Pain at the front of the knee can make simple things, like climbing stairs, squatting or getting out of a chair, feel like hard work. It often builds up gradually rather than after a single injury, which is part of what makes it confusing to pin down.

One of the most common causes is patellofemoral pain syndrome (PFPS), sometimes called “runner’s knee.” Despite the name it is not only a runner’s problem: it affects teenagers, older adults and anyone who loads the front of the knee repeatedly. PFPS accounts for a large share of the knee pain seen in sports and physiotherapy clinics.¹

This article explains what PFPS is, why it happens, how it is assessed, what treatment involves, and when it is worth being seen in person. The reassuring part is that most cases can be treated effectively with the right approach.

The Short Version

Patellofemoral pain syndrome (PFPS) is pain around or behind the kneecap, common in runners, cyclists and anyone who does a lot of stairs, squatting or sitting with bent knees.
It usually builds up from a mix of training load, strength and control around the hip and knee, and the way you move, rather than from one single cause.
Most cases can be treated effectively with the right intervention, mainly a structured, progressive loading programme that addresses the whole leg, alongside sensible activity adjustment. Scans and surgery are rarely needed.
If your knee gives way, locks, swells significantly, or follows a clear injury, it is worth being assessed in person.

Struggling with pain at the front of your knee? Book an assessment in Sandton and we will work out what is driving it.

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What Is Patellofemoral Pain Syndrome?

Patellofemoral pain syndrome, often called “runner’s knee,” causes pain at the front of the knee, around or behind the kneecap. It typically flares with running, squatting, going up or down stairs, or prolonged sitting. Unlike an acute injury, it usually develops gradually from repeated load on the knee rather than from a specific tear or damage.²

Who Does It Affect?

PFPS is most common in young, active people and runners, with up to around 10% of runners affected at some point.³ It is reported more often in women than in men, which may relate to differences in how the hip and knee load.⁸ It is also common in adolescents during growth spurts, when sport and rapid changes in load go together.⁸

Why Does It Happen?

PFPS is best understood as load-related. It usually develops when the demand on the front of the knee outpaces what it can currently handle, often after a change in training, activity or footwear.⁸ It is typically multifactorial, with several things contributing rather than one single cause, and the amount of pain does not always match what is seen on a scan or on how the leg looks.⁵

How the Kneecap Loads

The kneecap (patella) sits in a groove at the end of the thigh bone and helps the thigh muscle transmit force to the lower leg as you bend and straighten the knee. When the balance of forces around the knee is off, the load on the kneecap and the surrounding tissue can become uneven. This tracking or alignment idea is one proposed factor rather than the whole story, so it is best seen as a piece of the picture, not a diagnosis on its own.²

Load and Recovery

The knee handles large forces during running and jumping. When load is increased faster than the knee adapts, the tissues around the kneecap can become irritated. Long periods sitting with the knees bent can also aggravate it.⁸

Strength and Control

Reduced strength or control around the hip and thigh can change how the knee is loaded, and hip and glute strength in particular seem to matter.³ These are useful things to work on, but they are contributors rather than a guaranteed cause in every person.⁷

Movement and Foot Factors

How the foot and leg move can also play a part, for example a lot of inward foot roll or the knee falling inward under load. These are worth assessing, but again they are pieces of the picture rather than proof of the cause.²

Common Symptoms of PFPS

If you have PFPS, you may notice some or all of these:

Pain around or behind the kneecap, often a dull ache at the front of the knee, especially with squatting, running, stairs or long periods of sitting.
Pain after prolonged sitting, sometimes called the “theatre sign,” where the knee feels stiff or sore after sitting with bent knees.
Cracking or popping that you may hear or feel when bending or straightening the knee.
More pain going downhill or downstairs, where the load on the kneecap is higher.
Tenderness around the kneecap when you press on the edges or underside.
Mild swelling at times, particularly after a lot of activity.
A sense of the knee giving way, often from pain or reduced control rather than true instability.
Stiffness, for example first thing in the morning or after rest.
Discomfort with deep knee bending, such as squatting or kneeling.
Symptoms that flare after exercise rather than during it.⁸

What Other Conditions Could It Be?

Iliotibial Band (ITB) Syndrome

ITB syndrome irritates the band of tissue along the outside of the thigh, so the pain is usually felt on the outer side of the knee rather than around the kneecap, and it often worsens with downhill running or repeated knee bending.

Patellar Tendinopathy

Often called “jumper’s knee,” this causes pain and tenderness in the tendon just below the kneecap. The pain is more localised than PFPS and typically flares with jumping and landing.

Osgood-Schlatter Disease

This affects growing adolescents and causes pain at the bony bump below the kneecap where the tendon attaches. It is tied to growth spurts and often involves a tender lump below the knee.

Meniscal Tear

A meniscal tear involves the cartilage inside the knee joint. Unlike PFPS, it is often linked to a specific twisting injury and can cause locking, catching or a sense of instability, with swelling inside the joint more common.

Knee Osteoarthritis

More common in older adults, osteoarthritis involves gradual changes to the cartilage in the knee. The pain is often felt deeper in the joint and comes with stiffness, particularly after rest or first thing in the morning.

