Patellofemoral
(Kneecap) Pain
Understanding causes, diagnosis, symptoms and treatments
What is Patellofemoral Pain?
Patellofemoral pain is a condition where there is pain around or behind the kneecap. The pain is associated with movements that load the front of the knee e.g squatting, stairs, jogging.
Usually, the symptoms arise gradually rather than because of a particular injury. Increased sensitivity or pressure around or behind the kneecap can give rise to the pain. It can affect one or both knees.
This condition is sometimes called ‘runner’s knee’, ‘anterior knee pain’ or ‘chondromalacia patella’.
What is the patellofemoral joint?
This is the joint between the kneecap (patella) and the thigh bone (femur).
The kneecap rests in a small groove at the end of the thigh bone.
When you move your knee, the patella glides within the groove.
How common is Patellofemoral Pain?
This is one of the most common knee problems.
- About one in five of the general population have experienced kneecap pain within the last year.
- Women are twice as likely to experience kneecap pain compared to men.
- About one in four teenagers will have experienced some kneecap pain in the past year.
- Athletes like runners and long-distance cyclists are also more likely to be affected.
How do I know if I have Patellofemoral Pain?
Symptoms can vary from person to person but some of the following are typical:
- Pain, discomfort or aching around or behind the kneecap
- Symptoms aggravated by squatting, walking up or down stairs, downhill walking, running, jumping or straightening the knee after sitting.
- Discomfort around the front of the knee with prolonged sitting or driving
- Darts of sharp pain on sudden or twisting movement
- Grinding/crackling noises or sensations when squatting or on stairs
How is Patellofemoral Pain diagnosed?
A diagnosis of patellofemoral pain is usually made based on the activities that aggravate your symptoms, in combination with a physical exam of your knee.
Clues from the physical exam may include pain during a one-legged squat, or while the examiner presses down on your kneecap, or while you straighten the knee against pressure.
Your GP or physiotherapist will rule out other causes of pain at the front of the knee to help reach a diagnosis.
Usually, a scan or x-ray does not add any helpful information to aid the diagnosis.
What causes Patellofemoral Pain?
The exact cause is unclear. It’s usually a combination of several factors described below.
Physical Activity
A sudden increase in activity or exercise
Activities that load the kneecap
An increase in running or walking (especially on hills or steps), squatting or kneeling
Negative thoughts or emotions
Fear and anxiety about your knee pain or low mood can contribute to more severe symptoms
Biomechanical factors
Altered hip and knee movement patterns can play a role, particularly for runners
SEX
Females are more prone to developing patellofemoral pain
Sports specialisation
Teenagers who specialise in a single activity/sport at an early age are more at risk
What to expect over time with patellofemoral pain?
Prognosis is very individual and variable
- More than half of people make a good recovery
- About 40% of people will still experience episodes of patellofemoral pain after one year
- About 25% of people will need to learn to manage more persistent symptoms in the long-term
If you are someone with long-term kneecap pain, understanding what triggers symptoms and having strategies to manage a pain flare is key. Also learning about ‘load management’ (see below) and maintaining a good level of hip and knee strength with a programme of exercises is important.
In general, activity is very good for managing pain but you may need to learn how to grade, monitor and balance the activities you are doing.
Listen to physiotherapist Dr Ciarán Purcell talk about some of the psychological factors that can impact pain and tips for coping with pain.
Treatments for Patellofemoral Pain
Load
Management
Exercise Programme
Other
treatments
Load Management for Patellofemoral Pain
What is it?
- Joint tissues adapt to the load they bear on a regular basis. Too little load can cause them to weaken, and too much load can also be a problem.
- Load management is about understanding the amount of activity and load your knee will tolerate. Learning how to build up activity slowly and safely is key to managing your kneecap successfully.
- Lifestyle management may also be important to consider as not only the physical load, but mental load can contribute to this balance. Managing stress and prioritising overall wellbeing may help us to cope better with pain and help our recovery.
Listen to physiotherapist Dr Ciarán Purcell talk about how exercise and load management should be used to manage patellofemoral pain.
Tips for Load Management
- Complete rest or avoiding movement is generally not helpful. Finding the right level of activity, with symptoms that you can tolerate is important.
- Being consistent with your amount of movement and exercise, while building up gradually in a graded manner is important to avoid aggravating kneecap pain.
- Understand what activities or exercise stir up your symptoms and avoid any sudden increase in these. Running downhill, lots of stairs or squatting exercises are often pain provoking activities.
- If your symptoms are worse that evening or the next day, this is a clue that you need to do slightly less or something different.
- As symptoms settle, you can try very slowing re-introducing more activities that were previously irritating (e.g., climbing hills, running).
- Given that many people will experience pain flares from time to time, understanding what triggers symptoms and having strategies to manage a pain flare is key.
Learning how to monitor your response to exercise and activity
Some pain when exercising is ok. An example of how to progress your exercise before return to sport is given below. If walking/bicycling is tolerated with a pain rating of no more than 2/10, then it is time to move to the next exercise in the ladder until you have completed all progressions.
Walking/bicycling
Fast walking / medium to hard bicycling
Slow running
Stairs
Running medium pace
Running high pace
Exercise for Patellofemoral Pain
Which exercises are good for Patellofemoral Pain?
Exercises for patellofemoral pain should target both the hip and knee muscles for best results in the long-term.
Start with exercises in lying or sitting as these are often more comfortable, before moving onto exercises in standing positions. Hip strengthening exercises can also be better tolerated initially. Add in more targeted knee strengthening exercises after a few weeks as your pain starts to settle.
For knee focused exercises, the wall slide is a good option to begin with. Include more exercise that target both the knee and hip (chair squats, reverse lunges, step-ups) as you progress.
