Knee Physiotherapy 101: Patello-Femoral Pain


  • How to recognize patello-femoral knee pain (runner’s knee)
  • What’s happening within the knee 
  • How to know your training limits
  • Tips for quick relief
  • Rehabilitation and Physio involvement


With Vancouver marathon season right around the corner, and running groups cruising laps of the Seawall, it’s important to recognize and quickly address knee pain stemming from those increased kilometres.

What does runner’s knee feel like?

The common pain associated with patello-femoral (knee-cap to knee) issues is a diffuse aching around the kneecap. People will often say that they can’t put a finger on where exactly the pain is, or that it may feel like a pressure. Doing things such as going up and down stairs, spin class sprints, walking/hiking up and down hills can all be painful. Even those first few steps after sitting at the desk for a while can be quite unpleasant.

This pain is most often not associated with any particular mechanism of injury (no crack/pop/tear), but can often start after a notable increase in activity (not just running!) – whether it be a new plyometrics class, a long hike, epic powder ski day, or a big increase in running distance.  The main factors are too great a level of VOLUME–i.e. distance run, or INTENSITY–i.e. went at too high a speed, or up too many hills.

How does runner’s knee happen?Knee pain

Every time one bends his or her knee, the kneecap slides on top of it in a groove that takes it side to side slightly. There’s cartilage underneath that helps it move smoothly. However, if there is a large increase in activity level (as mentioned above), combined with one of several elements that can alter this movement, then the kneecap can run off track just enough to cause irritation in the area beneath the knee cap, and diffuse pain. If this overload occurs, and the body is not given enough time to recover, the problem will worsen.

The factors that are thought the play a roll in onset of patello-femoral pain include, but are not limited to:

  • quadriceps or hamstring tension, dysfunctional activation
  • IT Band tension, dysfunction
  • hip stabilizer (glute) weakness
  • foot collapse, over-pronation
  • shoe cushioning

What can be done to help runner’s knee?

If one has patello-femoral pain, it will generally be recommended that there be a period of unloading. This may include something along the lines of one week off/decreased activity, avoiding running sprints, stairs, hikes etc. Gradually progress to re-introduce appropriate ratios of activity to tolerance. But remember, the word is progressiveExercises should never increase your pain more than a 2/10, and that pain should not last more than 24 hours.  If it does, it’s too much.

Of course, every knee is different, but here are some quick tips for relief:

  • Roll the quads, front and side, pushing into discomfort for 2 minutes at least at the end of every run
  • Patellar mobilization: make sure your knee is relaxed and straight, grab the kneecap and wiggle it gently side to side for 2 minutes
  • Try a new pair of shoes. If your shoes are old with worn down cushion, new shoes can greatly decrease the load on your knees
  • For a short time, avoid positions that increase compression of the knee cap on the knee–i.e. sitting in a low chair, kneeling down, etc.

Utilizing a Physiotherapist in your recovery:

A Physiotherapist can individualize your rehabilitation to help:

  • guide you through proper volume and intensity progression to ensure you’re preventing additional injury
  • identify areas of weakness and give the appropriate exercises that correlate to the proper stage of progression
  • perform dry needling/acupuncture to reset dysfunctional muscle activation (this can also offer quick relief!)
  • perform soft tissue massage/release to release tension regions
  • re-train movement patterns to ensure proper form in activities to minimize stress on a joint
  • determine when, how, and how fast to return to the activity you want to do


Dixit, S., Difiori, J.P., Burton, M. & Mines, B. 2007. Management of Patellofemoral Pain Syndrome. American Family Physician. 75(2): 194-202.


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