grappled for 18-months with horrible knee pain that threw my life into a tailspin. Your books were critical for getting me on the path to healing. I have spent much of my career in health research and policy and really admire your ability to distill evidence and then present it clearly and accurately to a general audience. Thank you.

Franco Sargent

Your tutorial on patellarfemoral syndrome really cut through a lot of misinformation I’ve received from MDs and PTs.

Alastair Rosario

Given what I have learned about patellofemoral pain syndrome over the last two years through personal experience, your tutorial is probably the best summary of everything I have seen.

anonymous

This has already served as a massive eye opener for me. It makes a huge amount of sense where previously there was only confusion.

Greg Bruce, “struggling masters athlete”

Just reading tutorial has already given me hope that I can finally get some relief from my chronic patellofemoral pain syndrome. Why didn’t I find this 2 years ago?! It has been so frustrating, both physically and emotionally, as I’m sure you already know from your patients. Your eBook is very enlightening and well written. Please feel free to use my comments as a testimonial. I was glad to see other testimonials, too — it’s nice to know that I’m not the only one who is struggling with this.

Melanie Caldwell, Yonkers, NY

Finding this information was a huge relief for me. I really did think I had “tried everything.” But I found pages and pages of stuff in your article that no other doctor or therapist had ever even mentioned.

Jared Foster, long-distance runner

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most dissatisfied customers have strong themes:

• Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
• Too negative specifically. Some are offended by my criticisms of a treatment option that they personally use and like. Or sell!
• Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
• Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

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Thanks to Dr. Scott Dye for helping me to understand and believe in my own unconventional ideas about patellofemoral pain syndrome, and by extension every other joint problem.

Extra special thanks to Tony Ingram, for substantial contributions of expertise and writing to this book in 2014 — the book is much better for it.

Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

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The 2nd “edition” of the PFPS tutorial was launched on July 28, 2014, after months of collaboration with Tony Ingram, a Physical Therapist who did his Masters thesis on anterior knee pain. Tony was officially a co-author for a while, but retreated to focus on pursuing a PhD and a career in science.

Like all my books, this one was updated many times over the years, but changes were too small and spread out to constitute an “edition”: that had to wait for this, by far the largest ever major change to the book. It has several new sections, a lot of new science, and a strong (and overdue) new emphasis on the evidence-based value of exercise — reversing my grumpy anti-exercise position. It’s also much less exclusively about a single theory of knee pain than it was.

A new position on exercise

Exercise for patellofemoral pain syndrome is a good example of a treatment that works, but probably doesn’t work how most people think it works. I was anti-exercise before because the evidence just wasn’t there for it yet, and too many professionals fancied that they were prescribing exercise to change biomechanical parameters (e.g. patellar tracking) that correlated poorly with the condition. Such prescriptions tended to be overzealous: too much exercise, too soon for patients suffering from what is fundamentally an overuse condition.

Now there is good evidence that exercise is effective — hallelujah, some much-needed good news — but dosage and timing are key, and the biomechanical rationale still needs to be taken out with the trash.

Not just one guy’s theory any more

The previous version of the book had a significant weakness, a major idea about the nature of the beast (basically the whole “it’s the homeostasis, stupid,” ). The idea was plausible and elegant, but lacked adequate scientific support for an important basic point of the book. One advanced reader complained:

I didn’t buy your book so I could get one guy’s theory about how patellofemoral pain syndrome works.

Fair enough. She went on to say that it was probably a pretty good idea, just painfully unsupported. Simple as it is, that’s one of the best single constructive criticisms I’ve ever received. On the one hand, I unapologetically offer my take on these complex subjects. They are my books, and this is not a medical journal. On the other hand, I don’t want my take to be based solely on private speculation — if my opinion is to have much value, it should be clearly based on a diversity of expert and scientific sources. And so this is one of the major repairs in the 2nd edition. My basic point was sound, but badly needed some scientific and more diverse expert support — and now it has that.