Common Mistakes When Managing PFPS

PFPS can be persistent if the contributing load and strength factors are not addressed, but it is not a condition that inevitably causes lasting joint damage. A few common patterns tend to slow progress:

Only Treating the Pain, Not the Load

Focusing only on easing the pain, without adjusting load or building strength, tends to let symptoms return. Addressing the contributors gives a more durable result.⁶

Doing Too Much, Too Soon

Jumping back into running or intense training too quickly is a common cause of setbacks. Building load up gradually gives the knee time to adapt.⁴

Not Allowing Enough Recovery

Recovery between harder sessions is part of the plan. Stacking demanding sessions without it tends to keep the knee irritated and stall progress.

When Are Scans Needed?

PFPS is usually diagnosed from your history and a physical examination, not from a scan.⁹ Imaging is not routinely needed and is mainly used to rule out other problems when the picture is unclear or symptoms are not improving as expected. When imaging is used, the options are:

X-ray shows the bones and can help rule out things like fractures, arthritis or clear bony problems, though it does not show cartilage or soft tissue.
MRI shows bone and soft tissue in detail and can identify cartilage or tendon changes, usually reserved for unclear or stubborn cases.
Ultrasound gives a quick look at soft tissues around the knee and can show swelling or tissue irritation.

Is Surgery Needed?

Most people with PFPS do not need surgery, and non-surgical care, especially exercise, works well for the large majority. Surgery is only considered for specific structural problems, and usually only after a long course of conservative treatment has not helped. Where it is used, procedures may address tight lateral tissues, kneecap position, or cartilage. Rehabilitation afterwards helps restore strength, movement and a steady return to activity.

When to Have Knee Pain Assessed in Person

Patellofemoral pain is usually a load-related problem that can be treated effectively with the right approach, and most cases do not need scans or surgery. Now and then, though, knee pain points to something that deserves an in-person look. It is worth being assessed by a physiotherapist or doctor if you notice any of the following:

Your knee gives way, locks, or catches
Noticeable swelling, warmth or redness around the joint
Pain that started after a specific fall, twist or direct blow
You cannot put weight on the leg or fully straighten the knee
Pain at night or pain that is not linked to activity
Pain that is not improving despite several weeks of sensible loading

None of these necessarily mean something is seriously wrong, but they are worth getting assessed in person so you can be guided properly.

Treatment Options for PFPS

Treatment is individualised and guided by your assessment. Exercise and load management are the core of it, and the options below support that rather than replacing it.

Exercise Therapy and Load Management

This is the cornerstone of treatment. Progressive strengthening of the hips, thighs and calves, together with a graded return to activity, is the most strongly supported approach for PFPS.¹⁰ What is loaded, and how quickly, depends on your symptoms and goals.⁶

Myofascial Release

Myofascial release can help ease discomfort in tight or sensitive muscles around the knee, hip and thigh, and make movement and exercise feel more comfortable. It supports the active rehabilitation rather than correcting the problem by itself.

Orthopaedic Manual Therapy

Hands-on techniques can give short-term relief of stiffness and help nearby joints, such as the hip and ankle, move more freely, as part of a broader programme. It is used alongside exercise, not as a standalone fix.

Laser Therapy (Low-Level Laser Therapy)

Low-level laser therapy is sometimes used as a modest adjunct for comfort during rehabilitation. The evidence for it in PFPS is limited, so it is best seen as an optional extra rather than a core treatment.

Dry Needling

Dry needling targets tight or tender points in the muscles, and some people find it eases discomfort and makes movement feel easier. Like the other hands-on options, it supports the exercise plan rather than replacing it.

Taping and Strapping

Taping can give some short-term support and comfort at the front of the knee while you build strength. It is a helpful add-on for staying active, not a fix on its own.⁶

Frequently Asked Questions

How long does PFPS take to improve?

It varies. Many people notice meaningful improvement over several weeks with a consistent loading programme, while more stubborn cases take longer. Progress depends more on managing load and building strength than on a fixed timeline.

Can I keep running or exercising?

Often yes, within comfortable limits. Rather than stopping completely, the usual aim is to adjust how much and how hard you train so the knee is challenged but not overloaded, and build back up from there.

Do I need a scan?

Usually not. PFPS is diagnosed clinically from your history and examination. Scans are mainly used to rule out other problems when the picture is unclear or symptoms are not settling as expected.

Is it caused by my kneecap being out of place?

Not in a simple way. Kneecap tracking is one possible factor, but PFPS is multifactorial, and pain does not reliably match how the kneecap looks or sits. That is why treatment focuses on load and capacity rather than trying to force the kneecap into a position.

When should I see a physiotherapist?

It is worth getting assessed if the pain is limiting your activities, keeps returning, or is not improving with sensible load changes, or if you notice any of the warning signs above.

Conclusion

Patellofemoral pain does not have to keep you from the activities you value. Most cases can be treated effectively with the right approach: progressive strengthening, sensible load management, and a bit of patience. Recovery takes time, but each step, building strength, adjusting load and improving how you move, moves you forward.

If front-of-knee pain is holding you back, I am happy to help you work out what is driving it and put together a clear plan.

Dealing with stubborn front-of-knee pain? A proper assessment can pinpoint what is driving it and get you on a clear plan.