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Practice Guideline
. 2025 Feb;33(2):457-469.
doi: 10.1002/ksa.12367. Epub 2024 Jul 24.

Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy

Martin Ophey  1   2 , Sander Koëter  3 , Lianne van Ooijen  4 , Mathijs van Ark  5   6 , Fred Boots  7 , Shanna Ilbrink  8 , Nienke A Lankhorst  9 , Tom Piscaer  10 , Myrthe Vestering  11 , Mirre den Ouden Vierwind  12 , Robbart van Linschoten  10   13 , Sietske van Berkel  14
Affiliations
Practice Guideline

Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy

Martin Ophey et al. Knee Surg Sports Traumatol Arthrosc. 2025 Feb.

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.

Keywords: conservative treatment; knee; knee joint; patellofemoral pain syndrome; tendinopathy.

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Conflict of interest statement

The personal financial interests, personal relationships, external research funding, intellectual property, and other potential conflicts of all the authors are described in the online Supporting Information.

Figures

Figure 1
Figure 1
Modules and Scoping Questions. Overview of the eight distinct guideline Modules and Scoping Questions for PFP and PT. PFP, patellofemoral pain; PT, patellar tendinopathy.
Figure 2
Figure 2
Four‐step‐treatment‐plan for PT (adjusted from Rudavsky and Cook [43]). Structured treatment plan for PT starting with adequate pain management, followed by strength progression and restoration of the tendon's energy‐storage capacity, and concluded with maintenance strategies. PT, patellar tendinopathy; VAS, Visual Analogue Scale.
Figure 3
Figure 3
Evidence‐based clinical approaches for PFP and PT. Optimal treatment and timelines with exercise therapy as the cornerstone in the first 6 and 12 weeks for PFP and PT, respectively. Pain medications may play a role in this first part in cases with severe pain, with additional conservative treatments only when exercise therapy does not result in clinically relevant changes. Due to the limited additional value of imaging assessments for PT, its use should be considered only after 12 weeks. Reconsider diagnosis after 12 weeks (PFP and PT) and open surgery is reserved for very specific cases only. PFP, patellofemoral pain; PT, patellar tendinopathy.
See this image and copyright information in PMC

References

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