Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy
Dutch multidisciplinary guideline group (anterior knee pain) · 2024 · Europe
Source and licence
- Authors
- Martin Ophey, Sander Koëter, Lianne van Ooijen et al.
- Title
- Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy
- Journal
- Knee Surgery, Sports Traumatology, Arthroscopy, 2024
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC11792096
Licence statement of the original publication
This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Module 1: ‘Exercise therapy for PFP’
- RecommendationsPFP should be treated with quadriceps‐ and/or hip‐focused exercise therapy for at least 6 to 12 weeks, preferably [partly] under the supervision of a physical therapist. A structured exercise therapy programme (volume and intensity), which continuously adjusts to the patient's pain intensity, should be offered. Patient education should be prioritized. Progression (volume and intensity), pain (Visual Analogue Scale) and function (Kujala Anterior Knee Pain Scale [AKPS]) should be evaluated after 6 and 12 weeks of performing the exercise programme in a structured manner. Additional conservative treatments should be considered when, after 6 weeks of exercise therapy, no clinically relevant changes occur (Module 2: ‘Additional conservative treatments for PFP’). The diagnosis of PFP should be reconsidered if no improvement in pain and function occurs after 12 weeks of structured quadriceps‐ and/or hip‐focused exercise therapy.
Module 2: ‘Additional conservative treatments for PFP’
- RecommendationsInitially, PFP should be treated using exercise therapy for 6 to 12 weeks (Module 1: ‘Exercise therapy for PFP’). Tapes, braces, or foot orthoses should be considered as additional conservative treatments in combination with exercise therapy if no clinically relevant changes occur after 6 to 12 weeks of exercise therapy (Module 1: ‘Exercise therapy for PFP’). The patient should be informed of the lack of evidence regarding these additional conservative treatments and should be involved in decision‐making regarding the choice of additional treatments.
Module 3: ‘Pain medications for PFP’
- RecommendationsCaution should be exercised in advising any type of pain medication for PFP. PFP should not be treated with injection therapy.
Module 4: ‘Diagnosing PT’
- RecommendationsThe following criteria should be used for a correct clinical diagnosis of PT: o Load‐dependent pain at the inferior pole of the patella; and … ▪ … a positive palpation test for pain at the inferior patellar pole and/or … ▪ … a positive Royal London hospital test and/or … ▪ … pain at the inferior patellar pole during the single leg decline squat. Additional imaging assessments should be undertaken as a confirmatory test when uncertainty remains regarding the correct clinical diagnosis of PT or in the absence of clinically relevant changes after 12 weeks of exercise therapy (Module 5: ‘Exercise therapy for PT’). The patient should be informed of the lack of evidence regarding additional imaging assessments and the possible extra financial burden.*
Module 5: ‘Exercise therapy for PT’
- RecommendationsUse the following four‐step‐treatment‐plan to treat patients with PT(Figure 2): 1. Pain management: Patient education and loading advice. 2. Strength progression: ▪ A progressive resistance exercise programme for the quadriceps should be performed for at least 12 weeks while continuously adjusting exercise intensity for the individual patient. ▪ Heavy slow resistance training is preferred, although different types of training programmes/contractions (e.g., isometric contractions) may be used to minimize the reactive pain response of the patellar tendon. 3. Energy storage/stretch‐shorten cycle: Depending on the type of sport, start with plyometric exercises. 4. Maintenance of muscle strength. Additional conservative treatments should be considered when, after 12 weeks of thorough exercise therapy (including education and loading advice), no clinically relevant changes occur (Module 6: ‘Additional conservative treatments for PT’ and Module 7: ‘Pain medications for PT’).
Module 6: ‘Additional conservative treatments for PT’
- RecommendationsInitially, PT should be treated with exercise therapy (including education and loading advice) (Module 5: ‘Exercise therapy for PT’). Additional conservative treatments (‘patellar straps’) should be considered when no clinically relevant changes occur after 12 weeks of exercise therapy (Module 5: ‘Exercise therapy for PT’). The patient should be informed of the lack of evidence regarding these additional conservative treatments and should be involved in decision‐making regarding the choice of additional treatments.
Module 7: ‘Pain medications for PT’
- RecommendationsCaution should be exercised in advising any type of pain medication for PT. PT should not be treated with injection therapy.
Module 8: ‘Open surgery for PFP and PT’
- RecommendationsInitially, PFP and PT should only be treated with non‐operative treatments for at least 6 months (see Module 2: ‘Exercise therapy for PFP’, Module 3: ‘Additional conservative treatments for PFP’, Module 5: ‘Exercise for PT’ and Module 6: ‘Additional conservative treatments for PT’). Surgery should only be considered when conservative treatment fails; the variable and unpredictable outcomes and potential risks of open surgery for PFP and PT should be discussed, and shared decision‐making should be employed when choosing the treatment. Open surgery should be considered only when, following at least 6 months of non‐operative treatments, including exercise therapy, the patient continues to experience persistent and disabling symptoms and functional limitations, and o Anatomical morphology is determined to be the cause of persistent PFP confirmed by imaging assessments or o PT is confirmed by imaging assessments.
Abstract
Purpose: The purpose of this study was to develop a multidisciplinary guideline for patellofemoral pain (PFP) and patellar tendinopathy (PT) to facilitate clinical decision‐making in primary and secondary care.
Methods: A multidisciplinary expert panel identified questions in clinical decision‐making. Based on a systematic literature search, the strength of the scientific evidence was determined according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method and the weight assigned to the considerations by the expert panel together determined the strength of the recommendations.
Results: After confirming PFP or PT as a clinical diagnosis, patients should start with exercise therapy. Additional conservative treatments are indicated only when exercise therapy does not result in clinically relevant changes after six (PFP) or 12 (PT) weeks. Pain medications should be reserved for cases of severe pain. The additional value of imaging assessments for PT is limited. Open surgery is reserved for very specific cases of nonresponders to exercise therapy and those requiring additional conservative treatments. Although the certainty of evidence regarding exercise therapy for PFP and PT had to be downgraded (‘very low GRADE’ and ‘low GRADE’), the expert panel advocates its use as the primary treatment strategy. The panel further formulated weaker recommendations regarding additional conservative treatments, pain medications, imaging assessments and open surgery (‘very low GRADE’ to ‘low GRADE’ assessment or absence of scientific evidence).
Conclusion: This guideline recommends starting with exercise therapy for PFP and PT. The recommendations facilitate clinical decision‐making, and thereby optimizing treatment and preventing unnecessary burdens, risks and costs to patients and society.
Level of Evidence: Level V, clinical practice guideline.
Contents of the original publication
The section headings of the original.
- INTRODUCTION
- METHODS
- Terminology
- Panel selection and scoping questions
- Evidence review
- Consensus process
- RESULTS
- Patient perspective
- Recommendations
- DISCUSSION
- CONCLUSIONS
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