Patellofemoral Pain Syndrome
The kneecap is meant to glide through a shallow groove at the end of the thigh bone as the knee bends and straightens. When it does not travel cleanly through that groove, the cartilage on its undersurface takes load it was not built for, and the result is the aching, grinding pain that patellofemoral pain syndrome describes.
Steven Struhl, MD is board certified in orthopedic surgery and holds separate board certification in sports medicine, earned after a sports medicine fellowship at Penn State University. He has served as a medical consultant to the United States Open and as medical director for the physical therapy practice treating the Brooklyn Nets, which means he has watched a great deal of this condition resolve through rehabilitation rather than surgery.
Patellofemoral Pain Syndrome Symptoms
- Pain Around or Behind the Kneecap: usually described as an ache rather than a sharp pain, and hard to point to precisely.
- Worse on Stairs: particularly going down, when the kneecap is loaded against the groove.
- The Theater Sign: pain after sitting with the knee bent for a long period, named for what happens at the movies.
- Grinding or Grating: a sensation of the kneecap catching as the knee straightens.
- Squatting and Kneeling Pain: deep knee bend positions concentrate load on the patellofemoral joint.
- Mild Swelling: present in some patients and absent in many, which is why swelling does not rule the diagnosis in or out.
Why the Kneecap Tracks Poorly
Tracking is a balance problem more often than a structural one, which is why it usually responds to treatment.
- Quadriceps Imbalance: the inner portion of the quadriceps working less effectively than the outer, pulling the kneecap laterally.
- Hip Weakness: weak hip abductors letting the thigh rotate inward, which changes the angle the kneecap sits at.
- Tight Lateral Structures: a tight iliotibial band and lateral retinaculum tethering the kneecap outward.
- Foot Mechanics: overpronation altering rotation up the entire limb.
- Training Error: a sudden increase in mileage, hills, or jumping volume.
- Shallow Trochlear Groove: in a minority of patients, a groove that is anatomically flat, which offers the kneecap less to sit in.
That last one is the reason a small number of patients do not respond to rehabilitation. The rest respond because the causes are correctable.
How Patellofemoral Pain Is Diagnosed
The diagnosis is clinical, and it is made by examination rather than by MRI. Patellar tracking is watched through active knee extension, the kneecap is compressed against the groove to reproduce the pain, the lateral structures are tested for tightness, and hip strength is assessed directly. Plain radiographs including a skyline view show how the kneecap sits in its groove. MRI is reserved for patients who fail treatment or whose history suggests a cartilage injury rather than a mechanical one.
Patellofemoral Pain Syndrome Treatment
Treatment succeeds in the large majority of patients and it takes patience, which is the part most people are not told at the outset.
- Quadriceps and Hip Strengthening: the core of the program, addressing the imbalance driving the tracking problem.
- Structured Progression: starting with closed chain work in ranges that do not provoke symptoms, then advancing.
- Stretching: hamstrings, calves, quadriceps, and the iliotibial band, all of which influence patellar position.
- Load Management: reducing stairs, hills, and deep squats temporarily rather than stopping activity outright.
- Orthotics: helpful for patients whose foot mechanics are contributing.
- Anti Inflammatories: for symptom control during the early weeks, not as treatment on their own.
Meaningful improvement generally takes six to twelve weeks of consistent work. Patients who complete the program and continue maintenance strengthening tend to stay well. Patients who stop when the pain eases are the ones who return.
When Patellofemoral Pain Needs Surgery
Surgery for patellofemoral pain syndrome alone is rare and it should be. When a patient has completed a genuine rehabilitation program without improvement, the next step is usually reexamination rather than an operation, because persistent symptoms often mean the working diagnosis was incomplete. Where imaging shows a true cartilage defect on the undersurface of the kneecap, or where the kneecap is dislocating rather than simply tracking poorly, the problem is a different one with different answers.
Schedule a Patellofemoral Evaluation in New York City
Kneecap pain that has been treated as generic knee pain for months usually needs a more specific examination rather than a different medication. Dr. Struhl evaluates patellofemoral problems and anterior knee pain at his Manhattan and White Plains offices. Contact us to schedule an appointment.