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• “The pathophysiology of patellofemoral pain: a tissue homeostasis perspective,” Dye, Clinical Orthopaedics & Related Research, 2005. This article by Scott F. Dye, MD, an orthopaedic surgeon from San Francisco, was by far the most influential source for this article. I do not normally recommend scientific articles to my readers, most of whom are ordinary people with knee pain, and not especially interested in slogging through medical jargon. However, in this case, I have to make an exception: although Dr. Dye’s writing is certainly intended for a professional audience, patients should still be able to get something out of it. It’s clear (for a scientific paper) and sensible, and even somewhat visionary in tone. Despite the fact that it’s certainly harder reading than this article, and despite the cost — the article will set you back US$10 to access — I still think it’s worth it. If you really want a good depth of understanding of PFPS, it’s required reading.
• Massage Therapy for Your Quads will add to your understanding of the quadriceps muscle group and its relationship to the kneecap.
• There are other kinds of knee pain, and it’s not always easy to tell which kind you’ve got. In particular, the two main types of runners knee are often confused. Tell them apart with this quick guide and checklist: Diagnosing Runner’s Knee.
• The journal American Family Physician publishes free tutorials for doctors which may also be useful for patients. I have come to trust those tutorials as one of the best sources available when I am trying to understand conventional medical opinion. They are usually well-written and beautifully illustrated, and determined patients can often get plenty of value out of them despite the jargon. See “Patellofemoral pain syndrome: a review and guidelines for treatment” for a 1999 tutorial for doctors, and “Management of patellofemoral pain syndrome” for their 2007 article on the subject. Bear in mind that these articles present only the conventional wisdom, however, and primarily discuss structural explanations for knee pain. As such, I do not think that they are useful to my patients and readers except as the best available representation of conventional wisdom.
• One of the hottest and most controversial treatment ideas for patellar pain is the idea that strengthening your hips will help. I explore the controversy here: Does Hip Strengthening Work for IT Band Syndrome?

A few more articles about patellofemoral pain syndrome and related topics:

• Should You Get A Lube Job for Your Arthritic Knee? — Reviewing the science of injecting artificial synovial fluid, especially for patellofemoral pain
• Do Women Get More Knee Pain? — The relationship between sex and knee pain, especially runner’s knee (IT band syndrome, patellofemoral pain)
• Is Running on Pavement Risky? — Hard-surface running might be a risk factor for running injuries like patellofemoral pain, IT band syndrome, shin splints, and plantar fasciitis
• What Can a Runner With Knee Pain Do at the Gym? — Some training options and considerations for runners (and others) with overuse injuries of the knee
• The Dubious Science of Kinesiology Tape — The origin story and science of therapy tapes like Kinesio Tape, KT Tape, Spider-Tech, RockTape
• Knee Surgery Sure is Useless! — Evidence that arthroscopic knee surgery for osteoarthritis is about as useful as a Nerf hammer

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The original publication date of this tutorial has been lost, but I think it was in 2004. It was quite rudimentary until 2007, when significant upgrades began. This change log was started in May 2007, along with many major improvements. As you can see, the tutorial has been updated many times since, and remains a live document.

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 130 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

Jan 25, 2023 — Reorganization: Just a bit of housekeeping: rearranged the content and edited for clarity. [Updated section: 16 causes and diagnoses of anterior knee pain.]

2022 — Minor addition: Added a little information for cyclists about the effect of pedal crank length on knee loading. [Updated section: Make adjustments to bicycling … especially seat height.]

2022 — Major upgrade: Added more detail and several more uncommon diagnoses to consider. [Updated section: 16 causes and diagnoses of anterior knee pain.]

2022 — Added sub-topic: Added a discussion of ozone therapy, which just barely qualifies as a “regenerative” therapy, and my only advice is to avoid it, so it’s a minor addition here — but an interesting one. [Updated section: Regenerative medicine? PRP, ACI, stem cell therapy, ozone.]

2021 — New section: No notes. Just a new chapter. [Updated section: “Plantaris hypertonia” as a cause of runner’s knee.]

2021 — Proofreading: Top-to-bottom check for typos and other minor errors. They creep in over the years as I work on updates to the book. A good three dozen of the little buggers identified and fixed this time.

2021 — More and better: It’s not an important sub-topic for patellofemoral pain, but it certainly deserved more and better advice than I had previously offered. An obsolete point or two removed, and a more modern perspective added. [Updated section: Heat (briefly).]

2020 — New sub-topic: Added discussion of the (rather silly) idea that prolotherapy is a form of regenerative medicine. [Updated section: Prolotherapy is not relevant to patellofemoral pain syndrome.]

2020 — Major expansion: Added an introduction about regenerative medicine in general, a thorough discussion of autologous chondrocyte implantation, and some basic notes about stem cell therapy. [Updated section: Regenerative medicine? PRP, ACI, stem cell therapy, ozone.]

