Patellofemoral Pain Syndrome: How to Fix Front of Knee Pain

Knee pain can make even the simplest activities, like climbing stairs or getting out of a chair, feel like a challenge.

Whether you’re an athlete or just someone who enjoys staying active, knee issues can sneak up on you and disrupt your daily life.

Did you know that about 25–40% of all knee problems seen in sports clinics are related to the patellofemoral joint? This makes it one of the most common causes of knee pain for active individuals¹.

One of the leading culprits is patellofemoral pain syndrome (PFPS), often called “runner’s knee.” But it’s not just for runners—this condition can affect anyone, from teenagers to older adults, especially those who put repetitive strain on their knees. PFPS happens when the area around your kneecap gets irritated from overuse or alignment issues.

What is Patellofemoral Pain Syndrome?

Patellofemoral Pain Syndrome, often called “runner’s knee,” is a common condition that causes pain in the front of your knee, around or behind the kneecap. It typically flares up during activities like running, squatting, climbing stairs, or even prolonged sitting.

Unlike an acute injury, Patellofemoral Pain Syndrome develops gradually due to repeated stress on the knee joint. It’s not caused by a specific tear or damage but rather from irritation in the structures around the kneecap².

Who Does It Affect the Most?

Patellofemoral Pain Syndrome doesn’t just target athletes—it can affect anyone. However, it is most common among young, active individuals and especially runners, with studies showing that up to 10% of runners will experience this condition at some point³. Women are at higher risk than men, likely due to differences in hip and knee alignment, which can affect the way forces travel through the knee joint⁴.

How Common is Patellofemoral Pain Syndrome?

This condition accounts for up to 25–40% of all knee issues seen in sports medicine clinics¹. It’s also one of the most frequent knee problems reported by adolescents, as they tend to participate in sports and activities that put stress on the knees during growth spurts⁵.

Why Does it Happen?

Patellofemoral Pain Syndrome is often linked to overuse, poor biomechanics, or a combination of both. Activities that involve repetitive bending and straightening of the knee—like running, jumping, or cycling—can irritate the cartilage and tissues around the kneecap. Factors such as weak hip muscles, tightness in the quadriceps or hamstrings, or improper foot alignment can all contribute to the development of this condition⁶.

The Role of the Kneecap (Patella)

Your kneecap is like a guide for your thigh muscle (quadriceps) to transmit force down to your lower leg. It sits in a groove at the end of your thigh bone (femur) and moves smoothly when you bend and straighten your knee.

For this movement to happen properly, the muscles, tendons, and ligaments around your knee need to be balanced and aligned. When this balance is off, the kneecap can shift out of its groove or track incorrectly, leading to uneven pressure on the surrounding cartilage and tissues. Over time, this causes pain and irritation⁷.

Overuse and Repetitive Stress

Your knees handle a lot of force—sometimes 5–7 times your body weight during activities like running or jumping. When you repeatedly stress the knee without giving it enough time to recover, it can lead to irritation in the structures around your kneecap⁸.

High-impact activities that involve bending and straightening the knee repeatedly can overload the joint. Even sitting for long periods with bent knees can create pressure on the patellofemoral joint, triggering discomfort.

Muscle Imbalances and Weakness

Weakness in certain muscles, especially in the hips and thighs, can shift how your kneecap tracks. For example, weak glutes, which help stabilize your thigh bone, may allow the thigh bone to rotate inward, increasing stress on the kneecap.

Similarly, if the outer thigh muscle (vastus lateralis) overpowers the inner thigh muscle (vastus medialis), the kneecap can be pulled off-center, irritating the joint⁹.

Poor Alignment and Biomechanics

How your legs are aligned and move can also contribute. Excessive foot pronation, when your foot rolls inward too much while walking or running, can change the angle of your lower leg, putting extra stress on your kneecap.

Knee valgus (knock-knees), which brings the knees closer together, increases pressure on the inside of the kneecap, potentially causing pain¹⁰.

