Kneecap Pain (Patellofemoral)

Overview

what it is and why it matters

Patellofemoral pain, also called runner's knee, is a vague, achy pain in the front of your knee that comes from where the back of your kneecap rides against the groove on the end of your femur. It is one of the most common knee complaints in active teens and young adults. When the kneecap does not glide cleanly through its groove, usually because of muscle imbalances, weak hip muscles, or the shape of the bones themselves, the cartilage on the back of the kneecap takes too much pressure and starts to hurt.

The pain typically gets worse going up and down stairs, after sitting still for a long time (the classic movie-theater sign), squatting, or running. It is not really a single problem with a single cause; more a pattern of pain with several drivers stacked on top of each other.

Symptoms

what you may notice

A vague ache in the front of your knee or behind the kneecap that gets worse going up and down stairs, squatting, kneeling, or sitting for a long time with your knee bent (the classic movie-theater sign). Running, especially downhill, tends to flare it.

You may hear a grinding or crunching sensation (crepitus) when you bend and straighten your knee. The knee can feel stiff after prolonged sitting, and the pain often starts gradually without a single injury to point to.

Diagnosis

exam first, imaging second

Pain around or behind the kneecap, often reproduced when pressing the kneecap into its groove or when you do a single-leg squat. Your provider also looks at how strong your hip muscles are and whether your feet roll inward when you walk; both can throw off how the kneecap tracks. An MRI is reserved for when we are worried about cartilage damage on the back of the kneecap (chondromalacia patella) or another structural problem.

How We Treat It

what we try first, in order

Kneecap pain is almost always a tracking problem, not a structural one, so the care builds in layers rather than jumping to anything invasive. The first three steps below are the foundation. Each one is added on top of the last, not instead of it, and most people get better without ever needing the rest.

Hip and quadriceps strengthening

The single most effective treatment is strengthening the hip muscles that control how your knee tracks (the side hip muscles and rotators) plus the inner thigh muscle near the knee (the VMO). Fixing those imbalances usually fixes the kneecap's tracking and the pain that comes with it.

Activity modification

Cut back on hill running, stair climbing, and deep squats during the painful stretch. The activities that load the kneecap the most are the same ones that flare it.

Foot orthotics

If your feet roll inward when you walk or run, an arch-supporting insole can keep your knee from collapsing inward at each step, which takes pressure off the kneecap.

Patellar taping / bracing
A specific taping pattern (McConnell taping) or a brace with a built-in pad can pull the kneecap into better alignment, take the edge off the pain, and help you feel where the kneecap should sit while you do your rehab.
NSAIDs
An over-the-counter anti-inflammatory like ibuprofen can help calm a flare while you build strength.

Surgical Options

if non-operative care isn't enough

Surgery is rarely needed for kneecap pain. We only consider it when imaging shows real cartilage damage or a structural reason the kneecap cannot track straight (like a shallow groove), and only after a thorough non-operative program has not worked. The goal of surgery is to change the anatomy so the kneecap rides where it is supposed to.

Tibial tubercle osteotomy

Repositioning the patellar tendon attachment to correct tracking.

Learn about this procedure →

Providers Who Treat Patellofemoral Pain

sports-medicine team

Michael S. Vrana, M.D.

David B. Templin, M.D.

Trent Twitero, M.D.

Frequently Asked

questions we hear in clinic

Why does the front of my knee hurt?

In patellofemoral pain, the kneecap does not glide cleanly through its groove on the end of the femur, usually because of muscle imbalances, weak hip muscles, or the shape of the bones themselves. The cartilage on the back of the kneecap then takes too much pressure and starts to hurt. It is more a pattern of pain with several drivers stacked on top of each other than a single problem with a single cause.

What is the “movie-theater sign”?

It is the ache you feel in the front of the knee after sitting still for a long time with the knee bent, like through a movie. It is one of the classic patterns of kneecap pain, along with pain going up and down stairs, squatting, and kneeling.

What is the single most effective treatment?

Strengthening the hip muscles that control how the knee tracks (the side hip muscles and rotators) plus the inner thigh muscle near the knee (the VMO). Fixing those imbalances usually fixes the kneecap’s tracking and the pain that comes with it.

Can I keep running?

Running, especially downhill, tends to flare kneecap pain, so cutting back on hill running, stair climbing, and deep squats during the painful stretch is part of the plan. Those are the same activities that load the kneecap the most. As the hip and thigh strength builds, tolerance for running usually returns.

Do I need an MRI?

Usually not. Kneecap pain is diagnosed from the exam first. An MRI is reserved for when we are worried about cartilage damage on the back of the kneecap (chondromalacia patella) or another structural problem.

Will I need surgery?

Surgery is rarely needed for kneecap pain. We only consider it when imaging shows real cartilage damage or a structural reason the kneecap cannot track straight, and only after a thorough non-operative program has not worked. The goal of surgery is to change the anatomy so the kneecap rides where it is supposed to.