Patellofemoral pain syndrome (PFPS)

What is patellofemoral pain syndrome?

Patellofemoral pain syndrome is a collective term for pain symptoms at the front of the knee, specifically around the joint between the patella (kneecap) and the femur (upper leg). The kneecap acts as a lever for your thigh muscles, sliding through a groove in your thigh when bending and stretching.

In PFPS, this process does not go smoothly or the tissue around the kneecap becomes overloaded. This is sometimes called a ‘girl's knee’, runners' knee or chondromalacia mentioned. An interesting fact is that the cartilage at the back of the kneecap itself does not contain any nerves and therefore cannot hurt. The pain you feel probably comes from the irritated bone under the cartilage, the knee capsule or the retinaculum (the connective tissue around the kneecap).

How do you recognise it?

The symptoms often arise gradually, without obvious trauma such as a fall or twist. Typical symptoms are:

• Pain at the front of the knee, often ‘behind’ or ‘around’ the kneecap.
• Increase in symptoms when climbing stairs (especially downhill), squatting, kneeling or cycling against the wind.
• Stiffness or starting pain when standing up after sitting for a long time.
• Sometimes a creaking or crackling sound (crepitations) at bending.

Causes and risk factors

There is rarely one specific cause; it is often a combination of factors that cause the load on the joint to be greater than what the tissue can handle at the time.

One important factor is a sudden change in activity. Have you just started running, increased training intensity or done a lot of hiking in the mountains? If so, the tissue may have become overloaded.

In addition, the control of your muscles plays a big role. Research shows that people with PFPS often have less strength in the quadriceps (thigh muscles) and the muscles around the hip (abductors and exorotators). If your hip muscles are not strong enough, your knee may rotate inwards during loading (valgus position). This increases the pressure behind the kneecap. The position of your feet can also affect how your knee moves.

The theatre phenomenon

A classic symptom of PFPS is the ’theatre phenomenon’ (or cinema sign). This means that you get pain when you sit with bent knees for long periods of time, for example in the cinema, in the car or at your desk. The bent position causes the kneecap to be constantly pressed against the thigh, causing irritation. Just stretching your legs often gives immediate relief.

How do we make the diagnosis?

At Fysio Fitaal, we start with a comprehensive interview and physical examination. PFPS is diagnosed mainly based on your story and ruling out other causes. We look at:

• The localisation of the pain (often diffuse around the patella).
• Pain provocation during specific tests, such as squatting or tightening the thigh muscles.
• Kneecap mobility and muscle tension.

We use ultrasound in Fysio Fitaal mainly to rule out other conditions, such as a jumpers knee (tendinitis) or bursitis. Indeed, an X-ray or MRI often shows nothing abnormal in PFPS because the problem is functional and not structural.

Treatment at Fysio Fitaal

Treatment for pain around the kneecap is almost always conservative (without surgery) and focuses on improving the load-bearing capacity of your knee. Our approach is based on Sports Medicine Association guidelines and consists of three pillars:

1. Advise and adjust load

In the first phase, it is important to temporarily reduce painful activities (“relative rest”) to allow the irritation to subside. This does not mean not doing anything, but rather avoiding peak activity (such as deep squats, jumping or heavy stair climbing).

2. Exercise therapy: knee and hip

This is the core of the treatment. We not only focus on strengthening the thigh muscles (quadriceps), but also intensively train the hip muscles. Research shows that training the hip abductors and exorotators improves leg position and significantly reduces pain. We will draw up a personal exercise programme for you.

3. Taping (McConnell)

If pain is preventing you from exercising, we can medical taping or apply the McConnell taping method. This can instantly reduce pain and improve muscle control, allowing you to exercise more easily and pain-free.

Sports advice and prognosis

Many athletes fear that they have to quit their sport, but this is rarely necessary. However, it is crucial to build up training slowly to avoid relapse.

• Cycling: Raise your saddle slightly and cycle with a lighter gear (less resistance). This lowers the pressure behind the kneecap.
• Running: We analyse your walking pattern and footwear. Sometimes an adjustment in stride frequency can already give a lot of relief.

The prognosis of PFPS is favourable. Long-term studies show that a large proportion of patients recover well and can play pain-free sports. However, keep in mind that tendons and joint tissue take time to adjust; a trajectory of 3 to 6 months is not unusual.