Common Symptoms of Patellofemoral Pain Syndrome

If you’re dealing with Patellofemoral Pain Syndrome , you will notice some or all of these symptoms:

• Pain Around or Behind the Kneecap: A dull, aching pain in the front of the knee, especially during activities like squatting, running, climbing stairs, or sitting for long periods.
• Knee Pain During Prolonged Sitting: Sometimes called the “theater sign,” this occurs when your knee feels stiff or sore after sitting with bent legs for an extended time.
• Cracking or Popping Sounds: You might hear or feel grinding, popping, or cracking sounds when bending or straightening the knee, especially with activities like climbing stairs or getting up from a chair.
• Increased Pain with Downhill or Downstairs Movement: Descending stairs or walking downhill often puts extra stress on the kneecap, worsening the pain.
• Tenderness Around the Kneecap: Pressing on the sides or underside of your kneecap can feel tender or uncomfortable.
• Swelling Around the Knee: While not always present, you might notice mild swelling in the knee area, particularly after a long day of activity.
• Weakness or Instability: Your knee may feel like it’s “giving way” during activities, making it hard to trust your leg for support.
• Morning Stiffness: Knees often feel stiff or tight first thing in the morning, especially if the muscles around them are weak or tight.
• Difficulty with Deep Knee Bending: Activities that require full knee flexion, like squatting or kneeling, can be particularly painful and uncomfortable.
• Worsened Symptoms After Exercise: Pain may reduce during exercise but tends to flare up afterward, making recovery or rest periods uncomfortable⁸.

What Other Conditions Could It Be?

Iliotibial Band Syndrome (ITB Syndrome)

ITB Syndrome occurs when the iliotibial band, a thick band of tissue running along the outside of the thigh, becomes irritated. Pain is usually felt on the outer side of the knee, not around the kneecap. Unlike Patellofemoral Pain Syndrome, the pain is sharper and often worsens with downhill running or repetitive knee bending⁶.

Patellar Tendinopathy

This condition, often called “jumper’s knee,” involves pain and tenderness in the patellar tendon just below the kneecap. Unlike Patellofemoral Pain Syndrome, the pain is more localized and typically flares up with jumping or landing activities. It’s common in sports that require explosive movements⁷.

Osgood-Schlatter Disease

Osgood-Schlatter affects growing adolescents and causes pain at the bony bump below the kneecap where the patellar tendon attaches. The pain differs from Patellofemoral Pain Syndrome because it’s tied to growth spurts and often involves visible swelling or a lump below the knee⁹.

Meniscal Tear

A meniscal tear involves damage to the cartilage inside the knee joint. Unlike Patellofemoral Pain Syndrome, it’s often caused by a specific twisting injury and can include locking, catching, or instability in the knee. Swelling inside the knee is also more common with a meniscal tear¹⁰.

Knee Osteoarthritis

Osteoarthritis is more common in older adults and involves the gradual breakdown of cartilage in the knee joint. Unlike Patellofemoral Pain Syndrome, the pain is often felt deep inside the joint and is accompanied by stiffness, particularly after periods of rest or in the morning.

Common Mistakes and Risks in Managing Patellofemoral Pain Syndrome

When dealing with Patellofemoral Pain Syndrome, certain mistakes can slow your recovery or worsen the condition. Here’s what to watch out for:

Ignoring the Pain

Many people think the pain will go away on its own, but ignoring it often leads to chronic discomfort. Over time, even basic activities like walking or climbing stairs can become painful if the problem isn’t addressed⁴.

Not Addressing the Root Cause

Focusing only on the pain without tackling underlying issues like weak hip muscles, tight hamstrings, or poor foot alignment can cause recurring symptoms. Without addressing these root causes, recovery is slower and less effective⁵.

Doing Too Much, Too Soon

Jumping back into running or intense activities too quickly can lead to setbacks. Your knee needs time to heal, and pushing it too hard can make the condition worse⁶.

Skipping Recovery

Rest is a critical part of healing. Skipping recovery periods between activities can overload the knee, leading to further damage and potentially chronic pain⁷.

