Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome

Article by J. MillerS.Armfield

What is Patellofemoral Pain Syndrome?

Patellofemoral pain syndrome is one of the most common knee complaints of both the young active sportsperson and the elderly.

Patellofemoral pain syndrome is the medical term for pain felt behind your kneecap, where your patella (kneecap) articulates with your thigh bone (femur). This joint is known as your patellofemoral joint

Patellofemoral pain syndrome is mainly due to excessive patellofemoral joint pressure. The extreme pressure’s most likely cause is poor kneecap alignment, which in time, affects the joint surface behind the kneecap (retropatellar joint).

What Causes Patellofemoral Pain Syndrome?

Your patella glides typically up and down through the femoral groove as your knee is bent—retropatella kneecap pressure increases.

This retropatella pressure further increases if the patella does not regularly ride through the groove, but “mistracks”, meaning it travels more to one side, making it rub against the femur.

patellofemoral pain syndrome

Repeated trauma causes an increase in your retro patellar joint forces, which can lead to kneecap pain, joint irritation and eventually degeneration of your patella joint surface.

The most common causes of patellar malalignment are abnormal muscle imbalance and poor biomechanical control.

Aching kneecaps (patellofemoral pain) affect 25% of the population at some time in their lives, but it is more common in athletes. The sports where patellofemoral pain syndrome typically presents are those when running, jumping and landing or the squatting position is required.

Sports include running, tennis, netball, football, volleyball, basketball, skiing and other jumping sports.

Untreated patellofemoral pain syndrome can also predispose you to patellar tendonitis.

What Causes a Muscle Imbalance?

Your quadriceps (thigh) muscles attach to the patella and the patella tendon, which connects to the top of your shin.

If there is a muscle imbalance between the inner and lateral quadriceps muscles, your patella will track laterally in the groove. Vastus lateralis (VL), which pulls your patella up and outwards, and the vastus medialis oblique (VMO), which is the only quadriceps muscle that pulls your kneecap up and slightly in.

Common reasons for a weak vastus medialis oblique (VMO) include knee injury, post-surgery, swelling or disuse.

The longstanding tightness of your lateral knee structures (lateral retinaculum, VL, and ITB) will encourage your kneecap to drift sideways over time, especially if your VMO is also weak.

Your hip muscles have been shown in the research to be very important in the control of your thigh. Poor buttock muscle control allows your knee to roll in and apply a relative lateral displacement of the patella. Most successful rehabilitation programs require assessment and correction of your hip and buttock muscle control.

patellofemoral syndrome

Patellofemoral pain syndrome is more common during adolescence because the long bones are growing faster than the muscles, tendons and ligaments, putting abnormal stresses on the joints. Active children who do not stretch the appropriate muscles are predisposed to patellar malalignment.

What Biomechanical Issues Cause Patellofemoral Pain Syndrome?

Poor foot posture (e.g. flat feet) and weak hip control muscles can both allow your knee to abnormally twist and result in a lateral deviation of your patella.

When imperfect biomechanics repeat, with walking or running, that unfortunate habit repeatedly traumatises your patellofemoral pain.

What are the Symptoms of Patellofemoral Pain Syndrome?

The onset of your kneecap pain is ordinarily gradual rather than traumatic.

Patellofemoral pain symptoms typically present during weight-bearing or jarring activities that involve knee bending.

Stairs, squatting, kneeling, hopping, running or using stairs are commonly painful. As your patellofemoral pain syndrome progresses, your knee will become painful while walking and then ultimately even at rest.

You can also experience kneecap pain when you are in sustained knee bend, e.g. sitting in a chair. A nickname for this condition is “theatre knee”.

For specific advice regarding your anterior knee pain, please seek the professional opinion of your knee physiotherapist or doctor.

Patellofemoral Pain Syndrome Treatment

Researchers have confirmed that physiotherapy intervention is a very effective short and long-term solution for kneecap pain.

Over 90% of patellofemoral syndrome sufferers will usually respond favourably to exercise-based treatment. Becoming pain-free within six weeks of starting a physiotherapist guided rehabilitation program is commonplace.

For those who fail to respond, surgery may repair associated injuries such as severely damaged or arthritic joint surfaces.

Treatment aims to reduce your pain and inflammation in the short-term and then, more importantly, correct the cause to prevent it from returning in the long-term.

There is no specific time frame for when to progress from each stage to the next. Many factors will determine your injury rehabilitation during your physiotherapist’s clinical assessment.

You’ll find that in most cases, your physiotherapist will seamlessly progress between the rehabilitation phases as your clinical assessment and function improves. It is also important to note that you monitor each exercise progression. Attempting to progress too soon to the next level can lead to re-injury and the frustration of a delay in your recovery.

