Subjective:
Date of visit
Present illness:
Location of pain (anterior knee pain, retropatellar pain)
Onset (gradual, acute)
Duration
Character of pain (aching, sharp, stabbing)
Aggravating factors (activities, squatting, stairs)
Relieving factors (rest, ice)
Functional limitations (activities of daily living, sports participation)
Previous treatments (medications, physical therapy)
Response to previous treatments
Past medical history
Surgical history
Family history (arthritis, knee problems)
Objective:
General: vital signs, weight, height, BMI
Musculoskeletal:
Gait observation (antalgic gait, effusion)
Range of motion (knee flexion/extension, patellar tracking)
Joint tenderness (palpation of patellofemoral joint)
Patellar apprehension test
Quadriceps and hamstring strength
Joint effusion (if present)
Lachman test (optional, to rule out ACL tear)
Assessment:
Patellofemoral pain syndrome (PFPS)
Consider differential diagnoses (meniscal tear, bursitis, Osgood-Schlatter disease)
Plan:
Treatment recommendations:
Activity modification (avoid aggravating activities)
Ice therapy
Quadriceps strengthening exercises
Patellar taping/bracing (optional)
Physical therapy referral
Anti-inflammatory medications (consider NSAIDs)
Consider referral for imaging (X-ray, MRI) if pain persists or other diagnoses suspected
Follow-up:
Schedule next appointment in X weeks/months to monitor progress
Note: This is a template and may need to be modified based on the individual patient’s presentation.
Additional Information:
You may also want to document the patient’s functional limitations using a scoring system like the Lower Extremity Functional Scale (LEFS).
Include any patient education materials provided.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of patellofemoral pain syndrome.