Patellofemoral Pain Rehabilitation Protocol

This protocol outlines a comprehensive rehabilitation program for individuals diagnosed with Patellofemoral Pain (PFP). It is designed to progressively load the patellofemoral joint and surrounding tissues, ultimately enabling a safe and effective return to function. This protocol should be used as a guideline and modified based on individual patient presentation, pain levels, and functional goals. Close monitoring and communication with the patient are crucial throughout the rehabilitation process.

Pathophysiology

Patellofemoral pain (PFP) is a common condition characterized by pain around or behind the patella, often exacerbated by activities that load the patellofemoral joint such as squatting, stair climbing, running, or prolonged sitting. The exact etiology is often multifactorial and may involve:

• Malalignment: Abnormal patellar tracking due to factors like increased Q-angle, femoral anteversion, or tibial torsion.
• Muscle Imbalances: Weakness of the hip abductors, external rotators, and quadriceps muscles (specifically the vastus medialis oblique - VMO) can contribute to patellar maltracking. Tightness of the lateral retinaculum, IT band, and hamstrings can also play a role.
• Biomechanical Factors: Poor foot mechanics (e.g., excessive pronation), faulty movement patterns during dynamic activities.
• Overload/Overtraining: Sudden increases in training volume or intensity, especially in running or jumping activities.
• Patellar Instability: Prior history of patellar subluxation or dislocation.
• Soft Tissue Dysfunction: Changes in the soft tissue structures supporting the patella, such as the retinaculum or patellar tendon.

Common Special Tests

Several special tests can assist in diagnosing PFP. These tests can reproduce pain and help determine the source of the symptoms.

• Patellar Grind Test (Clarke's Test): The therapist applies a posterior and inferior pressure with their hand on the patella while the patient contracts their quadriceps muscle. A positive test is indicated by pain or crepitus under the patella.
• Patellar Apprehension Test: The therapist gently laterally translates the patella. A positive test is indicated if the patient becomes apprehensive or actively contracts the quadriceps to prevent further translation.
• Lateral Patellar Glide Test: Assess the amount of lateral patellar glide. Limited medial glide suggests tight lateral structures. Excessive lateral glide may indicate lateral patellar instability.
• Q-Angle Measurement: Measuring the angle between the quadriceps muscle and the patellar tendon. An elevated Q-angle (>15 degrees for men, >20 degrees for women) may contribute to PFP.
• Single Leg Squat Assessment: Observing for valgus collapse, trunk control, and overall biomechanics during a single leg squat.

Phase I: Protection (Pain and Inflammation Management)

Goals: Decrease pain and inflammation, restore pain-free range of motion (ROM), minimize muscle atrophy.

• Duration: 1-2 weeks (or longer, depending on severity)
• Pain Management:
  • Rest: Avoid activities that aggravate pain.
  • Ice: Apply ice packs for 15-20 minutes, several times a day.
  • Medications: Consider NSAIDs or other analgesics as prescribed by a physician.
  • Activity Modification: Adjust activities to reduce stress on the patellofemoral joint.
• Range of Motion (ROM):
  • Gentle Knee ROM exercises: Heel slides, pendulum exercises.
  • Patellar Mobilization: Medial glides to improve patellar tracking.
  • Hamstring Stretching: Gentle static stretching to improve flexibility.
  • Quadriceps Stretching: Gentle stretches.
• Muscle Activation:
  • Quadriceps Sets: Isometric contractions to activate the quadriceps without stressing the joint.
  • VMO Activation Exercises: Focus on isolated VMO activation.
  • Hip Abductor Activation: Side-lying hip abduction with a theraband (low resistance).
• Weight Bearing:
  • Weight bearing as tolerated (WBAT) with crutches if necessary.
• Criteria to Advance:
  • Pain level ≤ 3/10 at rest and with activities of daily living.
  • Full or near-full pain-free ROM.
  • Minimal swelling.

Phase II: Loading (Strength and Endurance)

Goals: Improve strength, endurance, and neuromuscular control of the lower extremity. Progressively load the patellofemoral joint.

• Duration: 2-4 weeks
• Strengthening Exercises:
  • Closed Kinetic Chain Exercises (CKC):
    • Mini Squats: Focus on proper form and avoid pain. Gradually increase depth.
    • Leg Press: Light weight, high repetitions.
    • Step-Ups: Start with low steps and progress to higher steps.
    • Wall Sits: Maintain proper alignment.
  • Open Kinetic Chain Exercises (OKC):
    • Short Arc Quadriceps Exercises: 0-45 degrees of knee extension to minimize patellofemoral stress, low weight, higher reps
  • Hip Strengthening:
    • Side-lying Hip Abduction: Progress resistance with theraband.
    • Clamshells: With theraband resistance.
    • Hip Thrusts: Progress from bodyweight to weighted.
  • Core Stabilization:
    • Plank exercises.
    • Bridge exercises.
• Endurance Training:
  • Low-impact cardio: Cycling, elliptical, swimming.
  • Increase duration and intensity gradually.
• Neuromuscular Control:
  • Balance exercises: Single leg stance, tandem stance.
  • Agility drills: Cone drills, lateral shuffles (begin once adequate strength is achieved).
• Criteria to Advance:
  • Pain level ≤ 2/10 with moderate activities.
  • Good strength in hip and knee musculature (at least 75% strength compared to the unaffected side).
  • Adequate neuromuscular control during functional activities.

Phase III: Return to Function (Sport-Specific Training)

Goals: Return to sport or desired activity level with minimal pain and full function. Optimize biomechanics and prevent re-injury.

• Duration: 2-4 weeks (or longer, depending on the sport/activity)
• Sport-Specific Training:
  • Gradually introduce sport-specific activities: Running, jumping, cutting, pivoting.
  • Focus on proper form and biomechanics.
  • Increase intensity and duration gradually.
• Plyometrics:
  • Start with low-impact plyometrics: Box jumps, jump rope.
  • Progress to higher-impact plyometrics: Depth jumps, single leg hops.
• Agility Drills:
  • Sport-specific agility drills to improve coordination and reaction time.
• Maintenance Program:
  • Continue strengthening and stretching exercises to maintain strength, flexibility, and neuromuscular control.
  • Implement proper warm-up and cool-down routines.
  • Monitor for any signs of pain or dysfunction and adjust activity levels accordingly.
• Criteria to Return to Sport:
  • Pain-free participation in all sport-specific activities.
  • Full strength and endurance in hip and knee musculature.
  • Adequate neuromuscular control and balance.
  • Successful completion of a functional testing battery.

Disclaimer: This protocol is intended as a general guideline and should be adapted to meet the specific needs of each individual patient. Consultation with a qualified healthcare professional is essential for proper diagnosis and treatment.