Phase 1 – Injury Protection: Pain Relief & Anti-inflammatory Tips

As with most soft tissue injuries, the initial treatment is – Rest, Ice and Protection.

(Active) Rest: In the early phase, your best to avoid all activities that induce your kneecap pain.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Pain-Relief & Protection. Your physiotherapist will usually apply kinesiology supportive taping, or similar, to provide instant pain relief. This assists with the initial patellofemoral joint realignment phase. The patellofemoral taping is normally immediately effective in providing you with pain relief.

Your physiotherapist will utilise a range of helpful tricks including pain-relieving techniques, joint mobilisations, massage, strapping and acupuncture to assist you during this painful phase.

Anti-inflammatory medication and natural creams such as arnica may help reduce your pain and swelling. Most people can tolerate paracetamol as a pain reliever.

Phase 2: Regain Full Range of Passive Motion

Your kneecap and knee must be able to glide through its full normal range of motion. Your physiotherapist will assess your movement and apply the necessary techniques to normalise your range of motion.

Phase 3: Restore Full Muscle Length

Your thigh, hamstring and calf muscles will require stretching is they are tight and are causing excessive tension or pressure on your kneecap. It is essential to regain reasonable muscle length to improve your lower limb biomechanics.

Phase 4: Normalise Quadriceps Muscle Balance

Your physiotherapist should assess your quadriceps muscle balance and its control. In most instances, you will require a specific knee strengthening program.

Your physiotherapist will prescribe the best exercises for you.

Phase 5: Normalise Foot & Hip Biomechanics

Patellofemoral pain syndrome can occur from poor foot biomechanics (e.g. flat foot) or poor hip control.

Your physiotherapist should assess your foot and hip control. In some instances, you may require a foot orthotic (shoe insert), or you may be a candidate for the Active Foot Posture Stabilisation program.

Other patients may require a hip stabilisation program. Your physiotherapist will happily discuss what you need.

Phase 6: Normalise Movement Patterns

Kneecap pain commonly occurs from poor habits, whether they be an abnormal gait, jumping, landing, running or squatting technique. To prevent a recurrence, please assess your walking pattern, jumping and landing technique, running style or squatting method, and correct as required.

Your physiotherapist will happily discuss what you specifically require.

Phase 7: Restore High Speed, Power, Proprioception and Agility

Most kneecap pain sufferers need to return to high speed or repetition activities, which place enormous forces on your knee. Your physiotherapist will guide you on your return to sports planning.

Balance and proprioception are both known to be adversely affected by patellofemoral pain. Both aspects need assessment and potential retraining.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepare you for light sport-specific training.

Phase 8: Return to Sport

If you play sport and depending on the demands of your chosen sport, you may require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

Your physiotherapist will discuss your goals, time frames and training schedules with you to optimise you for a complete and safe return to sport. The perfect outcome will have you performing at full speed, power, agility and function with the added knowledge that a thorough rehabilitation program has minimised your chance of future injury.

Patellofemoral Brace

An effective patellofemoral brace can be useful as an alternative to kneecap taping.

Common Causes - Knee Pain

Knee pain can have many origins from local injury, referred pain, biomechanical issues and systemic issues. While knee pain can appear simple to the untrained eye, a thorough assessment is often required to ascertain the origin of your symptoms. The good news is that once a definitive diagnosis is determined, most knee pain quickly resolves with the correct treatment and rehabilitation.

Knee Ligament Injuries

ACL Injuries

Knee Meniscus Injuries

Kneecap Pain

Knee Arthritis

Knee Tendon Injuries

Muscle Injuries

Knee Bursitis

Children’s Knee Conditions

Other Knee-Related Conditions

Knee Surgery

For specific information regarding your knee pain, please seek the assistance of a healthcare professional with a particular interest in knee conditions, such as your knee physiotherapist.

Knee Pain Products & FAQs

Acute Injury Signs

Acute Injury Management.

Here are some warning signs that you have an injury. While some injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop.

For detailed information on specific injuries, check out the injury by body part section.

Don't Ignore these Injury Warning Signs

Joint Pain

Joint pain, particularly in the knee, ankle, elbow, and wrist joints, should never be ignored. Because these joints are not covered by muscle, pain here is rarely of muscular origin. Joint pain that lasts more than 48 hours requires a professional diagnosis.


If you can elicit pain at a specific point in a bone, muscle, or joint, you may have a significant injury by pressing your finger into it. If the same spot on the other side of the body does not produce the same pain, you should probably see your health professional.  


Nearly all sports or musculoskeletal injuries cause swelling. Swelling is usually quite obvious and can be seen, but occasionally you may feel as though something is swollen or "full" even though it looks normal. Swelling usually goes along with pain, redness and heat.

