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Patellofemoral Pain Syndrome 

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Information about Patellofemoral Pain Syndrome

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What Is Patellofermoral Pain Syndrome?

Patellofemoral Pain Syndrome (PFPS) is the name given to a common knee condition which causes pain at the front of the knee around the area known as the patellofemoral joint. This is the joint between the kneecap (patella) and the thigh bone (femur). Pain is most commonly felt around or behind the kneecap. Symptoms are often experienced during activities such as sitting for too long, squatting, running, jumping and going up and down stairs.

Sometimes you may hear the condition being referred to as anterior knee pain.

PFPS usually responds well to management with specific exercise and lifestyle changes. It is very unlikely that surgery of any kind will be required.

Side view of right knee

What Are The Symptoms Of PFPS?

Pain is the main symptom of PFPS. Pain can be felt as an ache at the front of the knee which can increase to a sharper pain with certain activities. Symptoms can range in severity from mild to severe. It can affect one or both knees.

Common symptoms include:

  • Pain at the front of the knee, around and behind the kneecap
  • Worsening pain during or after increased activity or exercise
  • Pain after prolonged sitting
  • Pain when squatting or going down stairs

Some people get a clicking or grinding noise when they bend or straighten the knee.  This does not mean that you are causing damage and it is important to keep moving your knee joint.

How Common Is PFPS?

PFPS is one of the most common knee complaints and the most common overuse injury affecting the leg. Around a quarter of all adults and a third of adolescents may experience symptoms at some stage. The condition affects both men and women of all age groups but women are twice as likely as men to develop PFPS.  It can affect those who participate in sporting activities as well as those who do not.

What Causes PFPS?

PFPS usually occurs without an injury to the knee, but can very occasionally be as a result of an injury, such as a fall onto the knee. If you have not injured your knee, it may be difficult to find one specific cause of your PFPS, as it often occurs for a number of reasons. These include:

  • Starting a new activity
  • Increase in the intensity and/or frequency of an existing activity
  • Following a period of reduced activity that leads to weakening of the muscles
  • Muscle tightness or weakness around your hip and knee
  • Unsupportive footwear such as high heels or very flat shoes
  • Having an job which requires frequent, prolonged kneeling
  • Being overweight

Why can overuse cause pain?

Depending on your day to day routine, you will have a level of activity that your knee is happy with. This can be thought of as your knee’s comfort zone or happy place. Any sudden change to your daily activities which leads to putting more weight through your knee can take your knee out of its comfort zone.  Examples of this might be working extra shifts and being on your feet more or a sudden change in your sporting activities such as increasing your running distance. This sudden change can cause the knee to become painful without any physical injury to it.

What Can Help With PFPS

PFPS usually responds well to management with specific exercise and lifestyle changes. Only a handful of cases will ever require surgery.

The latest research into PFPS has found:

  • Exercise is recommended to reduce pain in the short, medium and long term
  • Exercise improves function in the medium and short term
  • Combining hip and knee exercises (e.g. squats) is recommended for all patients
  • Orthotics are special shoe inserts which help to support your foot and ankle. If there is an issue with the alignment of your foot/ankle such as over pronation (flat feet) then this may also impact on your knee pain. Better alignment of the foot takes stress off your lower leg and knee.
  • Patellar taping to improve the movement of the patella (knee cap) may be used by a physiotherapist to help reduce pain while you exercise/ move especially in the early stages.

Pain relief

Change your activity level

To ease the knee pain, it is recommended to pace yourself rather than stopping all forms of movement or exercise. Stopping all activity would result in muscles getting weaker which could lead to the knee pain getting worse. Instead, try to spread your activity out through the day with regular short rests. Break harder jobs down and do gentler activity in between.

When climbing stairs you may need to consider using handrails and go up one leg at a time until your muscles become stronger. It is easier to go upstairs leading with the non-painful leg and then come down with the sore leg leading.

If you only have pain while exercising try to reduce or change your exercise rather than stopping it completely. For example, if running causes you pain, reduce how long you run for or opt for a flatter route. Another option would be to choose an exercise you are more comfortable with (i.e. reduce the load on your knee) such as swimming or cycling and build up your leg strength that way. You may feel it is beneficial to reduce high impact exercise (two feet off the ground) to lower impact exercise (one foot on the ground at any one time). For example you could march instead of jogging in an exercise class.

Exercise

Exercise has been shown to be key in managing patellofemoral pain syndrome. There are three main types of exercise that can be beneficial :

  • Strengthening exercises
  • Stretching exercises
  • Endurance exercise

Strengthening exercises: Building up the strength of your hip and knee muscles can reduce knee pain. Research shows doing combined hip and knee exercises are the most effective. Some examples of strength exercises include free/machine weights in the gym, pilates or yoga. Here are some strength exercises you can do at home.

