Patellofemoral Pain Syndrome (Runner's Knee): Causes, Symptoms, and How We Can Help
- staystrongtherapy
- Jun 30
- 4 min read
All information in this blog is supported by peer-reviewed research. There is currently no dedicated NICE guideline for this condition, so current evidence is used throughout. Reference numbers appear throughout, with the full list at the bottom of the page.
What Is Patellofemoral Pain Syndrome?
Patellofemoral pain syndrome (PFPS), commonly known as runner's knee, is knee pain resulting from problems between the kneecap (patella) and the thigh bone (femur), where the two surfaces meet and track during knee movement. ¹ It's genuinely the most common cause of knee pain overall, affecting more than 20% of young adults, and occurring around 2.5 times more often in women than men. ¹
The causes are often multifactorial, involving biomechanical factors, muscle weakness affecting dynamic stability of the lower limb and altering how the kneecap tracks through its groove, alongside muscular tightness in the iliotibial band, calf muscles, hamstrings, and quadriceps. ²
Common Signs and Symptoms
Pain in and around the kneecap during activity
Pain after sitting for a long time with the knees bent, sometimes called the "movie theatre sign," occasionally causing weakness or a feeling of instability ³
Rubbing, grinding, or clicking sensations when bending and straightening the knee ³
Pain worsened by squatting, stairs, and running
Risk Factors
Female sex, women are affected considerably more often than men ¹
Running and repetitive knee flexion, particularly relevant given how the condition develops ²
Weak quadriceps and hip muscles, women specifically have been found to demonstrate weaker hip muscles in this condition ⁴
Previous knee trauma
Increased or sudden changes in training load
Muscular tightness, particularly of the iliotibial band, calf, hamstring, and quadriceps muscles ²
Why Recovery Matters Long Term
This condition genuinely deserves proper attention, since recurrent or chronic symptoms affect 70 to 90% of people following an initial episode, and prolonged cases can progress toward patellofemoral arthritis over time. ⁵ This is exactly why addressing the underlying contributing factors matters more than simply waiting for an acute flare to settle.
What to Look Out For
Please seek medical assessment if you experience:
A visible deformity or significant swelling following trauma
True locking of the knee, rather than simple clicking
Inability to bear weight
Fever or warmth around the knee
How We Can Help
Physical therapy is the primary, evidence-based treatment for patellofemoral pain syndrome. ⁶
Osteopathic manual techniques and manual therapy: addressing restriction and tension around the knee, hip, and surrounding structures, supporting overall movement quality.
Deep tissue and sports massage: targeted soft tissue work for the iliotibial band, quadriceps, calf, and hamstrings, the muscle groups most consistently linked to PFPS tightness. ²
Medical acupuncture and cupping: used alongside exercise-based treatment to support pain management.
Exercise: The Cornerstone of Recovery
Hip strengthening, alongside knee strengthening, outperforms knee strengthening alone. A systematic review and meta-analysis comparing combined hip and knee strengthening against knee strengthening on its own found the combined approach more effective for reducing pain and improving activity in people with patellofemoral pain. ⁷ Further research comparing the two approaches has consistently supported the addition of hip-focused exercise. ⁸
The evidence shows:
Quadriceps strengthening: a core, foundational component of treatment, directly addressing the muscle weakness commonly underlying patellar tracking issues.
Hip abductor and external rotator strengthening: research has shown this improves both pain and function, given the established link between hip muscle weakness and PFPS, particularly in women. ⁹
Combined hip and knee strengthening programmes: shown to be more effective than knee-focused exercise alone across multiple trials. ⁷ ⁸
Stretching tight surrounding structures: addressing tightness in the iliotibial band, calf, hamstrings, and quadriceps as part of a broader programme. ²
Strengthening exercise specifically, compared to other conservative treatments: a 2025 systematic review with meta-analysis confirmed strengthening exercise as an effective approach for reducing pain and improving function in patellofemoral pain. ¹⁰
Your practitioner will guide a structured, progressive programme combining hip and knee-focused strengthening, tailored to your specific presentation.
What to Expect at Your First Appointment
We will take a thorough history and carry out a hands-on assessment of your knee, hip, and surrounding muscle strength and flexibility, since the evidence is clear that effective treatment looks well beyond the knee itself. We will explain clearly what we find and build a progressive, evidence-based exercise programme combining hip and knee strengthening.
Frequently Asked Questions
Do I need a scan? Not usually. Diagnosis is generally based on history and physical examination.
Why are you focusing on my hip when my pain is in my knee? Because the research is genuinely clear on this, combined hip and knee strengthening produces better outcomes than knee strengthening alone, reflecting how hip muscle weakness contributes to altered kneecap tracking.
How long will it take to improve? This varies, but structured strengthening programmes typically show meaningful improvement within 4 to 12 weeks of consistent treatment.
Will this come back? Recurrence is genuinely common if the underlying strength and flexibility deficits aren't addressed, which is why a complete, hip-inclusive rehabilitation programme matters for lasting results.
Recognise these symptoms? Get in touch using the contact form and we will assess and build the right treatment plan for you.
References
Patellofemoral pain syndrome. Wikipedia. Available at: https://en.wikipedia.org/wiki/Patellofemoral_pain_syndrome
Efficacy of Adding Patellar Mobilization to Hip and Knee Exercises in Patients With Patellofemoral Pain Syndrome. ClinicalTrials.gov. Available at: https://clinicaltrials.gov/study/NCT05665452
Patellofemoral Pain Syndrome (Runner's Knee). Johns Hopkins Medicine. Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/patellofemoral-pain-syndrome-runners-knee
Prins MR, van der Wurff P. Females With Patellofemoral Pain Syndrome Have Weak Hip Muscles: A Systematic Review. Australian Journal of Physiotherapy. 2009;55(1):9-15.
Acute effects of negative heel shoes on perceived pain and knee biomechanical characteristics of runners with patellofemoral pain. Journal of Foot and Ankle Research. 2024. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11296720/
The Efficacy of Hip and Knee Muscles Strengthening Versus Knee Muscle Strengthening Alone in Managing Patellofemoral Pain Syndrome: A Systematic Review and Meta-Analysis. Musculoskeletal Care. 2025;23:e70059. Available at: https://onlinelibrary.wiley.com/doi/10.1002/msc.70059
Hip and Knee Strengthening Is More Effective Than Knee Strengthening Alone for Reducing Pain and Improving Activity in Individuals With Patellofemoral Pain: A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2018. Available at: https://www.jospt.org/doi/10.2519/jospt.2018.7365
Hip Strengthening Versus Quadriceps Based Training for Patellofemoral Pain Syndrome. ClinicalTrials.gov. Available at: https://clinicaltrials.gov/study/NCT02114294
Raju A, Jayaraman K, Nuhmani S, Sebastian S, Khan M, Alghadir AH. Effects of Hip Abductor With External Rotator Strengthening Versus Proprioceptive Training on Pain and Functions in Patients With Patellofemoral Pain Syndrome: A Randomized Controlled Trial. Medicine. 2024;103(7):e37102.
Conservative treatment of patellofemoral pain: effectiveness of strength exercises compared to other treatments. A systematic review with meta-analysis. BMC Sports Science, Medicine and Rehabilitation. 2025;17:303. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12533450/
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