Patellofemoral pain syndrome is aching pain behind or around the kneecap, and it is one of the most common knee complaints seen in physiotherapy. It hurts most going down stairs, squatting, running downhill and after long periods sitting with the knee bent. The strongest treatment by a clear margin is exercise that trains the hip and the knee together, which the 2018 international consensus recommends in preference to knee exercises alone. Load management, gait retraining, foot orthoses and short-term taping all have supporting roles, and the ranking below reflects how well each is evidenced and how widely it applies.
The stair-descent pattern that defines this problem is covered in more detail in PhysioHub’s guide to knee pain going down stairs.
Ranked by the strength of the evidence behind each one and how many people with patellofemoral pain it applies to.
| Treatment | Best for | Evidence |
|---|---|---|
| 1. Combined hip and knee strengthening | Almost everyone with PFPS | Strongest, recommended over knee work alone |
| 2. Load management | Anyone whose pain followed a training increase | Strong in principle, hard to trial |
| 3. Gait retraining | Runners | Good biomechanical evidence |
| 4. Foot orthoses | Short-term relief, especially with pronation | Supported for short-term pain |
| 5. Taping and manual therapy | Getting started when pain blocks exercise | Adjuncts only, weak alone |
The ranking is deliberate. Numbers four and five are worth using, and they are worth using alongside number one rather than instead of it, because the consensus statement is explicit that mobilisation on its own is not recommended.
This is a documentary review of published evidence and clinical guidance rather than advice about your knee. Five treatments were chosen because between them they cover what a physiotherapist would actually work through, from the core of the programme to the short-term measures that help someone get started.
The sources read were the 2018 consensus statement on exercise therapy and physical interventions for patellofemoral pain, produced by a panel of 41 experts at the 5th International Patellofemoral Pain Research Retreat and published in the British Journal of Sports Medicine; and Lenhart and colleagues in Medicine & Science in Sports & Exercise, who modelled patellofemoral joint forces in 30 runners across three step rates. Evidence checked in August 2026.
The main limitation is that patellofemoral pain is a clinical label covering several different presentations, so trial populations vary and average results hide people who respond very differently. Ranking treatments in general is a fair way to describe the evidence and a poor way to prescribe for one knee, which is why the section below is written as questions to ask rather than a programme to copy.
No prices are quoted, because retail and clinic costs could not be verified for this review.
Ask what provokes it. Pain going down stairs, squatting and after prolonged sitting is the classic pattern. Pain that is worse going up stairs and on explosive push-off points more towards the patellar or quadriceps tendon.
Ask whether the load changed. Most patellofemoral pain follows a change in training volume, terrain, footwear or job. If something changed in the six weeks before it started, that is the first thing to address.
Watch a single-leg squat in a mirror. If the knee drifts inwards over the big toe while the pelvis drops, the hip is a major part of the picture and hip strengthening becomes the priority rather than an add-on.
Separate irritability from severity. A knee that hurts during a session and settles within an hour tolerates more loading than one that flares for two days afterwards. The morning-after response is the more useful measure.
Rule out what does not belong here. True locking, a knee that gives way, a tense swelling inside the joint or a history of the kneecap dislocating all point away from straightforward patellofemoral pain and towards something that needs assessing, and our guide to knee pain covers how those are told apart.
What it involves
Strengthening the hip abductors and external rotators alongside the quadriceps, in the same programme. Typical hip work is side-lying abduction, banded clamshells, lateral band walks and single-leg bridging. Typical knee work is wall sits or Spanish squats held at around 45 degrees, straight leg raises, and step-downs progressed by height as tolerance improves.
What the evidence supports
The 2018 international consensus statement recommends combining hip and knee exercises to reduce pain and improve function in the short, medium and long term, and states that this combination should be used in preference to knee exercises alone. That is an unusually direct recommendation for a musculoskeletal condition, and it is the single most useful thing to know about this problem.
Why the hip matters for a knee problem
The hip controls the position of the thigh bone underneath the kneecap. When the hip abductors and external rotators are weak or slow to fire, the femur rotates inwards during weight-bearing and the kneecap ends up tracking against a surface that has moved beneath it. Training the hip changes where the femur sits, which changes the contact stress at the joint.
Who it suits
Nearly everyone with patellofemoral pain, including people with no obvious weakness on testing. It is the core of the programme rather than one option among several.
Limits and cautions
It takes time. Meaningful strength change needs six to twelve weeks of consistent work, and the first two or three weeks often feel like nothing is happening. Isometric holds are the part that tends to give earlier symptom relief, which is worth knowing when motivation is the limiting factor.
Why it ranks first
It has the clearest recommendation, it applies to the widest group, and it is the only entry on this list that changes the underlying capacity of the limb rather than the load going through it.
What it involves
Reducing the specific activities that spike patellofemoral load while keeping everything else going. In practice that usually means cutting hill running and stair volume first, reducing deep squatting and lunging, and dropping running distance temporarily rather than stopping altogether.