Reduced Range of Motion

If the swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion. Compare one side of the body with the other to identify major differences. If there are any, you probably have an injury that needs attention.


Compare sides for weakness by performing the same task. One way to tell is to lift the same weight with the right and left sides and look at the result. Or try to place body weight on one leg and then the other. A difference in your ability to support your weight is another suggestion of an injury that requires attention.

Immediate Injury Treatment: Step-by-Step Guidelines

  • Stop the activity immediately.
  • Wrap the injured part in a compression bandage.
  • Apply ice to the injured part (use a bag of crushed ice or a bag of frozen vegetables).
  • Elevate the injured part to reduce swelling.
  • Consult your health practitioner for a proper diagnosis of any serious injury.
  • Rehabilitate your injury under professional guidance.
  • Seek a second opinion if you are not improving.

Article by John Miller

Elite Sports Injury Management

You probably already know that a sports injury can affect not only your performance but also your lifestyle. The latest research continues to change sports injury management considerably.  Our challenge is to keep up to date with the latest research and put them to work for you.

How we treated you last year could vary significantly from how we treat you this year. The good news is that you can benefit considerably from our professional knowledge.

What Should You Do When You Suffer a Sports Injury?


Rest from painful exercise or a movement is essential in the early injury stage. "No pain. No gain." does not apply in most cases.  The rule of thumb is - don't do anything that reproduces your pain for the initial two or three days.  After that, you need to get it moving, or other problems will develop.

Ice or Heat?

We usually recommend avoiding heat (and heat rubs) in the first 48 hours of injury. The heat encourages bleeding, which could be detrimental if used too early. In traumatic injuries, such as ligament sprains, muscle tears or bruising, ice should help reduce your pain and swelling.

Once the "heat" has come out of your injury, you can use heat packs. We recommend 20-minute applications a few times a day to increase the blood flow and hasten your healing rate. The heat will also help your muscles relax and ease your pain. If you're not sure what to do, please call us to discuss your situation specifically.

Should You Use a Compressive Bandage?

Yes. A compressive bandage will help to control swelling and bleeding in the first few days.  In most cases, the compressive dressing will also help support the injury as you lay down the new scar tissue. This early healing should help to reduce your pain. Some injuries will benefit from more rigid support, such as a brace or strapping tape. Would you please ask us if you are uncertain about what to do next?


Gravity will encourage swelling to settle at the lowest point.  Elevation of an injury in the first few days is beneficial, especially for ankle or hand injuries.  Think where your damage is and where your heart is. Try to rest your injury above your heart.

What Medication Should You Use?

Your Doctor or Pharmacist may recommend pain killers or an anti-inflammatory drug. It is best to seek professional advice as certain medications can interfere with other health conditions, especially asthmatics.

When Should You Commence Physio?

sports injury

In most cases, "the early bird gets the worm".  Researchers have found that the intervention of physiotherapy treatment within a few days has many benefits.  These include:

  • Relieving your pain quicker via joint mobility techniques, massage and electrotherapy
  • Improving your scar tissue using techniques to guide the direction it forms
  • Getting you back to sport or work quicker through faster healing rates
  • Loosening or strengthening of your injured region with individually prescribed exercises
  • Improving your performance when you return to sport - we'll detect and help you correct any biomechanical faults that may affect your technique or predispose you to injury.

What If You Do Nothing?

Research tells us that injuries left untreated take longer to heal and have lingering pain.  They are also more likely to recur and leave you with either joint stiffness or muscle weakness. It's important to remember that symptoms lasting longer than three months become habitual and are much harder to solve.  The sooner you get on top of your symptoms, the better your outcome.

What About Arthritis?

Previously injured joints can prematurely become arthritic through neglect. Generally, there are four main reasons why you develop arthritis:

  • An inappropriately treated previous injury (e.g. old joint or ligament sprains)
  • Poor joint positioning (biomechanical faults)
  • Stiff joints (lack of movement diminishes joint nutrition)
  • Loose joints (excessive sloppiness causes joint damage through poor control)

What About Your Return to Sport?

Your physiotherapist will guide you safely back to the level of sport at which you wish to participate.  If you need guidance, ask us.

What If You Need Surgery or X-rays?

Not only will your physio diagnose your sports injury and give you the "peace of mind" associated, but they'll also refer you elsewhere if that's what's best for you. Think about it. You could be suffering needlessly from a sports injury.  Would you please use our advice to guide you out of pain quicker? And for a lot longer.

If you have any questions regarding your sports injury (or any other condition), don't hesitate to get in touch with your physiotherapist to discuss. You'll find our friendly staff happy to point you in the right direction.