Where to start?
Individual exercises that can be performed at home and are frequently prescribed for patellofemoral pain are described in the table below. They are accompanied by video links and downloadable files that you can print.
Level 1. If you are new to exercise or your kneecap pain is very easily irritated, we would suggest starting at here. It can take two or three weeks of repeating these exercises daily to build confidence and strength to progress.
Level 2. Start here if the Level 1 exercises feel too easy. When you’re comfortable with these exercises and have built up gradually to the number of recommended repetitions for Level 2, you are ready to progress.
Level 3. As you practice the exercises on this Level and if you need more of a challenge, you can hold a light weight (2 to 5 kg).
Monitoring your pain
Remember many people experience a temporary increase in knee discomfort when performing exercises. Review the advice in the Load Management section above on monitoring knee pain during and after exercise.
How many exercises?
Suggested repetitions for each exercise are provided but everyone will have a different starting point. Don’t worry if you cannot complete all repetitions together, you could repeat more than once a day. When you can perform more exercises together, we would suggest performing once a day or every other day.
What if I experience a setback?
Experiencing a setback or ‘flare up’ of knee pain after starting a new exercise programme or activity can be normal. Stay calm, switch to easier exercises and use ice or pain medication until symptoms improve. If your knee pain does flare, you have not harmed or damaged your knee.
Preparing to exercise
Warm up by walking or ‘marching on the spot’ for 3 to 4 minutes before you start your exercises. This will help your muscles prepare for the activity by increasing your circulation.
Level 1 Patellofemoral Pain Exercise Programme
Level 2 Patellofemoral Pain Exercise Programme
Level 3 Patellofemoral Pain Exercise Programme
other treatments
Taping
- Taping your knee can reduce pain during your exercise programme and help you to return to valued activities like running. It works best when combined with an exercise programme.
- If taping works you should feel an immediate pain reduction when you try something that’s usually aggravating, like coming downstairs or squatting.
- Learning how to tape your own knee can be useful for managing symptoms when doing an activity you find pain provoking e.g. jogging, hiking. You may wish to discuss taping with your physiotherapist who can assess your knee and find the most effective taping method for you. Usually a rigid strapping tape (i.e., Leuko® Sports Tape) works best.
- You should remove the tape again once the activity is over.
- The video link below demonstrates a taping technique you can try.
Shoe Inserts or Orthotics
- Insoles with an inbuilt arch support can help reduce pain. About 1 in 4 people are likely to benefit.
- Research has shown that “off the shelf” products are as useful as more expensive bespoke orthotics.
- It’s also more important that the insole feels comfortable rather than correcting any specific foot mechanics.
- You can test if the insole is likely to help you. Check if you feel an immediate reduction in kneecap pain when you repeat an activity that’s usually aggravating e.g. walking upstairs.
- A podiatrist or physiotherapist will be able to offer you more information about shoe inserts or orthotics. Click to Find a healthcare professional.
Injections and Surgery
- Current research tells us that surgery is generally not more effective than exercise at helping people with kneecap pain.
- There is no proof that platelet-rich-plasma (PRP) or corticosteroid injections are beneficial for people with kneecap pain.
Now you have an understanding of all treatment options for patellofemoral pain, check out some of the other resources:
- Go to the Irish Resources section for more help on your journey,
- Learn about another joint condition.
The information in this website page was informed by the following sources/references:
Scientific Publications
- Barton, C.J. and Rathleff, M.S., 2016. ‘Managing My Patellofemoral Pain’: the creation of an education leaflet for patients. BMJ open sport & exercise medicine, 2(1).
- de Oliveira Silva et al. Patient education for patellofemoral pain: A systematic review. J Orthop Sports Phys Ther. 2020 Jul;50(7):388-396.
- Crossley, K et al. “Patellofemoral pain.” British journal of sports medicine 50.4 (2016): 247-250.
- Lack S, Neal B, De Oliveira Silva D, Barton C. How to manage patellofemoral pain – Understanding the multifactorial nature and treatment options. Phys Ther Sport. 2018 Jul;32:155-166. doi: 10.1016/j.ptsp.2018.04.010.
- Lankhorst et al. Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: A multicentre observational analysis. Br J Sports Med. 2016;50(14): 881-886.
- Matthews et al. Does foot mobility affect the outcome in the management of patellofemoral pain with foot orthoses versus hip exercises? A randomised clinical trial. Br J Sports Med. 2020;54:1416-1422.
- Neal BS et al. Six treatments have positive effects at 3 months for people with patellofemoral pain: A systematic review with meta-analysis. J Orthop Sports Phys Ther. 2022 Oct;52(11):750-768.
- Neal, B et al. “Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning. ” British Journal of Sports Medicine 58.24 (2024): 1486-1495.
- Willy RW et al. Clinical practice guidelines patellofemoral pain. J Orthop Sports Phys Ther. 2019;49(9):1-95.
Patient Websites/Resources
- TREK ‘My KneeCap’ education and self-management toolkit. La Trobe University.
https://myknee.trekeducation.org/
Clinical Guidelines
- Neal, B et al. “Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning. ” British Journal of Sports Medicine 58.24 (2024): 1486-1495
- Willy, R.W., Hoglund, L.T., Barton, C.J., Bolgla, L.A., Scalzitti, D.A., Logerstedt, D.S., Lynch, A.D., Snyder-Mackler, L., McDonough, C.M., Altman, R. and Beattie, P., 2019. Patellofemoral pain: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American physical therapy association. Journal of Orthopaedic & Sports Physical Therapy, 49(9). https://www.jospt.org/doi/10.2519/jospt.2019.0302