Patellofemoral Pain Syndrome (PFPS) is one of the most common musculoskeletal conditions affecting the knee. It is particularly prevalent among adolescents, athletes, and physically active individuals. It can also impact the general population. PFPS often limits daily activities, including walking, running, squatting, and stair climbing (Pereira et al., 2022). Research shows its one of the most common knee conditions
seen by clinicians in active individuals and it may account for 25% to 40% of all knee problems seen in a sports medicine clinic (Bump et al., 2023). Interestingly, PFPS also affects women more than men with a 2:1 ratio. Sinclair et al., (2022) report that 71–91% of patients still experience symptoms 20 years after diagnosis and can progress to osteoarthritis, often forcing individuals to reduce activity, therefore early treatment is crucial to prevent long-term issues.
What Causes PFPS?
PFPS occurs due to abnormal movement or maltracking of the patella (kneecap) within the femoral trochlear groove. This results in increased stress on the joint and surrounding soft tissues. The following factors can contribute to this condition:
- Muscle weakness or imbalance – Poor activation or strength in the quadriceps (especially the vastus medialis oblique or VMO) and gluteal muscles can lead to improper tracking of the patella.
- Biomechanical issues – Altered hip, knee, and ankle mechanics, excessive foot pronation, or a high Q-angle (the angle between the hip and knee) can all contribute to PFPS. (Kasitinon et al., 2021)
- Tightness in lateral structures – Tightness in the iliotibial band (ITB), lateral retinaculum, or vastus lateralis can pull the patella laterally, leading to increased joint stress.
- Increased load or training volume – Sudden increases in exercise intensity or duration, such as running or jumping, can fatigue muscles and thus overload the patellofemoral joint.
- Poor neuromuscular control – Weak core and lower limb stabilising muscles (such as your gluteus medius) can result in poor movement patterns and altered biomechanics, exacerbating patellofemoral joint stress.
Risk Factors for PFPS
Several factors can predispose an individual to developing PFPS, including:
- Rapid increase in training volume (e.g., new running program, sudden change in activity levels)
- Pronated foot type (excessive inward foot rolling when walking or running)
- Increased Q-angle, particularly in females (due to wider hips relative to knee alignment) (Widhiantari et al., 2023)
- Reduced gluteal and quadriceps strength/activation
- Poor biomechanics affecting hip, knee, and ankle alignment
- Tightness in the quadriceps and calf muscles
Common Symptoms of PFPS
Patients with PFPS often report:
- Dull, aching pain in the front of the knee, especially behind or around the patella
- Pain during weight-bearing activities, such as climbing stairs, running, jumping, or squatting (Syed et al., 2024)
- Pain after prolonged sittingwith the knee bent (e.g., during car rides, desk work or watching a movie)
- Clicking or grinding (crepitus) in the knee during movement
Diagnosis and Physiotherapy Assessment
A comprehensive physiotherapy assessment is essential to determine the root cause and contributing factors of PFPS. Our examination typically includes:
- Detailed Subjective History: Understanding symptom onset, aggravating factors, lifestyle and load demands.
- Objective Assessment:
- Gait and running analysis to identify abnormal movement patterns
- Patella position and movement
- Hip, knee, and foot posture
- Joint range of motion (ROM) and mobility
- Muscle activation and strength testing (quadriceps, glutes, calf, core)
- Functional movement testing, such as squats and lunges, to observe knee mechanics
Physiotherapy Treatment for PFPS
Physiotherapy plays a central role in reducing pain, restoring function, and preventing recurrence.
Treatment typically includes:
1 – Load Management & Activity Modification. For some individuals a temporary reduction of high-impact activities (running, jumping) is required to reduce symptoms. Typically this involves a modification of aggravating movements while maintaining strength and fitness.
2 – Soft Tissue Techniques & Manual Therapy techniques like joint mobilisations help to release tight structures that affecting patella tracking. Dry needling can also help as an adjunct
3 – Strengthening & Motor Control Training:
- Quadriceps strengthening, with emphasis on the VMO to improve patella control.
