Patello-femoral

pain (PFP)
Your physiotherapist has diagnosed you with
Patello-femoral pain syndrome. This booklet
provides information on what this means and how
physiotherapy can help.
Contents
3 What is the Patello-femoral joint?

4 What is Patello-femoral pain?

4 What are the causes?

6 How is it treated?

7 How will physiotherapy help?

7 How long will it take to get better?

8 What will happen to the pain?

8 How will I manage ongoing pain?

9-16 Exercises in pictures

17 Contact us and Notes

18-19 Exercise prescription

20 Useful information

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What is the Patello-femoral joint?
It is formed by contact between the knee cap (patella)
and the thigh bone (femur). The knee cap normally sits
in a snug groove on the end of the thigh bone.

The knee cap acts as a lever for muscles controlling

movement of the knee. These movements are controlled
by a number of muscles that connect to the knee cap.
Together, these muscles help to stabilise the knee cap
and keep it running smoothly within the groove.

Knee bones and tendons

Tendon
attaching thigh
muscles to knee
cap
Knee cap (patella)

Thigh bone
groove:
behind knee
cap

Thigh bone
(femur)

Shin bone

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What is Patello-femoral pain (PFP)?
PFP is pain in, around and/or under the knee cap. This
is most commonly known as ‘anterior knee pain’ and
also known as ‘patella mal-tracking’, ‘chondromalacia
patellae’’. Activities that commonly aggravate PFP are
bending, prolonged sitting, squatting, kneeling, walking,
climbing stairs, running and jumping.

Additional symptoms can include stiffness, a sensation

of catching, clicking or grinding.

What are the causes?

There are no specific causes for PFP, but there are a
range of possible factors, which increase your risk of
developing it. Your PFP is unique to you, and factors
contributing towards your PFP may be different than
someone else with the same diagnosis.

Contributory factors

 Load tolerance
Depending on what you usually do, you will have a level
of activity that your knee is happy with (a load tolerance
level). Excessive loading or varied and rapid increases
in load can increase sensitivity in your knee, without
causing physical injury or damage.

Varied and rapid increases in loading

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 Strength
Pain at the front of the knee can limit how well your
quadriceps (front thigh muscles) work, and over time
cause weakness. Weak quadriceps, especially the
inside thigh muscle (also known as VMO) can affect the
movement of the knee cap as you do activities,
potentially causing further irritation, but not damage.
Looking above the knee, weak hip and bottom muscles
(glutei muscles) can impact on the control of single leg
movements like climbing stairs and walking.

 Movement biomechanics
Having strong muscles is key, but it’s also important to
have muscles that work efficiently to control your
movement – above, at and below the knee.
A lack of movement control can contribute towards
irritation of PFP.

 Tightness
Tight or restricted movement can reduce range of
movement and effect loading efficiency. Common
areas of tightness are the thigh muscles (quadriceps
and hamstrings), outside of your thigh (ilio-tibial band)
and calf muscles.

 Feet biomechanics
Flat feet or feet that roll in too much, can cause altered
movement mechanics further up the leg and altered
strain for the knee cap.

 Natural body shape

The natural position of your hip, knee and feet bones
can increase the chances of PFP.

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 Examples of factors leading to PFP

Tightness, Weakness of thigh Hip strength and

particularly on the muscles, including foot biomechemics
outside of the knee the inner muscle can contribute
(VMO) towards altered
movement control
during daily tasks

Muscles removed With muscles

How is it treated?
 Pain killers can be used to provide temporary relief.
This will give muscles an opportunity to work better.
 Physiotherapy is the most effective method of
management for PFP. Some people will also benefit
from seeing a Podiatrist (foot specialists).
 Surgery for PFP may be considered as a last resort
once all other methods of management for the
condition have been explored.

Surgery can be used to correct the muscle, bony and

joint physical positions. However surgery cannot
improve the effectiveness of muscles. In general,
surgical success rates are low for PFP.

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How will physiotherapy help?
Physiotherapy will identify the dominant ‘contributory
factors’ and provide a specific, targeted rehabilitation
program.

This will help to reduce strain through the knee by

stretching tight structures, strengthening weak
structures, improving your movement control and
improving your load tolerance.

