Anterior knee pain is known by many names including Patellofemoral Pain Syndrome (PFPS), chondromalacia Patella, or a “bum knee.” It is a common issue that is often felt as a dull ache or discomfort around the front or side of the kneecap. For gymnasts it often limits tumbling and vaulting and can also worsen with running, squatting, stair climbing, or sitting for long periods. While it may start as a minor annoyance, ignoring the underlying causes can lead to persistent pain and limit both athletic performance and everyday movement. Learning how the knee works, what contributes to patellofemoral pain, and strategies for prevention and recovery is essential for keeping your knees strong and functional.
What Is Patellofemoral Pain Syndrome (PFPS)?
Patellofemoral pain syndrome (PFPS) is a fancy sounding name and many people do not realize how vague of a diagnosis it is. The technical name for the kneecap is the patella, and the technical name for the thigh bone is the femur. The “diagnosis” of PFPS is more a description of where the pain is located – somewhere in the front or sides of the knee cap, at the end of the femur. When an athlete is told they have Patellofemoral Pain Syndrome, it really means “We are not sure what is causing your pain, but it does not seem to be a tendon or ligament problem.” Athletes are often told vaguely that it’s an “overuse injury.” It’s often called “runner’s knee” because it’s frequently seen in runners, cyclists, and athletes who repeatedly load the knee in flexion under weight-bearing conditions.
There are many theories for what PFPS is: some believe it to be a kneecap tracking issue, an issue of weak hips, or wearing down of cartilage. In my experience as a sports PT, there are many different causes of anterior knee pain so there are many causes of PFPS and so there is no one right answer on how to treat it. Personally, I have found that athletes with this diagnosis tend to fall into 3 different categories:
- Referral from the spine. The pain location is vague and changes because the primary source of the pain is not actually in the knee.
- Poor knee and hip stability, especially for lateral forces, which shows up as unstable movement patterns with specific skills or activities in their sport.
- Unbalanced use of knee range of motion which causes pinching in the joint. This can be hypermobile or otherwise unstable knees which frequently push into hyperextension while standing and with landings, or knee stiffness that using knee flexion much more than knee extension leading to an imbalance in the other direction.
Common PFPS Symptoms
Symptoms of PFPS can vary but often include:
- Pain on, under, above, or to either side the kneecap, especially during activities like squatting, running, tumbling, stair climbing, or prolonged sitting.
- Pain that increases with knee flexion under load, such as landings, lunges, jumping, or kneeling.
- Clicking or grinding sensation (crepitus) in the knee, though this is not always painful.
- Variable Knee Pain that is difficult to pin to a specific point. Pain might change locations around the knee, or sometimes feel better and sometimes feel worse.
Unlike structural knee injuries (like meniscus tears), PFPS rarely causes significant swelling or locking. Pain is usually activity-dependent.
Risk Factors for Anterior Knee Pain
Several factors can increase the likelihood of developing PFPS:
Spine Stiffness or Pain
Stiffness or pain in the lumbar (low back), thoracic (Mid back) and even occasionally cervical (neck) spine can cause problems down the extremities that they innervate. There has been research to show that as much as 30% of knee pain, where people believe the cause of the pain is in their knee, actually improves with spinal treatment. Sometimes the full source of the pain is in the spine and the knee pain goes completely away with spine treatment, and sometimes spine problems simply exacerbate an existing problem in the knee.
Overuse or Rapid Increase in Activity
Sudden spikes in running mileage, jumping, or squatting volume without adequate preparation, rest and recovery can overload the knee joint.
Poor Biomechanics
Gymnasts, runners, volleyball players, or other athletes with collapsing knees with running, tumbling, and landing put strain on their knee joint that does not get distributed to the muscles designed to handle the load. There can be many causes for poor hip and knee alignment, often including hip, knee, and core stability issues especially through single leg positions. Do not simply strengthen weak muscles, athletes must improve their stability through weightbearing strengthening exercises which mimic the stability challenges that their sports demand.
Imbalanced Knee Range of Motion or Strength
Individuals with hyperextending knees will require more strengthening and stability training into knee flexion (bending) positions to help protect against injury. Individuals with the opposite problem, whose knees are more difficult to fully straighten and often stiffen into flexion (bent) knee positions, require extra time spent working into full knee extension and strengthening into knee push off skills. The important point here is to recognize the imbalances each athlete or sport tends to possess and be sure to train in a way that helps protect against these imbalances.
Treatment and Recovery
Early intervention is key to preventing PFPS from becoming chronic:
Thorough Warm-Up
Joints are more resilient when warm. Include dynamic stretches and low-resistance exercises targeting the quadriceps, hamstrings, hips, and ankles.
Relative Rest
Avoid high-impact activities that obviously aggravate pain until symptoms improve, but continue lower load versions of these activities when possible to speed up healing. KT tape for decreasing knee hyperextension, assisting knee extension or kneecap tracking, or otherwise assisting with the athlete’s main issue will help an athlete stay more active without pain.
Single Leg Stability Strengthening
Developing single leg balance and power while maintaining good hip and knee alignment is often an element to fixing PFPS. Simple exercises include simple single leg balance, sometimes using a band or another cue to help improve knee position. Progress gradually until it’s possible to complete single leg hopping and jumping all directions with good alignment.
Gradual Return to Sport
Work with a physical therapist to create a plan that gradually reintroduces running, jumping, and sport-specific movements.
Stay Strong and Knee-Healthy
PFPS can be frustrating, but with proper strength training, mobility work, and gradual load progression, athletes can return to activity stronger and more resilient. Focusing on spine mobility, hip and knee stability, correcting imbalances, and listening to your body ensures long-term knee health and high performance.
Need personalized guidance for knee pain prevention or recovery? Contact us today to create a plan that keeps your knees strong, stable, and ready for every challenge.