Why it works
Patellofemoral joint reaction force rises steeply with knee flexion angle under load, which is why descending stairs and deep squats provoke symptoms while flat walking often does not. Removing the highest-load activities lowers the total daily stress on the joint without unloading the limb entirely.
Who it suits
Anyone whose pain began after a change in training or activity, which is the majority. It is also the fastest-acting item on this list, since it changes symptoms within days rather than weeks.
The common overcorrection
Relative rest is what works here. Unloading a painful knee completely lets the quadriceps and gluteal muscles weaken, so the knee tolerates even less when activity resumes. Keep walking, keep strengthening, and remove only the specific activities that provoke symptoms.
Limits and cautions
This is hard to test in a trial, because you cannot blind someone to how much they are running. The evidence for it is mechanical reasoning and clinical experience rather than randomised comparison, and this page states that plainly.
Why it ranks second
It gives the quickest relief and it creates the window in which strengthening can actually be done. It ranks below strengthening because on its own it returns the knee to the same capacity it had when the pain started.
What it involves
Increasing running cadence by around 5 to 10 per cent above your natural step rate, which shortens the stride and reduces how far the knee bends during stance. A metronome app or a music track at the target tempo is the usual method, run for short intervals at first and built up over several weeks.
What the evidence supports
Lenhart and colleagues modelled patellofemoral joint forces in 30 runners at 90, 100 and 110 per cent of their preferred step rate. Running at 110 per cent of preferred step rate reduced peak patellofemoral joint force by 14 per cent, and the reduction in peak knee flexion during stance was the strongest predictor of that drop.
Who it suits
Runners, and particularly runners who overstride with a long, low cadence. It has no application to someone whose knee hurts at a desk job and who does not run.
How to apply it
Count your current cadence over a minute at an easy pace, add roughly 5 per cent, and run to that for a few minutes at a time. The stride shortens by itself; deliberately trying to change foot strike is a different intervention with different consequences.
Limits and cautions
The study measured modelled joint forces in healthy runners rather than pain outcomes in people with patellofemoral pain, so it establishes the mechanism rather than proving the treatment. Increasing cadence also increases the number of loading cycles, which shifts stress towards the calf and Achilles, so it is a change to introduce gradually.
Why it ranks third
The biomechanical evidence is good and the effect size is meaningful, and it applies to one group of people rather than to everyone with this diagnosis.
What it involves
Prefabricated arch-supporting insoles, worn in everyday shoes and in running shoes. Custom devices are available and the evidence base rests largely on off-the-shelf versions.
What the evidence supports
The 2018 consensus statement includes foot orthoses among the interventions supported for improving pain in people with patellofemoral pain, alongside exercise therapy and combined interventions. The support is for short-term benefit rather than for a lasting change.
Who it suits
People with a markedly pronating foot posture, and people who need something to reduce symptoms quickly while the strengthening programme gets going. Response is variable and usually apparent within a couple of weeks.
How to try it sensibly
Start with an inexpensive prefabricated insole and give it two weeks. If it makes a clear difference, keep it. If it makes none, a more expensive version of the same idea is unlikely to change the answer.
Limits and cautions
An insole changes the load going into the limb rather than the limb’s capacity to take load, so it works best as part of a programme. Some people find a new insole provokes calf or foot symptoms for the first week while they adapt.
Why it ranks fourth
It is genuinely supported and it helps a defined subgroup, and the benefit is short-term rather than curative.
What it involves
Rigid patellar taping applied to glide or tilt the kneecap, and hands-on soft tissue work around the quadriceps, iliotibial band and lateral structures.
What the evidence supports
Combined interventions, meaning exercise therapy with taping or manual therapy added, are supported by the consensus statement. The same statement is explicit that patellofemoral, knee or lumbar mobilisations used in isolation are not recommended, and neither are electrophysical agents.
Who it suits
Someone whose pain is high enough that they cannot get into the exercises at all. Tape that takes symptoms from six out of ten to three out of ten for a session buys the loading window that actually changes things.
How to use it well
As a temporary measure with a purpose attached. Tape for the session in which you do your strengthening, and expect to stop using it as capacity improves rather than to depend on it.
Limits and cautions
Taping effects are short-lived and vary a great deal between people. Manual therapy alone has the weakest position of anything on this list, and treating it as the treatment rather than the accompaniment is the most common way patellofemoral rehab stalls.
Why it ranks fifth
It is useful, it is well established in practice, and the evidence supports it only in combination with the exercise programme it is meant to enable.
| Treatment | Evidence | Who it applies to | Time to effect | Works on its own |
|---|---|---|---|---|
| Hip and knee strengthening | Strongest | Almost everyone | 6 to 12 weeks | Yes |
| Load management | Reasoning, little trial data | Most people | Days to 2 weeks | Partly |
| Gait retraining | Good mechanistic evidence | Runners only | 2 to 6 weeks | No |
| Foot orthoses | Supported, short-term | Pronating foot posture | 1 to 2 weeks | No |
| Taping | Supported in combination | High-irritability knees | Immediate, temporary | No |
| Manual therapy alone | Not recommended in isolation | Adjunct only | Immediate, temporary | No |
The last column is the one worth reading twice. Only the first entry changes what the knee can tolerate; the rest either reduce what is being asked of it or make the first entry possible.
