Education

One potential solution to improve patellofemoral pain long-term outcomes may be to provide high-quality patient education (eg, patient-specific advice and information on the condition, empowering patients to manage their expectations), which is considered essential by clinicians and researchers.¹

In this section, you will find some information and guidance to educate patients with patellofemoral pain.

Education is considered a vital component in the treatment of patellofemoral pain by experts, despite an absence of research directly evaluating its efficacy.¹ Recently, a systematic review² investigated the effect of education interventions (combined with other treatments or in isolation) in people with patellofemoral pain. The authors found that health professional–delivered education produced similar outcomes in pain and function compared to exercise therapy plus health
professional–delivered education in people with patellofemoral pain at 3 and 6 months post-intervention. However, health education material alone was inferior to exercise therapy for improving pain and function at 3 months post-intervention.

These findings highlight the importance of education in the treatment of patellofemoral pain. However, what strategies can be used to educate the patient?

Education targets should include managing patient expectations, load management, weight management when appropriate, ensuring self-management, teaching the importance of adherence to exercise therapy, and implementing strategies to address fear of movement. See below for more details:

Exercise and physical activity are very good for a patient’s health and well-being. However, doing ‘too much, too soon’ may be a key reason they develop or continue to have patellofemoral pain?

If they are not sensible with how much exercise they do, other normally effective treatments may not actually end up helping their pain management. That’s why managing load is very important.

Take a look at the short video below to get some tips on how you can manage exercise and physical activity loads.

Why do patients need to be sensible with how much exercise they do?

The exact reason why patients develop patellofemoral pain is unclear. However, experts around the world tend to agree that doing ‘too much, too soon’ in relation to exercise may be a key reason.

There seems to be a spike in the number of patients with patellofemoral pain following rapid increases to how much exercise they do – e.g. ‘start to run’ programs (e.g. couch to 5K^TM).

The number of people developing patellofemoral pain when completing basic military training has been reported to be as high as 32%.³

In “start to run” programs it can be as high as 17%.⁴

There are no specific rules on how much exercise patients should complete in order to avoid developing patellofemoral pain. It is also not clear exactly how quickly to increase exercise when returning to sports and other activities if patients are recovering from patellofemoral pain.

The most sensible option is to monitor pain levels during and after exercise. Experts frequently recommend that if patients have a large increase in pain, or pain stays increased for more than 24 hours after exercise, they may be doing ‘too much, too soon’.

Load management education to modify patellofemoral joint loading may include appropriate activity modification, movement pattern modification, and training and exercise therapy to increase the capacity to handle exposure to load. Technologies, including smartphone applications and activity measuring ‘wearables’, provide an easily utilized objective method to analyze baseline levels of activity and determine the magnitude of change following specific interventions. A good summary of such devices can be found in an article published in the scientific journal Physical Therapy in Sport.⁵

Fear of movement may exist in patients with patellofemoral pain. However, the most recommended intervention for patellofemoral pain is exercise, passive treatments are not likely to help.

It is quite common for patients with patellofemoral pain to be fearful of some movements (e.g. running, jumping, and walking on stairs). However, some studies report that reductions in fear of movement are related to reductions in the level of knee pain.⁶ Therefore, it is highly recommended for patients to keep doing all daily activities alongside the exercise program.

If they are not so confident about walking on stairs at the moment, you may find the following infographic helpful for educating patients.

Knee crepitus or noisy knee is a common complaint/concern⁷ of patients with patellofemoral pain. We don’t know what causes the noise on the knees. But, recent data show that patients with patellofemoral pain who have noisy knees have similar levels of pain, function, fear of movement, and knee strength compared to those who don’t have noisy knees. In other words, if a patient has patellofemoral pain and a noisy knee, it doesn’t mean his/her condition is worse than those who have patellofemoral pain and no noisy knee.

Additionally, a previous study investigated 250 asymptomatic knees (knees with no pain) and found that 99% of people had knee crepitus.

The previously published education leaflet titled ‘Managing My Patellofemoral Pain’⁸ is a strong educational tool and provides a great visualization to guide patients on returning to exercise. See below the leaflet accompanied by translations into several languages (Spanish, Danish, Sweden, Portuguese, Italian)