2020 — Upgraded: Substantial revision and modernization, with more attention given to skeptical concerns about icing. [Updated section: The power of power icing.]

2020 — Science update: Added more about the rationale for exercise therapy, citing Fu. [Updated section: And then came the exercise: The long term solution.]

2020 — Addition: Added osteochondritis dissecans to the list of other diagnoses to consider. [Updated section: 16 causes and diagnoses of anterior knee pain.]

2020 — Minor addition: Added sex to the list of activities that can involve potentially harmful knee stresses, depending on the position and, er, endurance. [Updated section: The art of rest: the challenge and the opportunity for patients who have supposedly “tried everything”.]

2020 — Science update: Updated the discussion of inflammation with important perspective about more subtle types of inflammation in overuse injuries. [Updated section: Treating for inflammation: is there any point?]

2020 — New content: A minor but nice addition of information (and a story) about heels and heel lifts. [Updated section: Orthotics.]

2020 — Minor update: Added a couple small but good clarifications, and an amusing bit of perspective, in my never-ending quest to effectively explain the importance of rest. [Updated section: Rest first: The key to tough cases.]

2020 — New sub-topic: Compared and contrasted oral and injected corticosteroids. [Updated section: Steroid injections are powerful, but where would you put the needle?]

2020 — Added sub-topic: Expanded the scope of the section to include soft bracing as well as taping and strapping. [Updated section: Taping, strapping, and bracing for patellofemoral pain.]

2019 — Expansion: Previously this chapter was just about massage in general and foam rolling in particular. I’ve widened the scope to address the underlying assumption that there’s a need to “loosen” the quads, and now cover both stretch and massage. [Updated section: Loosening the quads with massage and/or stretch.]

2019 — Minor addition: Added a brief discussion of an important principle: exercise is a pain-killer! Sometimes. [Updated section: 2. Common Resting Pitfall No. 2: Being fooled by delayed pain.]

Archived updates — All updates, including 92 older updates, are listed on another page. ❐

2003 — Publication.

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1. Clarsen B, Krosshaug T, Bahr R. Overuse Injuries in Professional Road Cyclists. Am J Sports Med. 2010 Sep. PubMed 20847225 ❐
2. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101.

   This report on two year’s worth of injuries among Vancouver runners — many of whom I probably run with every day on Vancouver’s sea wall — found that “patellofemoral pain syndrome was the most common injury, followed by iliotibial band friction syndrome, plantar fasciitis, meniscal injuries of the knee, and tibial stress syndrome.”

3. Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician. 2007;75:194–202. PubMed 17263215 ❐ PainSci Bibliography 56699 ❐ “ … although management can be challenging, a well-designed, non-operative treatment program usually allows patients to return to recreational and competitive activities.”
4. As we’ll discuss in detail below, most “basic” physical therapy for PFPS consists of minor interventions of dubious value — mostly corrective exercises, stretching, ultrasound, taping and strapping — yet the clinical impression of most professionals is that mild patellofemoral pain does go away with conservative advice. The most likely explanation for this — and it’s a common “problem” in physical therapy — is simply that most of those cases would have gotten better regardless of the therapy. Of course, in some cases, some good advice may be mixed in with bad advice, and that may help. And there may be some placebo effect: being therapized really does help a lot of people to feel better, regardless of whether or not the therapy makes any sense, and yes this phenomenon can occur even with something as seemingly un-psychological as knee pain! See Moseley.
5. It is mostly a temporary condition: they recover from or grow out of more easily than adults do. Although serious cases certainly can and do occur in teenagers, their age is not particularly relevant to those cases. A serious case in a teenager has to be handled in pretty much the same way that you would handle a serious case in an adult. So although age is a factor I haven’t focused on, everything that I have focused on should be of interest to teens with persistent knee pain.
6. In 2010, the Journal of Bone & Joint Surgery reported that “the quality and content of health information on the internet is highly variable for common sports medicine topics” — a bit of an understatement, really. Expert reviewers examined about 75 top-ranked commercial websites and another 30 academic sites. They gave each a quality score on a scale of 100. The average score? Barely over 50! For more detail, see Starman et al. This reference is getting old, but nothing has really changed. 😜
7. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed 24758781 ❐

   Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine …

8. The science of this controversial claim will be discussed in great detail below.
9. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt. See The Medical Blind Spot for Aches, Pains, and Injuries: Most doctors are unqualified to care for many common pain and injury problems. Especially the stubborn ones.