What each option asks of you in practice, which is usually the thing that decides whether it gets done.
| Treatment | Time commitment | Effort | Cost |
|---|---|---|---|
| Hip and knee strengthening | 20 to 30 minutes, 3 to 4 days a week | High, and it is the effort that works | No cost at home; physiotherapy fees not quoted here |
| Load management | No added time | Moderate, mostly self-discipline | No cost |
| Gait retraining | Within existing runs | Moderate for several weeks | No cost |
| Foot orthoses | None once fitted | Low | Retail prices not verified for this review |
| Taping | 5 minutes per application | Low | Tape cost not verified for this review |
| Manual therapy | Appointment time | Low, passive | Clinic fees not quoted here |
The pattern is consistent across musculoskeletal rehabilitation. The interventions that ask least of you tend to do least, and the one that asks most is the one with the strongest recommendation behind it.
If your knee hurts going down stairs and after sitting, and there is no locking or giving way, this is the classic presentation. Start with hip and knee strengthening together and reduce stair and hill volume for a few weeks.
If you are a runner whose pain came on after a mileage increase, cut the volume and the hills first, add the strengthening, and look at cadence once the knee has settled enough to run comfortably.
If your knee grinds and crunches, that on its own is reassuring rather than alarming. Crepitus corresponds poorly with the state of the cartilage, and it is not a reason to avoid loading.
If pain is too high to do any exercise at all, taping and isometric holds are the way in. Four sets of 30 to 45 seconds in a wall sit often reduces symptoms enough to start.
If your knee locks, gives way or swells inside the joint, this is outside the patellofemoral picture and needs assessing rather than rehabilitating.
If your kneecap has dislocated or partly slipped out before, that is a separate problem with a different management pathway, and it warrants a proper assessment before starting a general programme.
Saturday morning at Uckfield parkrun, on the trail course at Hempstead Playing Fields, produces a steady trickle of this exact complaint. The course is not flat, the surface varies, and people who have been walking through the winter often return to it in one go. The knee that starts aching on the drive home, then complains coming down the stairs that evening, is a pattern the clinic sees most weeks between January and March.
What testing usually separates is where the problem sits. Someone points at the front of the kneecap, and a single-leg squat shows the knee drifting inwards while the pelvis drops on the opposite side, which puts the hip firmly in the picture. Someone else has point tenderness on the tendon below the kneecap and a completely different provocation pattern, and the treatment for that is heavier and slower. The two are managed differently, and the location of the pain and what brings it on tell them apart more reliably than any scan would.
At PhysioHub in Uckfield, the programme that follows is usually gym-based, because hip and quadriceps strengthening needs enough load to matter and progressing it week by week is easier with equipment than on a bedroom floor. Where the sticking point is knowing how much load to add and when, our 1:1 rehab and strength training is built around exactly that.
What is patellofemoral pain syndrome?
It is pain behind or around the kneecap, caused by how load is distributed across the joint between the kneecap and the thigh bone. It is commonly called runner’s knee, though it affects plenty of people who do not run.
Why does my knee hurt more going down stairs than up?
Descending stairs requires the quadriceps to control your body weight against gravity while the knee is bent, which produces much higher force across the patellofemoral joint than the push-off of going up. The same reasoning explains why downhill running provokes it and uphill running often does not.
Do hip exercises really help knee pain?
Yes, and the 2018 international consensus statement recommends combining hip and knee exercises in preference to knee exercises alone. The hip controls the position of the thigh bone underneath the kneecap, so strengthening it changes the contact stress at the knee.
Does knee grinding or clicking mean I have arthritis?
Usually not. Crepitus corresponds poorly with the actual state of the cartilage, and it is common in knees with no structural damage at all. Grinding that comes with true locking, giving way or joint swelling is a different matter and needs assessing.
How long does patellofemoral pain take to settle?
Symptoms often improve within two to six weeks once loading is managed sensibly, and the strength change that keeps it away takes six to twelve weeks of consistent work. Recurrence is common in people who stop the exercises as soon as the pain goes.
Should I stop running with patellofemoral pain?
Rarely entirely. Reducing volume, cutting hills and avoiding downhill running usually settles symptoms while keeping you running, and complete rest tends to leave the knee weaker than it started. Pain that persists into the following morning is the sign the volume is still too high.
Do I need a scan for patellofemoral pain?
Usually not. It is a clinical diagnosis based on where the pain sits and what provokes it, and imaging findings correspond poorly with symptoms. A scan becomes relevant where there is locking, giving way, significant swelling or a history of the kneecap dislocating.
Are insoles worth trying for kneecap pain?
They are supported for short-term pain relief, particularly for people with a pronating foot posture. A prefabricated insole trialled for two weeks answers the question cheaply, and an insole works best alongside strengthening rather than in place of it.
PhysioHub – Empowerment through Evidence-Based Education.
Every body is different. Book a thorough assessment and get advice that is specific to you and your goals.
Book an Appointment