Patellofemoral Pain Syndrome: Causes, Symptoms & Physiotherapy Treatment

Medically reviewed by Dr Ajay Shakya | Published June, 2026

Patellofemoral Pain syndrome is pain between the patella and the femoral joint. The exact cause varies between individuals, and management is typically conservative, beginning with the PRICE protocol. With the help of physiotherapy, you could significantly improve your daily activities. 

What is Patellofemoral Pain Syndrome? 

Patellofemoral pain syndrome is a condition in which pain occurs between the patella and the femoral joint or around the patella bone (kneecap). The exact cause of this condition is not always clearly identified, and management is typically conservative, such as the PRICE protocol. With the help of physiotherapy, patients can significantly improve their daily activities. 

Experts sometimes relate this condition to runner's knee because of pain around the knee that begins or worsens after activity starts. 

The patella is a small bone placed over the knee joint. It helps the knee move through a full range of motion and provides attachment points for muscles, tendons, and ligaments. 

Usually, the patella sits over the femoral groove and moves freely along that space while you walk or run. The patellofemoral pain affects this normal movement, making it painful and limited.

Causes of Patellofemoral Pain Syndrome

Causes: 

The causes of the patellofemoral pain syndrome are not fully known, but experts relate pain to recent activities and the following factors:

Muscular imbalance in the knee, especially in the hamstrings and quadriceps. Vigorous physical activities that put stress directly on the knees, such as squatting, jogging, and climbing stairs. A sudden change in activity level, such as increasing the duration or distance of a run. Changes in sports training techniques or equipment. Sometimes, switching footwear or playing surface -- for example, from a natural surface to an artificial field -- can trigger symptoms. 

One of the most common causes of patellofemoral pain syndrome is abnormal patellar tracking in the femoral groove. In this condition, the patella shifts to one side of the groove while the knee is bent. This abnormal movement increases pressure between the back of the patella and the groove, thereby irritating the surrounding soft tissues. 

Other risk factors include: Athletes who run, squat, or jump frequently; people who do heavy physical work; teenagers; adults aged 20 to 40 years; and females.

Symptoms of Patellofemoral Pain Syndrome

Symptoms:

In the patellofemoral pain syndrome, pain typically increases when you do these:

• Squat or climb stairs up and down.
• Bend your knees to pick up something from the ground.
• Stand up from sitting when you bend your knee for a long time.
• Change your training or daily activities surface.
• Increase your training level.
• Replace your footwear with new ones.

On clinical assessment, the patellar glides are typically limited and painful. Trigger points may be present around the patella and patellar tendon. The patient may present with pain on one side or both sides. 

Complications of Patellofemoral Pain Syndrome:

The condition worsens over time if it's left untreated or misdiagnosed. An untreated condition may increase the risk of injury. The persistent pain gets your body to adopt a poor walking pattern, which increases the load on your other joints, such as your hips and ankles, and may lead to secondary problems in those areas over time.

One of the recognised long-term consequences of untreated patellofemoral pain syndrome is chondromalacia patellae. In this condition, cartilage on the back surface of the patella gradually softens and breaks down due to sustained abnormal pressure and poor patellar tracking. Once cartilage damage reaches an advanced stage, recovery becomes significantly more difficult and may require medical intervention beyond physiotherapy.

Early diagnosis and consistent physiotherapy management are therefore essential to prevent the condition from progressing to this stage.

Physical Assessment and Diagnosis 

Physical assessment:

Your physiotherapist will ask for a detailed history of your knee pain:

• Site of pain: Left or right knee (Medial or lateral side)
• Onset of Pain (when your pain starts)
• Type of pain (Dull ache or pin & needle)
• Nature of your pain (Continuous or intermittent) 

Palpation: Tenderness or trigger point around your patella or patellar tendon.

On observation: The physiotherapist observes  any deformity 

Movements: Active and passive range of motion of the knee joint.

Joint play: An accessory movement of the knee and patellofemoral joint, such as anterior and posterior gliding movement of the knee and all four directions of patellar gliding movements. 

Special Orthopaedic Tests: 

1. Patellar Grind Test (Clarke's Test):

• Position: Patient in supine, knee extended.
• Technique: The physiotherapist places the web space of the hand just proximal to the superior pole of the patella, applying gentle downward and distal pressure. 
• Positive sign: Pain or inability to complete the contraction due to retropatellar pain. 

2. Patellar Apprehension Test (Fairbank's Test)

• Position: Patient in supine, knee at 30-degree flexion
• Technique: The physiotherapist applies a gentle glide pressure to the patella while slowly flexing the knee.
• Positive sign: Patient apprehension, guarding, or attempt to stop the movement-- suggests patellar instability or lateral reticular tightness.  

3. Medial Glide Assessment (McConnell's Test)

• Position: Patient sitting or supine
• Technique: The physiotherapist assesses patellar position (tilt, glide, rotation, anteroposterior tilt) and then applies medial patellar glide taping. The patient performs a painful activity before and after taping.
• Positive sign: Pain reduction of more than 50 % after medial glide taping confirms patellofemoral pain syndrome with a lateral tilt component.  This is both for diagnosis and therapy. 

4. Patellar Tilt Test:

• Position: Patient in supine, knee in full extension.
• Technique: The physiotherapist attempts to lift the lateral border of the patella (passive lateral tilt test). Normally, the lateral border should rise to neutral or beyond.
• Positive sign: Inability to raise the lateral border to neutral indicates a tight lateral retinaculum--a common contributor to patellofemoral pain syndrome.

5. Waldron Test:

• Position: Patient in standing
• Technique: The physiotherapist performs slow, full-range squats while palpating the patella and listening/feeling for crepitus. 
• Positive sign: Pain and/or crepitus during the squat--correlates with patellofemoral joint irritation.

