What Is Patellofemoral Pain?

Patellofemoral pain refers to discomfort around the front of the knee, often involving the relationship between the kneecap, known as the patella, and the thigh bone, known as the femur. The patella sits in a groove at the front of the femur and should glide smoothly as the knee bends and straightens.

This condition is commonly associated with front knee pain, runner’s knee, pain behind the kneecap, knee pain when squatting, knee pain going down stairs, or kneecap tracking pain. It is commonly experienced by runners, athletes, gym-goers, active individuals, and people whose daily activities involve repeated stairs, squatting, kneeling, cycling, or prolonged sitting.

Patellofemoral pain usually develops gradually rather than from one single injury. The knee may feel irritated during repetitive loading, especially when the kneecap is not tracking efficiently or when the surrounding muscles and joints are not controlling force well.

The alignment of the tibia in relation to the femur plays a key role in how forces are handled by the knee joint. When the shin bone and thigh bone do not coordinate well during movement, the kneecap may experience uneven pressure as it glides along the femur. This can increase stress through the patellofemoral joint during running, squatting, jumping, stairs, or lunges.

The knee also sits between the hip and foot, so it is strongly influenced by what happens above and below it. Poor hip control may cause the femur to rotate inward. Poor foot mechanics may cause the tibia to rotate or collapse differently during impact. When these mechanics are altered, the kneecap may not track as efficiently, increasing irritation around the front of the knee.

Individuals May Experience

• Pain around or behind the kneecap

• Front knee pain during stairs

• Discomfort when climbing or descending stairs

• Pain during squatting, lunging, or kneeling

• Knee discomfort after sitting for long periods

• A sensation of stiffness around the knee joint

• Pain during running, especially hills or longer distances

• Pain during jumping, landing, or sport

• Discomfort during cycling or repetitive knee bending

• Clicking, grinding, or pressure around the kneecap

• Tightness in the quadriceps, IT band region, or hip flexors

• A feeling that the kneecap is not tracking smoothly

• Knee pain that worsens with increased training volume

• Reduced confidence with running, squats, or lower-body workouts

Patellofemoral pain should be assessed by a licensed healthcare provider if symptoms are persistent, worsening, associated with swelling, locking, instability, trauma, or difficulty bearing weight.

What Contributes to Patellofemoral Pain?

Several factors may influence stress on the patellofemoral joint, including:

• Weakness in the hip or thigh muscles

• Poor glute control

• Quadriceps weakness or imbalance

• Limited mobility in the hip or ankle

• Repetitive running or jumping activity

• Changes in training intensity

• Increased running mileage or hill training

• Altered knee tracking during movement

• Poor tibia-femur alignment during squats, stairs, or running

• Femoral internal rotation during movement

• Tibial rotation from foot or ankle mechanics

• Flat feet, overpronation, or poor arch control

• Reduced single-leg stability

• Tightness in the quadriceps, hip flexors, calves, or lateral thigh

• Poor landing, cutting, or squatting mechanics

• Inadequate recovery between workouts or sports

These factors may influence how the kneecap moves during bending and straightening of the knee.

The tibia and femur must coordinate properly for the kneecap to track efficiently. If the femur rotates inward due to poor hip control, or if the tibia rotates because of foot and ankle mechanics, the kneecap may be pulled or compressed in a way that increases stress on the front of the knee. This is one reason patellofemoral pain is often not only a “knee problem.” It is frequently a lower-limb mechanics problem.

Foot mechanics also matter. When the foot collapses excessively or does not absorb impact well, the tibia may rotate in a way that changes knee alignment. Hip mechanics also matter because the hip controls the position of the femur. If the glutes and hip stabilizers are not controlling the thigh well, the knee may drift inward during squats, stairs, running, or landing.

Over time, these movement patterns can increase irritation around the patellofemoral joint.

How Manual Therapy May Help

Manual therapy and rehabilitation may help identify why the front of the knee is being overloaded. The goal is not only to reduce pain around the kneecap, but to improve how the hip, knee, ankle, foot, pelvis, and surrounding tissues work together.

Care may focus on improving joint mobility, reducing soft tissue tension, restoring strength, improving knee alignment, and retraining movement patterns that contribute to patellofemoral stress.

Osteopathic Manual Therapy

Osteopathic Manual Therapy may evaluate how the knee functions in relation to the hip, pelvis, ankle, foot, and spine. Since patellofemoral pain is often influenced by how forces travel through the lower limb, osteopathic care may assess the entire kinetic chain rather than only the painful area.

Treatment may include:

• Assessing knee joint mobility

• Addressing hip and pelvic mechanics

• Improving ankle and foot mobility

• Reducing fascial tension around the thigh and knee

• Supporting balanced movement through the lower limb

• Assessing tibia and femur positioning during movement

• Improving hip mobility to reduce strain through the knee

• Addressing sacroiliac or pelvic mechanics that may affect leg loading

• Reducing compensatory tension in the quadriceps, hamstrings, calves, and lateral thigh

• Supporting better load transfer through the hip, knee, ankle, and foot

Osteopathic treatment focuses on how surrounding joints influence movement of the knee. If the hip, pelvis, ankle, or foot is not moving efficiently, the knee may absorb stress in a less balanced way. Improving these mechanics may help reduce unnecessary strain on the patellofemoral joint.

Physiotherapy

Physiotherapy often plays an important role in managing patellofemoral pain because strength, movement control, and load management are key factors in knee function. Rehab usually focuses on improving how the knee tracks during real activities such as walking, stairs, squats, running, jumping, and sport.

Treatment may involve:

• Strengthening hip and thigh muscles

• Glute strengthening to improve femur control

• Quadriceps strengthening to support kneecap tracking

• Hamstring and calf strengthening when needed

• Movement retraining during squatting, stairs, running, and lunges

• Improving knee alignment during activity

• Single-leg stability and balance exercises

• Gait or running mechanics retraining

• Gradual return to sport or exercise

• Education on activity modification

• Load management for running, gym training, or sport

• Training progression to reduce recurring flare-ups

These rehabilitation strategies aim to improve knee mechanics and reduce stress on the joint. For runners, this may include adjusting mileage, hills, cadence, stride mechanics, and strength work. For gym-goers, this may include modifying squats, lunges, leg press, step-ups, or jumping exercises until the knee can tolerate more load.

The goal is to help the knee become strong, stable, and better aligned during movement.

Massage Therapy

Massage therapy may support care by addressing muscular tension around the knee, hip, and lower limb. When patellofemoral pain is present, muscles around the quadriceps, hip flexors, glutes, IT band region, calves, and hamstrings may become tight or overactive.

Treatment may include:

• Reducing tightness in the quadriceps muscles

• Addressing tension in the IT band region and surrounding tissues

• Supporting circulation in the thigh muscles

• Reducing compensatory tension patterns

• Addressing tightness in the hip flexors, glutes, and calves

• Helping reduce muscular guarding around the knee

• Improving comfort during mobility and strengthening work

• Supporting recovery between training or rehab sessions

Massage therapy may help relieve muscular tension that contributes to discomfort around the knee. It is often most effective when combined with strengthening, movement retraining, and load management.

Book an Assessment

If knee pain is interfering with running, squatting, stairs, kneeling, workouts, or sport, our team can assess your movement patterns and guide a personalized rehabilitation plan.

A comprehensive assessment can help identify whether your patellofemoral pain may be influenced by knee tracking, tibia-femur alignment, hip mechanics, foot mechanics, ankle mobility, strength deficits, muscle tension, running form, or training load.