   Comic by Loren Fishman, HumoresqueCartoons.com

10. Sports medicine specialists are probably the least of all evils — although no professional category seems generally well-informed about PFPS, you probably stand a somewhat better chance of getting competent help from a sports medicine doctor than from any other kind of health care professional. Although they are more or less as prone to the toeing the line of conventional wisdom as any other health care professional, at least their expertise is directly concerned with non-surgical management of conditions like PFPS — and so there is at least some respectable chance that a doctor in this speciality will have paid some attention to the scientific controversies.
11. Orthopaedic surgeons are surgeons — not only do surgeons strongly tend to perceive musculoskeletal problems only in terms of surgical solutions, but they are (quite correctly) professionally preoccupied with their surgical expertise and professional development, which means that they are typically not knowledgeable about conservative physical therapy methods for relatively minor overuse injuries like PFPS. Many of them certainly try to make a professional point of avoiding the overprescription of surgery, but that doesn’t necessarily make them experts in what to do instead of surgery. And PFPS is a particularly bad problem to take to a surgeon for the simple reason that, among knee injuries, PFPS is just about the last one that you’d want to operate on. This will be fully explained as we continue with the tutorial.
12. Surgeons often oversimplify patellofemoral pain syndrome as simply a case of “arthritis” of that joint, and recommend a debridement (filing or smoothing) of the knee cartilage, either of the patellofemoral joint, or of the main joint between the tibia and femur (which is particularly irrelevant to patellofemoral pain). However, debridement has been proven to be ineffective even for arthritis (let alone PFPS, which isn’t arthritis), originally and most spectacularly by Moseley in 2002, then most authoritatively by The Cochrane Collaboration in early 2008 (see Laupattarakasem), and most recently by New England Journal of Medicine in September 2008 (see Kirkley). This is one of the most straightforward scientific slam dunks in surgery research in recent history — surgical debridement doesn’t work!
13. There are more misspelled searches for this than any other topic on this huge website. A lot more. Femoral patella syndrome, patellar femoral, patellafemoral, femoropatellar syndrome! Those are the actual four most common, and there are many more, and much worse: patel, patlofemal, patalafremerol, fermopaltela, etcetlero! Both “petalla” and “femoral” are easy to get wrong independently, and when people try to merge them… well, it’s a spelling meltdown.
14. Reid DC. The myth, mystic and frustration of anterior knee pain. Clin J Sport Med. 1993;3:139–43. PainSci Bibliography 56702 ❐
15. Wilk KE, Davies GJ, Mangine RE, Malone TR. Patellofemoral disorders: a classification system and clinical guidelines for nonoperative rehabilitation. Journal of Orthopaedic & Sports Physical Therapy. 1998;28(5):307–322.
16. Juhn MS. Patellofemoral pain syndrome: a review and guidelines for treatment. Am Fam Physician. 1999;60(7):2012–2022. PainSci Bibliography 56687 ❐
17. A one-minute excerpt from his 2008 stand-up show Chewed Up is embedded below, but you can also watch the full segment (2:30) on YouTube. Funny stuff!
18. Näslund J, Näslund UB, Odenbring S, Lundeberg T. Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. Physiotherapy Theory and Practice. 2006 Jun;22(3):105–18. PubMed 16848349 ❐ In this study of 80 patients with a diagnosis of PFPS, with all other likely diagnoses already eliminated from consideration, signs of pathology were found in only 17 of 75 patients, and the authors conclude that even these “cannot be detected from ... commonly used clinical tests.” That’s quite a few mysteriously painful knees.
19. Piva SR, Fitzgerald GK, Irrgang JJ, et al. Associates of physical function and pain in patients with patellofemoral pain syndrome. Arch Phys Med Rehabil. 2009 Feb;90(2):285–95. PubMed 19236982 ❐

    Researchers tested 74 patients diagnosed with patellofemoral pain syndrome for the presence of several factor that are commonly suspected to be associated with that condition, the “usual biomechanical suspects”: muscle weakness and tightness, coordination, and postural and anatomical abnormalities. They also considered psychological factors, which is quite unusual for a study of knee pain.

    They found no correlation at all with between the biomechanical factors and chronic anterior knee pain.

    Interestingly, the researchers did find that “psychologic factors [anxiety and fear-avoidance beliefs about work and physical activity] were the only associates of function and pain in patients with PFPS.”

There are 298 more footnotes in the full version of the book. I really like footnotes, and I try to have fun with them.

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