Patellofemoral joint pain

Common in adolescents / young adults; seen across active & general populations 

Questionably more frequently found in women

(Barton et al 2015, Crossley, K.M. et al. 2016)

Diffuse anterior / peripatellar pain, worse with squatting, stairs, prolonged sitting 

Additional criteria- not essential: 

• Crepitus during knee flexion movements 

• Tenderness on facet palpation 

• Small effusion 

• Pain on sitting, rising from siting or straightening knee following sitting 

Crossley, K.M. et al. (2016)

No definitive clinical test 

Best available test= anterior knee pain on a squatting movement- 80% sensitivity 

Provocative PFJ loading (e.g. squats, step down), movement quality, hip/knee strength, use PROMs 

Other tests (limited evidence): 

Tenderness on palpation of patellar edges 

(note patellar grinding and Clarke’s test have low sensitivity and limited diagnostic accuracy) Crossley, K.M. et al. (2016)

• Patellar compression (Gilchrist, 2004) (Video link)
  
  
  Can also be known as Clarke’s sign and patellofemoral grind test. The patient is positioned in long-sitting with their knee fully extended and quadriceps relaxed. The clinician places the web space of their hand on the superior aspect of the patella. A caudad movement is applied. The patient is asked to contract their quadriceps. A positive result is reproduction of symptoms

Structural:

Hip/knee muscle weakness, abnormal biomechanics (valgus, foot pronation), training load changes, psychosocial factors 

Proximal mechanics such as excessive hip adduction and/ or internal rotation may be relevant (reported consistently in women with PFP) 

Trunk mechanics including contralateral pelvic drop may be relevant ,  

Hip muscle weakness (especially gluts) relevant in PFP and possible PF OA 

Barton et al 2015, Crossley et al 2016, 

Patellar tendinopathy 

PFJ Subluxations & Dislocations 

PFJ OA 

Osgood Schlatters Disease 

Sinding Larsen Johansson Syndrome (SLJS) 

(NICE Guidelines 2022)

Trauma/Fracture 

Infection 

Auto-Immune Condition 

Tumour 

DVT 

Spontaneous Osteonecrosis of the Knee 

Slipped Capital Femoral Epiphysis 

(NICE Guidelines 2022)

Exercise

Combined hip and knee strengthening 

• Strong evidence supports programmes targeting both the quadriceps and proximal hip musculature (particularly hip abductors and external rotators). 

• Combined programmes demonstrate greater reductions in pain and improved function compared with knee-focused exercise alone. 

Exercise type 

• Both closed-chain and open-chain exercises are effective and commonly used in combination. 

• Closed-chain exercises (e.g. squats, step-downs, lunges) may provide greater functional carryover and are often prioritised during rehabilitation progression. 

• Open-chain exercises (e.g. knee extension, straight-leg raise, hip abduction) may be useful in early stages when weight-bearing is limited. 

Evidence-based programmes commonly strengthen: 

• Quadriceps 

• Hip abductors 

• Hip external rotators 

• Hip extensors 

Contraction type 

• Both concentric and eccentric strengthening are beneficial. 

• Eccentric control during functional tasks (e.g. step-downs or squats) is frequently incorporated to improve load tolerance and movement control. 

Exercise selection 

• Current evidence indicates no single “best” exercise. Outcomes are improved when exercises are delivered within a structured, progressive programme targeting hip and knee strength and functional movement patterns. 

Neal BS et al. (2024), Barton et al., 2015;  Crossley et al., 2016;  Willy et al., 2019 de Oliveira Silva D et al. (2020) 

Other Interventions

Taping, orthoses, gait retraining, manual therapy as adjuncts

Barton et al., 2015;  

Willy et al., 2019 

Factors that might predict better outcome 

Adherence, shorter symptom duration, lower baseline pain/disability → better outcomes 

(Lack et al., 2014)

Factors that might predict poor outcome 

Longer duration of symptoms (>12 months) 

Greater pain severity 

Lower self-reported function 

Greater height 

Positive patella apprehension test 

Crepitation during physical examination 

(Lankhorst et al., 2016; Lack et al., 2014) 

Imaging to rule out other pathology rather than routinely for PFPS. 

