Patello-Femoral Pain

Patello-femoral pain (PFP) comprises of pain under, around or below the knee cap.

What You May Be Feeling

It is a common source of anterior knee pain in both males and females of all activity levels. Pain can present in daily activities such as walking, running, prolonged sitting, squatting and walking up and down stairs.

What’s Really Going On Inside

PFP is considered to be caused by excessive friction on the back of the knee cap and can result from several causes.

Excessive training load or sharp increases in physical activity beyond that of which, the loading capacity of the knee can cope.

Poor movement patterns at the hip, knee and/or ankle, which may promote what is thought to be movement of the knee cap toward the outside of the knee. This impedes correct tracking of the knee cap within the groove of which it sits on the end of the thigh bone.

A number of factors can contribute to this poor tracking of the knee cap including the natural structure of the knee and/or biomechanics of the lower limb such as weakness of the muscles around your hip and front of the thigh. These thigh muscles control the straightening movement of the knee and are known as the quadriceps.

  • Poor muscle control and weakness around the hip muscles can cause the pelvis on the opposite side to drop and increase tension on the outside of leg
  • These deficits can also cause the hip to rotate the thigh inward.
  • Weak thigh muscles (quadriceps) provide inadequate support for the knee especially when loaded through propulsion and landing-type activities.
  • Foot can excessively roll inward, promoting the knee to roll inward also, and increase pressure on the knee cap.

How a physio can help

If you think have PFP, you should seek help and advice as soon as possible from a qualified health care professional to guide your treatment and optimise your chances of a successful recovery. As there are many causes of this condition, there are also many treatment options available.

Avoid sitting with your knee bent for prolonged periods of time as this can agitate your knee. Try to sit with knees relaxed or extended. Avoid kneeling or squatting positions and minimise sitting with your legs crossed. When going down hills or stairs, try to do it slowly to minimise impact.

Decrease high impact activities such as those involving running, jumping and stair climbing.

With weight training, it is generally best to avoid full squats and lunges with the knee is loaded in a highly flexed or bent position. Leg extension machines can also be irritable and leg press is generally tolerated if the knees are not bent more than 90 degrees. Knee sleeves can be worn during weight training to support the knee cap in keeping it tracking more centrally. Once the quadriceps muscles are strong enough however, you should not need to keep using them.

Icing the knee especially after aggravating activity can help reduce the pain and prevent symptoms from worsening.


Most successful recoveries are those, which involve active participation.

Appropriate activity modification is a good initial strategy towards a successful recovery.

Ongoing research is further recognising tissue-overload to be a significant contributing factor to PFP. This can come from returning to exercise too much too fast after a period of rest or drastically increasing the amount of exercise you are already doing. If there is a particular activity that is aggravating your knee pain, you should look to reduce the amount that you are doing. In some instances, if your pain is particularly irritable, you may need to cease, modify or switch your physical activity completely.

Your therapist may direct you to rest or switch exercise options before commencing exercise again.

Exercise in sitting or lying are good ways to start off improving muscle function without provoking pain.

These exercises should progress into more functional positions, which are reflective of your everyday activity such as standing. Supervision by your therapist should be provided when introducing new exercises into your rehab to ensure your technique is correct. This can be helped with use of mirrors, pictures or video recordings. Exercises should be performed with correct technique and be performed regularly as prescribed by your therapist.

Weakness and poor function of the hip and thigh muscles are common. You are likely to need exercises to improve these areas. Starting you on a progressive rehab program focusing on strengthening your quadriceps and hip muscles can help distribute load more evenly through your knee and reduce pressure and pain at the knee cap. Other areas which may need to be addressed include exercise for the foot and stretches for your quadriceps, calves and hamstrings. Exercises should be progressed to activities that were problematic previously such as squatting, running and stair use, while ensuring good movement patterns are reproduced and maintained.


Taping or strapping around the knee can be an effective method for temporary pain relief with facilitating corrective patella alignment.

Foot Orthotics

Foot orthotics may be helpful in improving lower limb movement and limiting knee cap stress for people with too much foot roll (pronation) or otherwise known as “flat feet”. Your physiotherapist can help determine if this is a reasonable option for you.


You may be advised to alter your current footwear, such as avoid wearing high heels, shoes with a soft sole to reduce impact, or shoes which provide more support particularly around the “arch” of your foot.

How else can a physio help

Approximately 2.5 million runners are affected each year and 74% of sufferers result in decreasing the level of physical activity for at least 5 years. Between 70-90% of people with experience more than 1 episode of pain.

Your physiotherapist will evaluate your movement patterns during functional activities such as running, squatting and moving up and down stairs. They will help identify areas of weakness and inflexibility through assessing Strength of the thigh and hip muscles. The foot and ankle will be examined for any restricted or excessive movement, in addition to any abnormal wear of your shoes, which may be contributing to your knee pain.

Your physiotherapist will help decide which options will work best for you. They can help guide which exercises will be most beneficial to your recovery. They can answer questions related to your knee pain and help understand why you have developed knee pain and what factors have most likely caused it to occur. Your physio can help you manage your current training load, assess and modify your technique and provide alternative exercise options to maintain your strength and conditioning where appropriate.

Finally, your physio can provide various forms of manual therapy to help improve pain and facilitate other aspects of your rehab.

Adapted from:

  1. Barton, C.J. and Rathleff, M.S., 2015. Managing My Patellofemoral Pain. InForsknings-Og Udviklingssymposium I Nordjylland.
  2. J Orthop Sports Phys Ther 2012;42(6):573.

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