Patellofemoral Pain: Assessment and Rehab That Actually Works

Patellofemoral pain syndrome (PFPS) accounts for a quarter of knee complaints in active populations and recurs in over half of patients at five years. The good news: high-quality evidence now points clearly to what works - combined hip and knee strengthening with progressive load - and what doesn't.

Defining the problem

PFPS is anterior or retropatellar knee pain aggravated by loading the flexed knee - squatting, stairs, prolonged sitting, running, jumping. Diagnosis is clinical: there is no single special test or imaging finding that confirms or refutes it.

Assessment essentials

Confirm the pattern, rule out alternatives, and identify modifiable contributors.

  • Reproduce pain with a functional test the patient identifies as aggravating (single-leg squat, step-down, decline squat).
  • Screen hip strength: abduction and external rotation, both isometric and through range.
  • Assess movement quality on single-leg squat - dynamic valgus, trunk lean, foot pronation.
  • Rule out patellar tendinopathy (inferior pole, jumping athletes), Hoffa's fat pad irritation, and referred lumbar or hip pathology.

What works: combined hip and knee exercise therapy

Best evidence supports a programme combining hip-targeted strengthening (abductors, external rotators) with quadriceps strengthening, progressed over at least 6 weeks. Hip-led programmes typically produce faster pain reduction in the first 4 weeks; combined programmes produce the most durable outcomes.

  • Hip: side-lying abduction, clamshells progressing to banded squats, single-leg bridges, monster walks.
  • Knee: closed-chain squats and step-ups, open-chain quad work in pain-free range.
  • Loading should be progressive - pain up to 3/10 during exercise is acceptable if it settles within 24 hours.

Load management for runners

For running-related PFPS, temporary reduction in weekly volume of 20–50%, increased step rate (~5–10% above preferred), and a short-term shift away from steep downhill running each have evidence for symptom reduction while strength work takes effect.

What to skip

Patellar taping and bracing give short-term symptom relief but do not change long-term outcomes - useful as an adjunct, not as the plan. Foot orthoses help a subset (excessive pronators with rearfoot eversion) but are not first-line for everyone. Routine arthroscopy, electrotherapy, and dry needling lack supporting evidence for PFPS.

Key takeaways

  • PFPS is a clinical diagnosis - no single test or scan confirms it.
  • Combined hip and knee strengthening is the strongest evidence-based intervention.
  • Allow pain up to 3/10 during loading provided it settles within 24 hours.
  • For runners, manage volume and consider a small step-rate increase.
  • Skip routine arthroscopy, electrotherapy, and passive-only treatment plans.

Frequently asked questions

What is the best exercise for patellofemoral pain?

There is no single best exercise. The strongest evidence supports a combined programme of hip abductor and external rotator strengthening with quadriceps strengthening, progressed over at least 6 weeks. Hip-led work tends to reduce pain faster; combined programmes produce more durable outcomes.

Is it OK to run with patellofemoral pain?

Often yes, with adjustments. Reducing weekly volume by 20–50%, slightly increasing step rate, and avoiding steep downhill running can keep most runners running while strength work takes effect. Pain up to 3/10 during running that settles within 24 hours is acceptable.

Do knee braces help patellofemoral pain?

Bracing and taping can give short-term symptom relief and may help a patient tolerate rehab exercise, but they don't change long-term outcomes. Use them as an adjunct to active rehab, not as the primary intervention.