Patellofemoral pain rehabilitation program^[1-7]

Goals	Protection	Exercises	Sets and repetitions	Frequency	Criteria for progression
Acute phase (2 to 4 weeks)*
Reduce pain. Improve hip and knee mobility as necessary. Prevent muscle atrophy.	Exercise at pain level 3/10^¶ or less.	Isometric quadriceps contractions with 30 to 60 degrees knee flexion (use pillow under knee).	2 to 3 sets × 5 reps; 45- to 60-second hold per rep at 7/10^¶ effort; 2-minute rest between sets.	2 to 3 times per day.	Able to walk down stairs with pain no greater than 3/10.^¶
		Seated heel slides from knee extended to knee flexed.	2 sets × 10 reps; knee flexion should not exceed 90 degrees or cause pain greater than 3/10.	1 to 2 times per day.
		Standing hip abduction and adduction.	2 sets × 10 reps.	1 to 2 times per day.
Subacute phase (4 to 8 weeks)* – Early stage
Improve knee and hip mobility and strength.	Perform exercises with no more than 3/10 pain.^¶	Hamstring stretch supine – Perform with knee in full extension and hip at 90 degrees flexion.	2 sets × 5 reps; 45-second hold per rep.	Subacute phase training performed 1 to 2 times per day; 2 times preferred.	Able to walk down stairs and walk at fast pace on level surface with pain no greater than 3/10.
		Short-arc quadriceps extension.	3 sets × 10 reps; knee flexion no more than 45 degrees.
		Clamshell (hip external rotation).	3 sets × 10 reps.
Subacute phase – Progressive stage
Improve knee and hip mobility and strength.	Perform exercises with no more than 3/10 pain.^¶	Quarter squats (knee flexion ≤45 degrees) – Dumbbell or goblet squats may be used.	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^Δ	Subacute phase training performed 1 to 2 times per day; 2 times preferred.	Able to perform all exercises with pain no greater than 3/10.
		Standing exercises with resistance bands:	3 sets × 10 reps for each exercise/movement listed.
		Hip abduction.
		Hip internal rotation.
		Hip external rotation.
		Hip extension to 45 degrees.
Functional phase*
Improve knee and hip mobility and strength. Improve balance.		Half squats (knee flexion ≤75 degrees).	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^Δ	Functional phase training performed once per day.	Able to perform all exercises with pain no greater than 3/10.
		Walking lunge.	3 sets × 10 reps/leg; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^Δ
		Balance exercises:
		Plank.	3 sets × 30 seconds each; build to 60 seconds.
		Single-leg half squats on affected leg.	3 sets × 5 reps.^Δ
		Side step-ups on affected leg.	3 sets × 5 reps; use approximately 10 cm step.
		Single-leg stand.	1 set; build to 60 seconds – When can hold stance for 60 seconds wearing shoes, perform without shoes, then progress to standing on rolled towel or comparable unstable surface.
		Stair climbing.	Begin by walking up and down 5 stairs. Increase the number of stairs by 2 each day, provided pain is no greater than 3/10.^¶ Goal is 20 stairs. Complete 1 set daily.
Sport-specific phase
Prepare for return to full sport.	Completes exercises with pain no greater than 3/10.	Exercises vary by type of sport.			Approximately equal strength of hamstring and quadriceps in each lower extremity. Approximately symmetric strength of lower extremities. Able to perform full-speed, sport-specific movements without difficulty or pain. Able to complete 15 minutes continuous dynamic exercise.
		Generally includes ballistic movements (eg, skipping, jumping) and sport-specific movements (eg, cutting); gradually increase movement intensity.		Sport-specific training performed once per day.
		Squat (progress to 90 degrees knee flexion).	3 sets × 10 reps; weight should be increased gradually as soon as all repetitions can be completed without difficulty or pain greater than 3/10.^Δ	2 to 3 times per week on nonconsecutive days.

The basic rehabilitation program above is for patients with patellofemoral pain without a significant concomitant musculoskeletal injury or condition. Note that patellofemoral pain is a diagnosis of exclusion and for the purposes of this rehabilitation program it is assumed that other important injuries and conditions affecting the knee and lower extremity have been ruled out.

* Timeframes are estimates, and patients can proceed to the next phase as soon as they meet the criteria for advancing.
¶ Clinicians can use a scale of 1 to 10 to judge pain and exertion. During exercise, pain should not exceed 3 out of a maximum of 10 (ie, 3/10).
Δ Resistance for weighted exercises should be challenging but not overwhelming (about 7/10). Weight should be increased judiciously but steadily once all repetitions can be completed without difficulty. Increased resistance stimulates additional strength gains. Depending on the present weight being used and patient fitness, an increase of 10 to 20% weekly is a reasonable estimate. If pain greater than 3/10 recurs, the weight should be reduced to that used the prior week.

References:

Dolak KL, Silkman C, Medina McKeon J, et al. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: A randomized clinical trial. J Orthop Sports Phys Ther 2011; 41:560.
Peters J, Tyson N. Proximal exercises are effective in treating patellofemoral pain syndrome: A systematic review. Int J Sports Phys Ther 2013; 8:689.
Harvie D, O'Leary T, Kumar S. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: What works? J Multidiscip Healthc 2011; 4:383.
Bradbury M, Brosky JA Jr, Walker JF, West K. Relationship between scores from the Knee Outcome Survey and a single assessment numerical rating in patients with patellofemoral pain. Physiother Theory Pract 2013; 29:531.
Powers CM, Ho KY, Chen YJ, et al. Patellofemoral joint stress during weight-bearing and non-weight-bearing quadriceps exercises. J Orthop Sports Phys Ther 2014; 44:320.
Oliver GD, Di Brezzo R. Functional balance training in collegiate women athletes. J Strength Cond Res 2009; 23:2124.
Bennell KL, Hinman RS, Metcalf BR, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Ann Rheum Dis 2005; 64:906.

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Patellofemoral pain rehabilitation program[1-7]

Patellofemoral pain rehabilitation program^[1-7]