It is important to note it can take 6 – 8 weeks of doing specific exercises to notice a difference in your knee pain.  It can take a further couple of months before you feel better. The exercises below are divided into early, middle and late stages. You should start doing the early exercises first and should find them easy before you progress to the middle exercises. Again you should begin to find the middle exercises easy before you progress to the late exercises.

In the online NHS fitness studio there are many videos you can access for free.

The aim is to do exercises that are challenging your muscles but are relatively pain free. Do them regularly, usually daily, for 12 weeks. As soon as the exercises become easy to do move onto the more challenging exercises. If the exercises become painful, stop and choose an easier level of exercise.

Stretching exercises: Loosening tight muscles around the knee and hip can help reduce pain. For example hamstring, quadricep and calf muscles.

Endurance exercise: This includes exercises that work your muscles over a long period of time e.g. walking, running, cycling, swimming or aerobics. Choose an exercise that matches your fitness level and your pain level and aim to do it several times a week.

If you are used to exercising regularly but find your usual exercise painful you may need to reduce the amount you are doing or change exercise altogether (cross training) until your pain has improved.

If you are not used to exercising regularly you could try starting with a short walk a few times a week. Try to increase this as your pain allows.

Footwear

Some people benefit from wearing supportive shoes. For example a training style shoes which lace up and provide good support for the arches of your feet.

Weight Management

Being overweight can contribute to this condition so maintaining a healthy weight can help reduce pain.

Helpful Tops

  • Wear well-fitting, supportive trainers ideally supporting the arch of your foot
  • If you are increasing any sporting activity do it gradually. Sudden increases can overload the patellofemoral joint and increase pain
  • It is important to maintain good flexibility and strength in your thigh and calf muscles so a regular exercise programme is recommended
  • Maintaining a healthy weight can help to reduce symptoms
  • Avoid wearing high heeled shoes

Timescales/Prognosis

It may take up to 12 weeks before you notice a significant improvement in your symptoms but you should notice some gradual improvements along the way. Change will not happen overnight so it is important that you follow the advice regarding lifestyle changes, training modification and exercise. Doing this will help you successfully manage your condition and increase your chances of a successful outcome.

Help And Support

If after following the above advice, your symptoms have not improved within 6 to 12 weeks, a referral to a physiotherapist may be beneficial.

You can access physiotherapy by any of the following:

Additional information

Acute Injury Management

POLICE is an acronym (Protection, Optimal Loading, Ice, Compression and Elevation) that is used as a management strategy for many injuries and conditions for the first 24 to 72 hours.

  • Protection and relative rest are advised immediately after injury for the first 24 to 72 hours.
  • Optimal Loading refers to having a balanced rehabilitation program which encourages early and gradual activity to improve recovery. How you progress will vary from person to person depending on the injury. It is about finding the injured areas happy place and increasing slowly and gradually.
  • Ice may be used for reducing pain and swelling. There are safety points to follow when you use ice:
    • Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound can increase the risk of infection.
    • Be wary of ice burns – don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes is usually adequate.
    • Apply crushed ice/frozen peas wrapped in a damp towel for 10-20 minutes, 2-3 times per day for the first 5-7 days post injury/ flare up of pain.
    • Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.
  • Compression and Elevation are helpful for reducing inflammation. This can be done by keeping your joint raised on a pillow and compressed by wrapping a bandage around it.
    Do not make the bandage too tight and do not wear tubi-grip or any compression bandage in bed at night.
  • Heat: After 2-3 days, you may find that heat is more relaxing.

You could use a heat pad or a hot water bottle with an insulated cover on it. Make sure this is not too hot and is not directly touching your skin.

You should do this for 10 to 15 minutes, 3 to 4 times a day.

What do I do if my symptoms flare up?

Flare ups of pain are common. Some people have recurrent flare ups of pain so it is important to know how best to manage these flare ups. In most cases a pain flare-up will settle within 6 weeks.

Top Tips

  • You will likely find it helpful to rest a bit more but it is still important to keep active. This will help to avoid becoming stiff and your muscles becoming weak.
  • If you aim to get a balance between rest and activity it should help your pain to settle down. You may be sore at first, however, start slowly and gradually increase the amount you do.
  • Reduce movements or tasks that aggravate your symptoms. This can help especially in the early days.
  • Adopting positions or movements that reduce your pain can be useful.

