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Patellofemoral Pain – A common cause of anterior knee pain

Patellofemoral (PF) pain is a common cause of anterior knee pain in young adults and adolescents. This is described as knee cap pain that is worsened by activities that load onto a flexed knee. These include squatting, stairs, hiking, and running.1,2

The patella acts as a lever which helps extend the knee.1 The patella moves within the trochlear groove of the femur during leg extension and flexion. PF pain is thought to be due to incorrect tracking of the patella.3 More specifically, in PF pain, the patella tracks laterally.

Risk Factors for developing PF pain1

  • Activities including running, squatting, stairs (rapid increase in activities/training)
  • Dynamic valgus (caving in of knees)
  • Female sex (increased Q angle)
  • Foot abnormality (eversion and pes pronatus)
  • Sudden increase in activity level
  • Patellar instability
  • Quadriceps weakness

Diagnosis of this condition is made on a combination of history and physical examination findings. On history, the cardinal feature is that pain around and behind the knee cap is worse during weight-bearing knee flexion activities. Patients may also complain of worsening of their pain after a prolonged period of sitting with the knee flexed (on a plane, in a movie theatre).2

On physical exam, pain with squatting is most sensitive for PF diagnosis.2 Other tests, such as the patellar grind test, apprehension test, and tilt tests, have low diagnostic yields. These do not present with joint swelling, and range of motion is preserved.2

Imaging is not required for the diagnosis of PF pain.1 Radiographs should be obtained in cases where the diagnosis is not clear, or when the patient does not respond to first-line treatment options.2

The treatment of PF pain includes rest, activity modification, and physical therapy. The key is to work on and correct the underlying causes of the pain. This may include avoiding repetitive activities, assessing footwear, and most importantly addressing hip and knee muscular imbalances that cause the knee cap to track incorrectly. Patients should begin with a structured physiotherapy program to help correct imbalances.2 In some cases, foot orthotics can be considered to help with leg alignment and reduce pain in the short term.4 Bracing and taping techniques, while not fully supported by evidence, can help patients during periods of activity by stabilizing the patella.3

Sonam Maghera, MD, BMSc

Sports and Exercise Medicine Fellow, University of Ottawa

Advisor: Dr. Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

1.    Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral Pain Syndrome. Am Fam Physician. 2019;99(2):88-94.

2.    Crossley KM, Callaghan MJ, Linschoten R van. Patellofemoral pain. Br J Sports Med. 2016;50(4):247-250.

3.    Jin J, Jones E. Patellofemoral Pain. JAMA. 2018;319(4):418-418.4.         Collins NJ, Barton CJ, Middelkoop M van, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170-1178.

Pain Management Resources for Ontario Providers

Helping patients manage their pain is complex. To support primary care providers as they navigate this challenging landscape, partners across Ontario have come together to provide a one-stop spot for family physicians, nurse practitioners and other primary care clinicians to find resources to help manage their patients’ pain.

A range of supports – from guidelines on appropriate opioid use to CME-accredited webinars on topics like chronic pain – are included. Plus, access direct links to medical mentors who can provide timely advice and guidance on challenging care issues.

Resources are updated regularly and can be found at: http://www.hqontario.ca/Quality-Improvement/Guides-Tools-and-Practice-Reports/Primary-Care/Partnered-Supports-for-Helping-Patients-Manage-Pain

For more information about this coordinated approach to provide clinicians in Ontario with pain management resources contact:  http://www.hqontario.ca/