Published via DMIHER School of
Open Access Case Report Epidemiology and Public Health
Comprehensive Management of Patellofemoral
Pain Syndrome in a Recreational Long-Distance
Received 06/25/2024
Runner: A Case Report
Review began 07/01/2024
Review ended 07/07/2024 Chaitali S. Vikhe 1, Swapnil U. Ramteke 1
Published 07/17/2024
© Copyright 2024 1. Department of Sports Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education
Vikhe et al. This is an open access article and Research, Wardha, IND
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
Corresponding author: Chaitali S. Vikhe, [email protected]
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.
DOI: 10.7759/cureus.64706 Abstract
Patellofemoral pain syndrome (PFPS) is a major concern in the field of orthopedic medicine, affecting a
substantial portion of the population and significantly impacting the quality of life. This condition,
characterized by anterior knee pain increasing with various activities, shows higher susceptibility in certain
demographic groups, such as women and adolescents. PFPS arises from a multifactorial etiology involving
anatomical, biomechanical, psychological, and social factors, making it a complex condition to manage.
Despite numerous therapeutic interventions available, including strengthening exercises, manual therapy,
and patellar realignment techniques, the long-term efficacy of these interventions remains debated. This
case report describes the case of a 21-year-old female recreational long-distance runner with bilateral knee
pain diagnosed with PFPS. Through a comprehensive intervention plan targeting strength, function,
flexibility, proprioception, and pain management, significant improvements were observed in pain levels
and functional outcomes after physiotherapy intervention. This case underscores the importance of a
holistic approach in managing PFPS and highlights the need for further research to optimize treatment
strategies and improve patient outcomes.
Categories: Pain Management, Physical Medicine & Rehabilitation, Sports Medicine
Keywords: proprioceptive deficits, physiotherapy intervention, multifactorial etiology, recreational runners, sports
physiotherapy, patellofemoral pain syndrome
Introduction
Patellofemoral pain syndrome (PFPS) is a prevalent and consequential condition affecting a substantial
portion of the population, with a prevalence of 22.7% [1]. It stands out among knee disorders accounting for
25-40% of cases and significantly impacting their quality of life (QOL) [2]. PFPS exhibits a higher
predisposition in specific demographic groups, particularly women and adolescents without structural or
significant pathologic changes in the articular cartilage. This demographic susceptibility underscores the
need for targeted interventions and management strategies [3]. The hallmark of PFPS is pain exacerbated by
various activities that load the knee joint, such as squatting, running, and stair climbing. These symptoms
greatly limit the daily activities and QOL of individuals [4]. It is evident in medical settings that PFPS
represents 11-17% of knee pain cases in general practice and a significant 25-40% in sports injury clinics [5].
PFPS is a multifactorial clinical condition stemming from abnormal patellofemoral joint loading, leading to
increased joint stress and retropatellar pain [6]. The etiology involves a complex interplay of anatomical and
biomechanical factors, making it a challenging condition to treat [7]. The syndrome is often described as a
"black hole" in orthopedic medicine due to the absence of a single explanation or therapeutic intervention
capable of addressing all aspects of patellofemoral dysfunction [8,9]. Common treatment approaches for
PFPS include physiotherapeutic interventions, such as strengthening exercises, manual therapy procedures,
and patellar realignment techniques. However, the effectiveness of these interventions remains debated,
with limited evidence supporting their long-term efficacy [10,11]. Despite positive short-term outcomes,
long-term management of PFPS remains challenging, with a significant proportion of individuals
experiencing recurrent or chronic symptoms [12].
Furthermore, individuals with concurrent patellofemoral dislocation may face proprioceptive deficits,
implicating damaged neuro-proprioceptive structures [13,14] The aim of this case report is to investigate the
multifaceted nature of PFPS and to explore effective strategies for managing recurrent pain and preventing
its recurrence, particularly in runners.
Case Presentation
A 21-year-old female recreational long-distance runner presented to the sports physiotherapy department
due to experiencing bilateral knee pain, which was significantly impacting her running ability. She reported
a six-month history of bilateral retropatellar pain, gradually onset over a month without specific trauma or
injury. The pain is exacerbated by activities involving prolonged knee flexion, such as ascending stairs, rising
How to cite this article
Vikhe C S, Ramteke S U (July 17, 2024) Comprehensive Management of Patellofemoral Pain Syndrome in a Recreational Long-Distance Runner:
A Case Report. Cureus 16(7): e64706. DOI 10.7759/cureus.64706
Published via DMIHER School of
Epidemiology and Public Health
from a chair, prolonged sitting, deep squatting, and patellar maltracking during walking. The patient found
that symptoms eased with rest, particularly if she avoided sitting for longer than 30 minutes with her knees
in a flexed position. After examination, she was diagnosed with PFPS, a common condition characterized by
anterior knee pain exacerbated by activities, such as running, squatting, and stair climbing.