Imaging may be considered when: 

• Symptoms are atypical  

• Persistent pain not improving after ≥3 months of appropriate rehabilitation 

• Older patients where degenerative changes are suspected 

• Pre-surgical planning (rare in PFPS alone) 

Crossley et al., 2016; Lack et al., 2014 

As per normal pathway discuss at case review/senior staff member and/or request second opinion with MSK APP. 

Relevant local links/ resources/Masterclasses etc: 

Patellofemoral pain syndrome | NHS inform 

Patellofemoral Pain Syndrome - Physiopedia (physio-pedia.com) 

Patellofemoral Pain Syndrome Masterclass | Physiotutors Podcast ep.037 | Claire Robertson :https://youtu.be/I10l-ANhHiE?si=eXcK6zMmeKA328Wg 

Understanding Red Flags in Patellofemoral Pain - Physiopedia (physio-pedia.com) 

GGC-MSK Physiotherapy - Documents - Knee - All Documents

Manage my knee cap pain - My knee cap

https://youtu.be/NQOZZgh5z8I?si=Pzv7jiZdMSZJLOfj

References: 

1. Barton, C.J., Lack, S., Hemmings, S., Tufail, S. & Morrissey, D. (2015) ‘The “Best Practice Guide to Conservative Management of Patellofemoral Pain”: incorporating level 1 evidence with expert clinical reasoning’, British Journal of Sports Medicine, 49(14), pp. 923–934. doi:10.1136/bjsports-2014-093637. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning | British Journal of Sports Medicine
2. Crossley, K.M. et al. (2016) ‘2016 Patellofemoral Pain Consensus Statement … Part 2: Physical interventions’, British Journal of Sports Medicine, 50(14), pp. 844–852. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome … | British Journal of Sports Medicine
3. Crossley, K.M. et al. (2016) ‘2016 Patellofemoral Pain Consensus Statement … Part 1: Terminology, definitions, clinical examination …’, British Journal of Sports Medicine, 50(14), pp. 839–843. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions) | British Journal of Sports Medicine 
4. Willy, R.W. et al. (2019) ‘Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health’, Journal of Orthopaedic & Sports Physical Therapy. Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association: Journal of Orthopaedic & Sports Physical Therapy: Vol 49, No 9 
5. Non-traumatic causes | Diagnosis | Knee pain - assessment | CKS | NICE Available at: https://cks.nice.org.uk/topics/knee-pain-assessment/diagnosis/non-traumatic-causes/
6. Lack, S., Barton, C., Vicenzino, B. & Morrissey, D. (2014) ‘Outcome Predictors for Conservative Patellofemoral Pain Management: a systematic review and meta-analysis’, Sports Medicine, 44, pp. 1703–1716. doi:10.1007/s40279-014-0231-5. Outcome predictors for conservative patellofemoral pain management: a systematic review and meta-analysis - PubMed 
7. Neal, B.S., Barton, C.J., Gallie, R., O’Halloran, P. & Morrissey, D. (2024) ‘Best practice for patellofemoral pain should include delivering knee-targeted exercise therapy, with supportive interventions as required’, British Journal of Sports Medicine, 58(24), p.1486. Neal, B.S., et al.  https://bjsm.bmj.com/content/58/24/1486 
8. Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013 - PubMed (nih.gov) 
9. Spontaneous Osteonecrosis of the Knee - StatPearls - NCBI Bookshelf Di Li et al 2024 
10. Patient Education for Patellofemoral Pain: A Systematic Review - PubMed (nih.gov) Danilo de Oliveira Silva,  2020 
11. Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning | British Journal of Sports Medicine 
12. Lankhorst, N.E. et al. (2016)  Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis - PubMed 
13. Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis | British Journal of Sports Medicine (Winters et al 2000)