A 17-year-old girl comes to the office for evaluation of right knee pain. For the past 3 months, the patient has had poorly localized, achy pain at the anterior right knee that is worse when she runs, sits for extended periods, or goes up or down a staircase. She has been taking nonsteroidal anti-inflammatory drugs, which partially relieve the pain but have lost effectiveness over time. The patient also has a sensation that the knee is "giving way" when she is running. Vital signs are normal. BMI is 19 kg/m². Physical examination shows a normal gait and no visible knee deformities. There is mild pain with flexion of the right knee. With the knee extended, compressing the patella into the trochlear groove reproduces the pain. Which of the following is the best next step in management of this patient?

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11ec25c8_d2c2_ee6b_bc81_e32d0bca152c_MD0003_00 This patient with poorly localized anterior knee pain has typical features of patellofemoral pain syndrome (PFPS). PFPS is one of the most common causes of chronic knee pain in young women. It is usually related to chronic overuse but can also occur acutely following trauma. Symptoms are typically worse during weight bearing with the knee flexed (eg, squatting, ascending/descending stairs) or when running or sitting for extended periods. The precise source of pain is variable and not well understood, but generally involves the track of the patella in the trochlear groove of the femur. The diagnosis of PFPS is primarily based on characteristic history and examination findings; however, no individual finding has high clinical utility, and the examination is often normal. In general, the pain is provoked by maneuvers (eg, squatting) that involve tonic contraction of the quadriceps with the knee in flexion. The knee should also be examined for rotational or angular (varus/valgus) malalignment and dynamic abnormalities (eg, weakness or atrophy of the quadriceps or hip abductors). The patellofemoral compression test (reproduction of pain when the patella is compressed into the trochlear groove) is often helpful but may generate significant discomfort for the patient. The initial management of PFPS includes activity modification (eg, reduced intensity of exercise) and nonsteroidal anti-inflammatory drugs. Patients also should be counseled on stretching and strengthening exercises with an emphasis on the quadriceps and hip abductors. (Choice A) Soft patellofemoral braces and customized taping can be considered for patients with PFPS, but the benefits are inconsistent. In contrast, hinged knee orthotic braces are primarily used for the treatment of acute ligamentous injuries. (Choice B) Intraarticular glucocorticoid injections are occasionally used in PFPS but are not likely to provide better long-term results than exercise and carry a small but clinically significant risk of complications (eg, tendon injury). (Choice C) Rigid knee immobilizers are used for patellar fractures and tears of the quadriceps or patellar tendon, which present following major trauma with inability to extend the knee. Functional weakness (eg, buckling, giveway sensations) does not indicate tendon rupture but can occur in a wide variety of tendon, ligament, and joint disorders, including PFPS. (Choice D) Nonweight-bearing ("3-point") crutches are typically used for acute fractures and sprains of the lower extremity. Although patients with PFPS should temporarily reduce the intensity of exercise and avoid activities that aggravate their symptoms, nonweight-bearing crutches are not necessary. Educational objective: Patellofemoral pain syndrome is a common cause of anterior knee pain in young women. It is usually due to chronic overuse or malalignment. The pain is provoked by maneuvers (eg, squatting) that involve contraction of the quadriceps with the knee in flexion. Initial management includes activity modification, nonsteroidal anti-inflammatory drugs, and stretching and strengthening exercises. References: Knee orthoses for treating patellofemoral pain syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/26645724) Exercise for treating patellofemoral pain syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25603546)

A 17-Year-Old Girl Comes to the Office for Evaluation of Right