Clinical findings
The patient's informed consent was obtained before the examination, following which a physical assessment
was conducted. On assessment, there was a decrease in range of motion, strength, function, and
proprioception. The patient reported pain levels using the Numerical Pain Rating Scale (NPRS). For pain
while running, the patient reported a level of 7 out of 10, and for pain at rest, the patient reported a level of 3
out of 10. Table 1 illustrates the pre-intervention and post-intervention findings with specific assessment
parameters.
Assessment Pre-intervention Post-intervention
Impaired functional movements (single-leg
Function Improved stability and function
squats, double-leg squats, and step-down tests)
moderately impaired, as assessed using a
Proprioception Improved
goniometer at 45 degrees of knee flexion
Patellar tracking Lateral patellar tracking observed Improved alignment
Running: 0/10 Stairs: 2/10 (ascending)
Running: 7/10 Stairs: 8/10 (ascending) Stairs:
Pain assessment by using the NPRS Stairs: 1/10 (descending) Deep squatting:
7/10 (descending) Deep squatting: 9/10
2/10
Tightness in hamstrings iliotibial band (Ober’s test
Flexibility Improved flexibility
- positive) Hip flexors (Thomas test- positive)
Neuromuscular Control and Balance
Moderate instability Improved stability and balance
by using Star Excursion Balance Test
TABLE 1: Pre-intervention and post-intervention findings with specific assessment parameters
NPRS: Numeric Pain Rating Scale
Table 2 presents the results of manual muscle testing conducted on both lower limbs before and after the
physiotherapy intervention.
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Pre-intervention Post-intervention
Joint Muscles Left Right Left Right
Flexor 4 4 5 5
Extensor 4 4 5 5
Abductors 4 4 5 5
Hip
Adductors 4 4 5 5
Internal rotators 3 3 5 5
External rotators 3 4 5 5
Flexor 3 3 5 5
Knee
Extensor 3 3 5 5
Dorsiflexors 5 5 5 5
Ankle
Planter flexors 5 5 5 5
TABLE 2: Pre- and post-intervention manual muscle testing of both lower limbs
Pre-intervention
The subject showed a variation in achieving the target angle, with an average deviation of 3 degrees
Post-intervention
The subject's accuracy improved significantly, with an average deviation of 0 degrees from the target angle,
as shown in Table 3.
Trial 1 Difference Trial 2 Difference Trial 3 Difference
Phase
(degrees) (degrees) (degrees) (degrees) (degrees) (degrees)
Pre-
49° +4° 43° -2° 48° +3°
intervention
Post-
45° 0° 46° +1° 44° -1°
intervention
TABLE 3: Knee joint positional sense by using a goniometer
Physiotherapy intervention
Table 4 outlines the specific interventions implemented during the physiotherapy treatment for PFPS [15].
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Sr
Goals Intervention Dosage Frequency
no.
Thrice weekly
1 To Improve strength Strengthening of hip adductors and lateral rotators 10 reps × 3 sets
for four weeks
30 s hold with three
Closed kinetic chain exercises for knee - terminal knee For four weeks
2 To Improve function repetitions with
extension with a theraband - wall squats - step-up with progression
progression
Stretching: hamstring muscle, gastrocsoleus, and 30 s hold with 10 reps, Thrice weekly
3 To Increase flexibility
Iliotibial band three sets for four weeks
To enhance neuromuscular Thrice weekly
4 Proprioceptive exercises using a wobble board 10 minutes
control and joint awareness for four weeks
To Reduce pain and
5 Mcconnell patellar taping 1 session 1 session/week
Improve patellar alignment
TABLE 4: Physiotherapy intervention for patellofemoral pain syndrome (PFPS)
Closed kinetic chain exercises for the knee to improve function and to reduce pain are shown in Figure 1.
FIGURE 1: Closed kinetic chain exercises for the knee to improve
function and to reduce pain: a) terminal knee extension with a
theraband; b) squats
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Proprioceptive exercises using a wobble board to enhance neuromuscular control and joint awareness are
shown in Figure 2.
