Runner’s knee — properly called patellofemoral pain syndrome (PFPS) — is the most common running injury, accounting for approximately 25% of all running-related presentations to physiotherapy. If you have pain around or behind the kneecap that worsens going downstairs, squatting, or after prolonged sitting with the knee bent, there is a good chance PFPS is the diagnosis.
What Is Patellofemoral Pain Syndrome?
The patella (kneecap) glides in a groove at the front of the femur (thigh bone) called the trochlear groove. PFPS occurs when the patella tracks incorrectly within this groove, creating abnormal pressure and friction on the cartilage behind the patella. This sensitises the surrounding soft tissues and produces the characteristic anterior knee pain of runner’s knee.
Importantly, PFPS is not a structural diagnosis — imaging (X-ray, MRI) is often normal. The condition is driven by biomechanical and load factors rather than structural damage, which means it responds very well to physiotherapy.
Why Does Runner’s Knee Develop?
PFPS develops when the cumulative load through the patellofemoral joint exceeds the tissue’s capacity to adapt. This can occur from:
- Training load errors: Rapidly increasing mileage, adding hill work, or returning to running after a break without adequate progressive build-up
- Hip weakness: Weak hip abductors and external rotators allow the femur to rotate inward (medial femoral collapse), which worsens patella tracking. This is one of the strongest biomechanical predictors of PFPS.
- Foot pronation: Excessive subtalar pronation during running causes tibial internal rotation, which also disrupts patellofemoral mechanics
- Quadriceps dysfunction: Reduced VMO (vastus medialis oblique) activation relative to the lateral quadriceps alters patellar tracking
- Tight lateral structures: A tight ITB and lateral retinaculum can pull the patella laterally, increasing lateral facet pressure
Classic Symptoms of Runner’s Knee
- Dull, aching pain around or behind the kneecap
- Pain that worsens going downstairs (more so than upstairs)
- Pain with squatting, lunging, and prolonged sitting with the knee flexed (“theatre sign”)
- Pain after running, cycling, or exercise — initially improving with warm-up
- Occasional crepitus (crunching or grinding sensation) under the kneecap
How Is Runner’s Knee Treated?
Load Management
The first step is reducing the provocative load to a level the patellofemoral joint can tolerate. This does not mean stopping exercise entirely — it means temporarily reducing running volume, avoiding downhill running, and modifying any activities that significantly aggravate symptoms. Complete rest is counterproductive in PFPS.
Hip Strengthening
This is the cornerstone of PFPS rehabilitation. Strengthening the hip abductors and external rotators — through exercises like clamshells, hip thrusts, lateral band walks, and single-leg deadlifts — reduces medial femoral collapse during running and significantly improves patellar tracking. Multiple systematic reviews confirm that hip-focused programmes produce better outcomes than quad-focused programmes alone.
Quadriceps Strengthening
Quadriceps strengthening — particularly VMO activation through exercises like terminal knee extensions, step-ups, and leg press within pain-free range — is also important. The knee should be progressively loaded through increasing range as symptoms allow.
Running Retraining
Biomechanical modification of running technique is highly effective in PFPS. Increasing step rate (cadence) by 5–10% reduces patellofemoral load substantially. Cueing a forward trunk lean, shorter stride length, and a midfoot strike pattern also reduce anterior knee loading. These changes are surprisingly easy to implement with real-time cue feedback.
Patellar Taping
McConnell patellar taping — which medially repositions the patella using rigid tape — can dramatically reduce pain during exercise sessions. It is used therapeutically during rehabilitation to allow higher-quality exercise at less painful loads, rather than as a permanent solution.
Foot Orthotics
Where excessive pronation is contributing, custom or off-the-shelf foot orthotics can reduce tibial rotation and improve patellofemoral mechanics. We assess whether orthotics are appropriate based on your biomechanics and the degree of pronation contributing to symptoms.
How Long Does Runner’s Knee Take to Heal?
With appropriate physiotherapy, most people with PFPS improve significantly within 6–8 weeks. Return to pain-free running typically takes 8–12 weeks. Chronic or long-standing cases (over 12 months of symptoms) may take longer — 3–6 months of structured rehabilitation.
The biggest predictor of delayed recovery in PFPS is inadequate hip strength and biomechanical correction. Runners who only rest and wait for pain to settle invariably have a recurrence when they return to running — because the underlying biomechanical drivers have not been addressed.
When to See a Physiotherapist
If you have had anterior knee pain for more than 2–3 weeks, or if it is affecting your training, book in for an assessment. PFPS that is treated early responds significantly faster than chronic presentations.
At Burwood Physio, we see runners across all distances — from 5km recreational runners to marathon competitors. We perform a comprehensive running assessment including video gait analysis to identify the specific biomechanical contributors to your knee pain and build an individualised rehabilitation programme.
Located at Shop 2, 36-38 Victoria St E, Burwood NSW 2134. Open Mon–Fri 7AM–7PM, Sat 7AM–2PM. Call 02 8322 9022 or book online.
Reviewed by the Burwood Physio Clinical Team
BPhty (Hons) | AHPRA Registered Physiotherapists | Member, Australian Physiotherapy Association
Our clinical team has over 20 years of combined experience in musculoskeletal physiotherapy, sports rehabilitation, and pain management. All content is reviewed for clinical accuracy and updated in line with current evidence-based practice guidelines. Meet our team →