- Gluteal strengthening, especially gluteus medius to optimise hip control and knee alignment.
- Calf and tibialis posterior strengthening to improve push off and foot position
- Core stabilisation exercises to enhance lower limb control and balance.
- Compound movements toimprove strength, power and force production/absorption
4 – Biomechanics & Movement Re-Education:
- Isometric exercises and somatosensory training improve proprioception, balance, and significantly helps to reduce symptoms of PFPS (Kochar et al., 2024).
- Gait and running technique retraining to reduce knee stress (de Souza Júnior et al., 2021)
5 – Stretching & Mobility Work:
- Targeted stretching for tight quadriceps, ITB, and hip flexors to reduce stress on the patellofemoral joint. Foam rolling is often used as an adjunct
6 – Use of Orthotics & Taping as Needed:
- Foot orthoses can assist in correcting excessive pronation and redistributing forces at the knee (Chen et al., 2022).
- Patellar braces or taping may provide additional support in certain cases.
What Does the Evidence Say?
Research strongly supports physiotherapy-based interventions for managing patellofemoral pain syndrome (PFPS). Studies indicate that exercise therapy is more effective than passive treatments for PFPS. Strengthening exercises targeting the hip and knee muscles are the most effective rehabilitation approach (Manojlović et al., 2021), but it is imperative that the whole kinetic chain is assessed and deficits targeted. Early intervention is crucial, as recognising and addressing PFPS promptly can prevent it from progressing into a chronic or more complex condition (Rathleff & Collins, 2025). Additionally, early physiotherapy treatment significantly reduces long-term pain and recurrence rates (Young et al., 2021).
Preventing PFPS Recurrence
To minimise the risk of recurrence, patients should:
- Maintain strength and mobility in the quadriceps, glutes, calf and core.
- Gradually increase training loads to avoid overuse injuries.
- Perform regular flexibility exercises to prevent muscle tightness.
- Use proper footwear suited to their biomechanics and activity level.
- Monitor movement mechanics during sport and exercise to ensure good knee alignment.
Conclusion
PFPS is a highly treatable condition with physiotherapy-based rehabilitation. Addressing the underlying causes through individualised exercise programs, movement retraining, and biomechanical adjustments leads to significant improvements in function and pain reduction. Early intervention is key in preventing chronic symptoms and ensuring long-term knee health.
Exercise
Static Lunge
Aim: A dynamic lower-body exercise that enhances glute, calf, hamstring, and quadriceps strength (especially Rectus Femoris), along with core stability.
How: Stand in a split stance, front foot flat, back foot on toes. Slightly bend both knees, engage your core, and tense the back leg’s glutes. Lower straight down, keeping glutes engaged, until the back knee reaches a 90-degree angle. Press up to the start position and repeat.
Inner Range Quad
Aim: Strengthens and activates the VMO (Vastus Medialis Obliquus), which helps guide the patella medially for proper tracking. This muscle is crucial in the last 30° of knee extension, aiding movements like stair climbing, squatting, and full leg straightening. It is often weakened in PFPS due to pain or poor endurance.
How: Place a rolled towel or roller under your knee crease. Extend your knee fully, tensing the muscle on the inside of your knee. Hold for 5 seconds, then relax. Repeat 10 times. Increase difficulty by adding reps, longer holds, full movement, or weights.
Side-lying Single leg Squat on Reformer
Aim: Strengthens Gluteus Medius to improve stability and endurance, preventing valgus knee collapse and overpronation, which can stress the plantar fascia. Also enhances quadriceps strength for better push-off in walking and running.
How: Lie on your side on the reformer, hips facing forward. Place the top foot on the foot bar, parallel to the ground. Press out to extend the top leg, moving the carriage up. Bend the knee to return the carriage down, keeping the knee aligned with the second toe or slightly lifted. Adjust difficulty by modifying spring resistance.
If you or someone you care for has an injury, a flare up, requires some rehabilitation or experiences an increase in pain, give the clinic a call on 9713 2455 or book online.