FIGURE 2: Proprioceptive exercises using a wobble board to enhance
neuromuscular control and joint awareness: a) unilateral knee flexion;
b) single-leg stance; c) crossed leg sway.
Outcome measures
Pre- and post-physiotherapy intervention outcomes are mentioned in Table 5, which show a significant
improvement.
Sr. no. Outcome measures Pre-treatment Post-treatment
NPRS on running 7/10 0/10
1
NPRS at rest 3/10 0/10
2 KOOS 55% 100%
TABLE 5: Pre- and post-physiotherapy intervention outcome measures
NPRS: Numerical Pain Rating Scale; KOOS: Knee Injury and Osteoarthritis Outcome Score
Discussion
PFPS presents a multifaceted challenge in both diagnosis and treatment due to its diverse etiology and
varied clinical presentations [16,17]. Despite being a prevalent condition, its complexity is underscored by
these factors [18]. Previous research has highlighted several challenges associated with managing PFPS,
including high recurrence rates and the limited efficacy of traditional treatments [19,20]. In addition,
disruptions to position sense receptors caused by various knee injuries, including PFPS, have been shown to
impact knee joint proprioception [21]. This discussion aims to explore key aspects highlighted in the case
presentation and intervention strategies shedding light on the complexities of managing PFPS, particularly
in a recreational long-distance runner. The case presentation underscores the typical clinical manifestations
of PFPS, characterized by bilateral retropatellar pain exacerbated by weight-bearing activities, such as
running, squatting, and stair climbing. The patient's symptoms, which had developed gradually over six
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months and were not associated with a specific traumatic event, align with the insidious onset commonly
observed in PFPS cases. Moreover, the presence of decreased range of motion, strength, function, and
proprioception further emphasizes the multifactorial nature of PFPS, implicating abnormalities in both
biomechanical and neuromuscular domains.
The multifactorial approach included strengthening exercises focusing on hip adductors and lateral rotators,
which play a crucial role in stabilizing the patellofemoral joint during dynamic movements like running and
squatting. In addition, closed kinetic chain exercises such as terminal knee extensions and step-ups were
employed to improve knee function and proprioception, essential for restoring optimal movement patterns
and reducing joint stress. Flexibility exercises targeting tight muscle groups like the hamstrings,
gastrocnemius, and iliotibial band were incorporated to enhance joint mobility and alleviate muscular
imbalances contributing to PFPS symptoms. Proprioceptive training using a wobble board aimed to enhance
neuromuscular control and joint awareness, facilitating better dynamic stability during weight-bearing
activities. McConnell patellar taping was utilized to provide external support and optimize patellar
alignment, thereby reducing pain and improving biomechanical efficiency. These interventions were
systematically applied over a structured treatment period, emphasizing progressive overload and adaptation
to ensure sustained improvements.
The outcomes of the intervention demonstrated significant symptomatic relief and functional
enhancement. The patient reported reduced pain levels during activities that previously exacerbated
symptoms, such as running and descending stairs. Functional assessments, including single-leg squats and
step-down tests, showed improved stability and movement control. Objective measures, such as joint
positional sense and manual muscle testing, indicated gains in proprioception and muscular strength,
respectively, challenges in managing PFPS persist, including the potential for recurrence and variability in
treatment response among individuals. Long-term follow-up and continued research are essential to
evaluate the durability of treatment effects and refine therapeutic strategies. Future studies should explore
novel interventions or combinations of therapies to optimize outcomes and address the complex
pathophysiology of PFPS effectively.
Conclusions
This case study illustrates the effective physiotherapy management of PFPS in a recreational runner. The
holistic approach targeting strength, function, flexibility, proprioception, and pain management led to
significant improvements in symptoms and functional outcomes. This underscores the importance of
personalized, multifaceted treatments for PFPS and suggests avenues for future research to refine
therapeutic strategies and enhance patient outcomes.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Chaitali S. Vikhe, Swapnil U. Ramteke
Acquisition, analysis, or interpretation of data: Chaitali S. Vikhe, Swapnil U. Ramteke
Drafting of the manuscript: Chaitali S. Vikhe
Critical review of the manuscript for important intellectual content: Chaitali S. Vikhe, Swapnil U.
Ramteke
Supervision: Swapnil U. Ramteke
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
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