Consequences of Neglect

If left untreated, Patellofemoral Pain Syndrome can result in chronic pain, difficulty with everyday activities, and permanent joint issues. Early intervention is essential to avoid these long-term problems and improve your overall prognosis⁸.

Types of Scans

Scans can help rule out other conditions and provide a clearer picture of what’s happening in your knee. Here are the three most common scans used to diagnose Patellofemoral Pain Syndrome:

X-Ray

An X-ray gives us a clear look at your bones. While it doesn’t show soft tissues like cartilage or ligaments, it helps identify issues like fractures, arthritis, or alignment problems that may be contributing to your knee pain⁹.

MRI (Magnetic Resonance Imaging)

An MRI provides detailed images of both the bones and soft tissues in your knee. This scan can show cartilage damage, inflammation, or tears in the tendons and ligaments, which are common in chronic cases of knee pain¹⁰.

Ultrasound

An ultrasound is a quick and painless way to look at the muscles, tendons, and other soft tissues around the knee in real-time. It’s particularly useful for identifying swelling, tissue irritation, or signs of overuse.

Is Surgery Needed?

Most people with Patellofemoral Pain Syndrome don’t require surgery. Non-surgical treatments, like physiotherapy, are highly effective. Surgery is only recommended for structural misalignment or severe cartilage damage after months of non-surgical care.

Common surgeries include lateral release (to loosen tight tissues), realignment surgery (to reposition the kneecap), and cartilage repair procedures.

Physiotherapy after surgery is essential for regaining strength and restoring function. Sessions focus on reducing swelling, restoring mobility, and strengthening muscles around the knee to prevent future problems¹⁴.

Treatment Options for Patellofemoral Pain Syndrome

As a physiotherapist, I can provide several treatments to help you manage PFPS and regain strength and mobility. These include:

Exercise Therapy

Exercises are the cornerstone of PFPS treatment. Strengthening the hips, thighs, and calves helps stabilize the kneecap and improves its movement. Stretching tight muscles like the hamstrings also reduces strain on the knee. Controlled, gradual progress in activity helps restore function without causing flare-ups⁶.

Myofascial Release

This hands-on technique relieves tightness in the muscles and tissues around the knee. By improving blood flow and releasing tension, it reduces pain and promotes healing. Myofascial release can target specific problem areas to improve movement patterns and comfort⁷.

Orthopedic Manual Therapy

Manual therapy involves hands-on techniques to improve joint mobility and reduce stiffness. This can include gentle adjustments to the kneecap or loosening up stiff joints in the hips or ankles. These techniques help improve alignment and reduce pressure on the patellofemoral joint⁸.

Laser Therapy

Low-level laser therapy uses light to calm inflammation and promote tissue healing. It’s a non-invasive option that can speed up recovery when combined with other treatments. Laser therapy is particularly helpful for reducing pain during the early stages of rehabilitation⁹.

Dry Needling

Dry needling involves placing thin needles into tight muscles to release tension and improve blood flow. This can help reduce pain and relax overworked muscles, especially in areas like the quadriceps or calf¹⁰.

Strapping and Taping

Taping supports the kneecap, reduces strain, and improves alignment during movement. It’s a simple but effective way to manage symptoms while staying active. This technique also provides short-term relief while strengthening exercises address the underlying issues.

Conclusion

Patellofemoral Pain Syndrome doesn’t have to hold you back from the activities you love. With the right combination of exercises, treatments, and patience, you can reduce pain, strengthen your knee, and return to living pain-free.

Recovery takes time, but every step—whether it’s strengthening weak muscles, taking rest days, or learning proper movement patterns—brings you closer to healing. I’m here to guide you.

References

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10. van der Heijden, R. A., Lankhorst, N. E., van Linschoten, R., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2016). Exercise therapy for adolescents and adults with patellofemoral pain syndrome: A systematic review. British Journal of Sports Medicine, 49(4), 205-217.