Patellofemoral pain syndrome is diffuse pain around or behind the kneecap that worsens with activities like running, squatting, climbing stairs, or sitting for long periods with the knee bent. It’s one of the most common reasons people visit a musculoskeletal clinic, accounting for roughly 25% of all knee complaints seen in sports medicine settings. The good news: it responds well to targeted rehabilitation when the underlying drivers are identified and addressed.
What causes pain around the kneecap?
The patellofemoral joint is where the kneecap (patella) sits in a groove on the front of the thighbone (femur). During bending and straightening, the patella tracks up and down this groove, distributing load across the joint surface. Problems arise when that tracking is disrupted, when the load exceeds the tissue’s capacity, or when both happen simultaneously.
A persistent myth is that the pain comes from cartilage damage or “bone rubbing on bone.” For most people with patellofemoral pain, imaging shows no structural damage at all. A landmark consensus statement from the 4th International Patellofemoral Pain Research Retreat confirmed that patellofemoral pain is best understood as a load management problem rather than a purely structural one (Collins et al., 2018, Br J Sports Med). The pain often reflects irritation of the richly innervated tissues around the joint, including the fat pad, retinaculum, and synovial lining.
Who gets runner’s knee?
Despite the name, patellofemoral pain isn’t exclusive to runners. Cyclists, hikers, office workers who sit for hours, and gym-goers who increase squat volume too quickly all develop it. On the Costa del Sol, Costa Health sees this condition frequently in people who’ve recently taken up hiking in the hills around Mijas or increased their padel frequency without adequate preparation.
Women are affected roughly twice as often as men, partly due to wider pelvic anatomy that changes the angle of pull on the kneecap, and partly due to differences in neuromuscular activation patterns during landing and single-leg tasks. Adolescents going through growth spurts are another high-risk group, as rapid bone growth can temporarily outpace muscular development.
What really drives patellofemoral pain?
Hip weakness is one of the strongest and most consistent findings. Weakness in the hip abductors and external rotators, particularly the gluteus medius, allows the thigh to drop inward during weight-bearing activities. This increases the lateral force on the patella and overloads the outer aspect of the joint.
Quadriceps dysfunction is the other major player. Delayed or reduced activation of the vastus medialis oblique (VMO) relative to the vastus lateralis creates an imbalance in the forces controlling patellar tracking. Tight lateral structures, including the iliotibial band and lateral retinaculum, can compound the problem.
Training load errors are the trigger in many cases. A runner who jumps from 20 km per week to 40 km, or a weekend warrior who plays three padel matches in two days after a sedentary week, is asking more of the patellofemoral joint than the tissues can tolerate. The pain is a capacity problem, not a damage problem, and that distinction changes the treatment approach entirely.
How is patellofemoral pain treated?
Exercise-based rehabilitation is the gold standard. A systematic review by van der Heijden et al. (2015, British Journal of Sports Medicine) found strong evidence that exercise therapy, particularly combined hip and knee strengthening, reduces pain and improves function in patellofemoral pain syndrome.
At Costa Health, Daniele Delicati builds individualised programmes that typically progress through three phases. Initial work targets hip strengthening and quadriceps retraining in non-provocative positions. Intermediate phases introduce loaded squats, step-ups, and single-leg exercises as symptoms allow. Late-stage rehab adds sport-specific drills, plyometrics for runners, or lateral movement patterns for padel and tennis players.
Physiotherapy and chiropractic assessment often reveals contributing factors away from the knee. Restricted ankle dorsiflexion forces the knee to compensate during squatting and lunging. Lumbar or pelvic stiffness can alter hip muscle recruitment. Treating these upstream and downstream joints is part of a thorough approach.
Sports massage can help manage quadriceps and iliotibial band tightness, reduce muscle guarding, and improve tissue compliance during the strengthening phases. Patellar taping or bracing may provide short-term symptom relief during exercise, though the evidence suggests these are best used as adjuncts rather than standalone treatments.
What about rest? Does it help?
Complete rest is actually one of the worst things for patellofemoral pain. Stopping all activity leads to muscle deconditioning, reduced tissue capacity, and often worsening symptoms when activity resumes. The key is relative load management: reducing aggravating activities to a tolerable level while progressively building strength and capacity.
Running through significant pain isn’t helpful either. The practical approach is to find a training volume and intensity that keeps symptoms below a 3 out of 10 during and after activity, and build from there.
When should someone seek help?
Knee pain that persists beyond two weeks of self-managed load reduction, or that consistently worsens with stairs and squatting, is worth getting assessed. Locking, catching, or significant swelling suggests a different or additional diagnosis that needs ruling out.
Costa Health’s team in Marbella and Riviera del Sol provides thorough biomechanical assessments and evidence-based rehabilitation for patellofemoral pain. Book a consultation to identify what’s driving your knee pain and start a structured recovery plan.