Patellofemoral Pain (Anterior Knee Pain)

Patient information — Dr Christopher Spelman, Orthopaedic Surgeon

Overview

Patellofemoral pain – pain around or behind the kneecap – is one of the most common knee complaints, especially in active teenagers and young adults, runners, and women. It is felt at the front of the knee and is typically worse with running, squatting, stairs (particularly going down), kneeling, and after prolonged sitting with the knee bent (the “theatre sign”). It is a pain condition, not an instability condition: the kneecap does not slip out of place (that is patellofemoral instability, a separate condition).

Why it happens — a multifactorial problem

Patellofemoral pain is rarely due to a single cause; several factors usually combine, and identifying the dominant ones guides treatment. Recognised contributors include:

●      Load – a rapid increase in training or a change of activity that overloads the joint (the most common trigger)

●      Muscle performance – weakness or poor timing of the quadriceps and, importantly, the hip muscles (which control the position of the thigh under the kneecap)

●      Movement patterns – the way the knee, hip and foot move during running, squatting and landing

●      Foot posture and footwear, and, in some people, the shape and tracking of the kneecap in its groove

Diagnosis

The diagnosis is usually made clinically from the history and examination. Imaging is often not required, but may be used to exclude other causes (such as a cartilage lesion, tendinopathy or, in adolescents, other conditions) where the pain is atypical or does not settle as expected.

Treatment

Treatment is non-surgical and centres on exercise, tailored to the individual:

Exercise therapy (the cornerstone)

A progressive programme that strengthens the core, hip and the knee muscles works better than knee exercises alone, and hip-focused work is often emphasised early. This is the single most important and evidence-based treatment. This is done under the guidance of a physiotherapist.

Load management and movement retraining

Adjusting training volume, and, for runners, gait retraining (for example a modest increase in cadence, or changing how the foot lands) can reduce the load through the joint.

Adjuncts

Foot orthoses and patellar taping can help in the short term, particularly when combined with exercise, and are useful for getting on top of pain early. Simple pain relief is occasionally used for flare-ups. Surgery has essentially no role in routine patellofemoral pain.

What the evidence shows

International clinical practice guidelines and Cochrane evidence support exercise therapy as the first-line treatment, with combined hip- and knee-targeted exercise preferred over knee exercise alone; combining exercise with adjuncts such as foot orthoses or taping improves short-term outcomes. Importantly, the evidence also shows that patellofemoral pain can be persistent – a substantial proportion of people still have symptoms years later if it is not managed well – which is why early, consistent rehabilitation and load management matter.

Outlook and things to be aware of

Patellofemoral pain is a benign condition and does not usually cause lasting joint damage. Its main downside is that it can be recurrent or slow to resolve, and it commonly flares with rapid increases in activity. Consistency with the exercise programme and sensible load management are the keys to a good result.

Summary

Anterior knee pain is common and multifactorial, and usually settles with a structured hip-and-knee exercise programme, load management and (where helpful) taping or orthoses – not surgery. Dr Spelman will confirm the diagnosis, exclude other causes, and guide the right rehabilitation approach.