Pain Relief

Analgesia

  • Analgesia also known as pain relief can be an important part in helping you manage your symptoms and allow you to stay active.
  • Taking suitable pain relief regularly allows you to move more normally and continue your usual activities without causing any damage. It is unlikely that medication alone will resolve your pain totally. For this reason we are using the term pain relief (A 30-50% reduction in pain would be deemed to be a good success).

Paracetamol

  • Paracetamol is a good general pain management medication. It is used to help manage lots of different types of pain.
  • Sometimes people believe they need something ‘stronger’ than paracetamol when in fact, taking a regular dose rather than a one-off dose is more effective.
  • Spreading the doses of the paracetamol evenly out over a day will help you control your pain. Visit NHS Inform for more detailed information on paracetamol.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

  • NSAIDs are medications that can reduce swelling around joints and nerve endings to give pain relief. They are particularly useful
    in treating inflammatory type pain. Two commonly prescribed NSAIDs are ibuprofen and naproxen.
  • Although NSAIDs can be very useful they are not suitable for everyone. Visit NHS inform for further information related to NSAIDs.

There are other forms of pain relievers available. If you feel your current pain relievers are not helping your pain or you are
experiencing any side effects from your medication, please seek advice from your GP or pharmacist.

For general information on medication visit NHS Inform.

Staying in work and returning to work

We know that staying in work or returning to work as soon as possible is good for your mental and physical health.

If you have problems with activities at work, it may be helpful to ask for a workstation/workplace assessment or talk with your manager or Occupational Health Department. This can help with alterations or provision of equipment or altering your working day or tasks.

There are organisations which can support you at work or help you return to work. You can visit Knowledge Scotland for further information.

Weight Management

Weight Reduction – People who are overweight tend to have more prolonged pain and poorer tissue healing due to increased levels of inflammation in the body. Reducing your weight can generally help improve the healing process.

A good indicator of whether you need to lose weight is your body mass index (BMI), which you can calculate with the NHS BMI calculator.

If your BMI states you are overweight or obese it is likely that losing weight will reduce your symptoms. Carrying extra fat also increases your risk of heart disease, stroke, type 2 diabetes, and some cancers. Reducing your portion sizes and eating a balanced diet can be helpful in reducing weight. NHS informs provides a free online 12-week weight management programme to get you started right away.

If you need a little more help and feel that you would benefit from working with others in group sessions NHS Lanarkshire’s Weigh to Go programme, groups in North and South Lanarkshire, will help you become more active, eat well and lead a healthier lifestyle.

Smoking

Smoking can affect how your body recovers from musculoskeletal problems. If you smoke then the good news is that by stopping smoking it can improve your health in many different ways. Giving up smoking is not something you have to do on your own. You’re twice as likely to stop smoking successfully if you get the right support from the NHS. There is a free NHS stop smoking service available in Lanarkshire to help you succeed.

Chronic Pain

Some people will have pain which persists beyond the expected time frame for their condition. For further information on this and how best to manage it please visit our Chronic Pain webpage.

Pain Association Scotland is a national charity that delivers professionally led self-management pain education in the community.

Active Health Programme

South Lanarkshire

Active Health is a programme for residents of South Lanarkshire living with long term conditions. Residents are referred via Acute, Physio & specialist nurses to a 10-week programme and then signposted onto a wide variety of mainstream physical activity, sport & outdoor opportunities.

South Lanarkshire Leisure and Culture have many active community opportunities as well as specialised referral programmes. Full details of the 20 leisure centres can be found on the SLL website. Contact details across South Lanarkshire or call 01698 476262 to find out the number of your local leisure centre.

Please contact your health professional to discuss this referral or contact SLLC on 01698 476262.

Contact details

North Lanarkshire

North Lanarkshire Leisure’s Active Health Programme in partnership with NHS Lanarkshire provides a range of supported programmes to help individuals realise the benefits of becoming more physically active whilst also assisting those who are recovering from minor or even more serious illness.

The Active Health Programme has both a General Programme where individuals can access the mainstream health and fitness programmes running within NL Leisure Venues including swimming, jogging, golf and more!

A Specialised Health Class Programme which requires a referral from a health professional, this option is available to individuals who require additional specialised support in taking part in physical activity and classes include Strength and Balance, Cardio I, Cardio II, Back Care and Macmillan Move More classes.

A health and social care professional can make a referral by using the Active Health referral form found at the bottom of the page in the link below.

Contact Details - Health & Wellbeing Information

Mental Wellbeing

It is very important to look after your own mental wellbeing. This can have an influence on your recovery or management of your Musculoskeletal problem. Visit our mental wellbeing page for more information.

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