6. Imaging:

The patient might need a knee X-ray or an MRI to get a clear picture of the patient's knee joint and the tissue around it.

Management and Treatment 

Physiotherapy Treatment for Patellofemoral Pain Syndrome

The physiotherapist plans a treatment protocol on the basis of physical assessment and special test results. The physiotherapist's treatment plans are as follows:

• PRICE: Stands for Protection, Rest, Ice, Compression, and Elevation. It's a first-line conservative management protocol used in the early stage of musculoskeletal injuries.
• Lateral retinacular stretching or release: A tight lateral retinaculum pulls the patella out of its normal tracking path. Stretching or soft tissue release of this structure helps restore normal patellar alignment.
• Strengthen and stretch the quadriceps muscle: Weak quadriceps, particularly the VMO (vastus medialis oblique), are a primary contributor to poor patellar tracking. Targeted strengthening restores control and reduces joint stress. 
• Improve patella gliding: Manual therapy techniques and patellar mobilisation improve the accessory movement of the patella, reducing stiffness and pain.
• Activity modification: Temporarily reducing or replacing aggravating activities allows the irritated tissue to settle while maintaining overall fitness.
• Use IFT or TENS modalities for pain relief: Interferential therapy and transcutaneous electrical nerve stimulation are effective electrotherapy modalities for short-term pain management during the early stages of rehabilitation.

Clinical Pearl:

McConnell taping serves both a diagnostic and a therapeutic purpose. If a patient reports more than 50% pain reduction after medial glide taping, it confirms a lateral tilt component to their patellofemoral pain and guides the treatment plan toward retinacular stretching and taping-based rehabilitation. 

Prognosis and Prevention 

Prognosis:

Most patients need a month or two to improve from patellofemoral pain syndrome. Younger, active patients who follow their physiotherapy programme consistently tend to recover faster than older or sedentary individuals, where recovery may take longer due to reduced muscle strength and slower tissue adaptation. The physiotherapist will give you a realistic timeline based on severity, strength and activity level.

Prevention:

• Choose the right protective training equipment
• Make sure shoes are supportive and fit according to your activity.
• If you have pain in your knee, don't play or train
• Always warm up before and cool down after the activity.
• Train your lower body muscles to help and support your knee and other joints. 

Continue reading

• IT Band Stretches: 7 Exercises to Relieve Knee & Hip Pain
• Back of Knee Pain: Causes, Symptoms & Physiotherapy Treatment
• Tailbone Pain Exercises for Fast, Lasting Relief
• Hamstring Exercises: Complete Guide for Strength & Recovery

FAQS:

What is patellofemoral pain syndrome?

Patellofemoral pain syndrome is a condition in which pain occurs around or behind the kneecap where it meets the femur. The exact cause varies between individuals, but muscular imbalance, abnormal patellar tracking, and overuse are common contributing factors. With physiotherapy and conservative management, most patients recover well.

How long does PFPS take to heal?

Most patients begin to notice significant improvement within four to eight weeks of starting physiotherapy. However, recovery time depends on the severity of the condition, your strength level, and how consistently you follow your physiotherapy programme. Your physiotherapist will give you a realistic timeline based on your individual assessment.

Can I walk with patellofemoral pain syndrome?

Yes, in most cases, walking on a flat surface is well tolerated and even encouraged. However, prolonged walking, climbing stairs, or walking on uneven terrain may aggravate your symptoms. Your physiotherapist will advise you on activity modification, so you stay active without increasing pain or delaying recovery.

What exercises should I avoid with PFPS?

You should avoid deep squats, lunges, leg press with a heavy load, stair climbing under load, and high-impact activities such as running or jumping until your symptoms settle. These activities place direct compressive force on the patellofemoral joint and can worsen irritation. Always consult your physiotherapist before starting or stopping any exercise.

Is PFPS permanent?

Patellofemoral pain syndrome is not permanent in most cases. With proper physiotherapy, activity modification, and strengthening of the surrounding muscles, the majority of patients achieve full recovery. In a small number of cases where the condition is left untreated for a long time, symptoms may become chronic, which makes early intervention important.

References

1. Witvrouw, E., Werner, S., Mikkelsen, C., Van Tiggelen, D., Berghe, L. V., & Cerulli, G. (2005). Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surgery, Sports Traumatology, Arthroscopy, 13(2), 122–130.

2. McConnell, J. (1986). The management of chondromalacia patellae: a long-term solution. Australian Journal of Physiotherapy, 32(4), 215–223.

3. Lankhorst, N. E., Bierma-Zeinstra, S. M., & van Middelkoop, M. (2013). Factors associated with patellofemoral pain syndrome: a systematic review. British Journal of Sports Medicine, 47(4), 193–206.

4. Petersen, W., Ellermann, A., Gösele-Koppenburg, A., Best, R., Rembitzki, I. V., Brüggemann, G. P., & Liebau, C. (2014). Patellofemoral pain syndrome. Knee Surgery, Sports Traumatology, Arthroscopy, 22(10), 2264–2274.

5. Dutton, M. (2020). Dutton's Orthopaedic Examination, Evaluation, and Intervention (5th ed.). McGraw-Hill Education.

Medical disclaimer:

The information provided in this article is for educational purposes only and is not a substitute for professional medical advice. Consult a qualified physiotherapist or physician before beginning any treatment. 

AS

Dr. Ajay Shakya BPT, MPT (Neurological Conditions) · 10+ years experience Certified physiotherapist and manual therapist with over 10 years of clinical experience. Specialises in neurological rehabilitation, back pain, neck pain, and sports injuries. Runs Physio Health and Wellness clinic in Jaipur, Rajasthan. BPT Graduate   MPT Neurological   Certified Manual Therapist