Successful management requires adherence to a

regular exercise program outside of physically attending
physiotherapy appointments. Alongside your exercise
programme, this may include resting from aggravating
activities and working to gradually build them back up
over time.

How long will it take to get better?

 There are no quick fixes with PFP
 We would expect to see improvements with
rehabilitation over a 3-6 month period.
 However, improvements can continue beyond this.
 Maintenance of your specific exercise programme is
crucial in sustaining improvements.

You may need to continue indefinitely to ensure that

your problems do not return. Most people will get back
to normal function including sport.

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What will happen to the pain?
Fortunately most people will gain somewhere between
60% and 80% improvement with physiotherapy.

Although you may experience discomfort from time to

time most of you will return to your normal activities.

How do I manage ongoing pain?

You may sometimes get an increase to your pain, with
or without warning. This is normal with patello-femoral
joint problems. It is important to reduce the effect from
these ‘flare-ups’ as quickly as possible. During a flare
up, aim to reduce your accumulative load by regressing
your exercises and daily activities. Over time, gradually
build back up your normal activity levels.

The use of ice or heat and pain killers may offer some
temporary relief, whilst you are building your daily
activities back up. With the correct management, flare
ups can be well controlled allowing you to continue with
normal activities.

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Exercises in pictures
Stretches: Calf Stretches: Quadriceps

Stretches: Hamstrings Stretches: Foam rolling

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Quads: Leg press. Double leg

Quads: Leg press. Single leg

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 Quads: Squat

Quads: Step down. Front view

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Quads: Step down. Side view

Quads: Wall slide

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 Quads: ‘VMO’ lunge

Quads: Progression of lunge

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 Quads: Single leg dip

Glutes: Double leg bridge Glutes: Single leg bridge

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 Glutes: Side lying hip abduction

Glutes: Standing hip extension and abduction

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 Glutes: Hip turn out

Glutes: Side and front crab walk

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 Contact us
If you have any questions or concerns please contact
the Physiotherapy Department, t: 020 7188 5094,
Monday to Friday, 8.30am to 5.00pm

Notes

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 Exercise Prescription
The load, volume and frequency of exercise will depend
of your training goals. These two pages show a chart
summarising key training markers to guide your exercise
prescription.

Required Action Load % of 1RM Number of reps

outcome
Motor Variable Light load <30% 20+
control

Maximal Ecc/ con/ iso Novice to Intermediate 8-12

Strength 60-70%
Advanced 80-100%

Power Ecc/ con Upper body 30-60% 3-6

Lower body 0-60%
Advanced 85-100%

Hypertrophy Ecc/ con/ iso Novice to Intermediate Novice to Intermediate

70-85% 8-12
Advanced 70-100% Advanced 1-12

Endurance Ecc/ con/ iso ‘Multidimensional’ Novice 10-15

Light loads with high Advanced 10-25
reps and moderate to fatigue
loads with fewer reps

Older adults
Strength +
hypertrophy 60-80% 8-12
power 30-60% 6-10

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 Adapted from: Ratamess N.A., Alvar B.A., Evetoch T.K., Housh T.J., Kibler W.B., Kraemer W.J. Triplett N.T. (2009) American College of Sports
Medicine position stand. Progression models in resistance training for healthy adults. Medicine and Science in Sports and Exercise 41, 687-708.

Number of Rest period Repetition velocity Frequency per week

sets (minutes)
Prior to <1 min Focus on control rather 5-7
strength than velocity but can Twice daily
work vary
3-5

1-3 2-3 min 1:1:1 Novice 2-3

Intermed. 3-4
Advanced 4-6

Multi-joint 2-3 min Explosive tempo Novice 2-3

1-3 Intermed. 3-4
Advanced 4-6

Novice to Novice to Novice slow to moderate Novice 2-3

Intermed. 1- Intermed. 1-2 Advanced – mixture of Intermed. 4
3 min speeds Advanced 4-6
Advanced Advanced 2-3
3-6 min
‘High- 1-2 min for Moderate to fast velocity Novice 2-3
volume high reps (15- for high reps Intermed. 3
Multiple 20) Slow velocity for lower Advanced 4-6
sets < 1 min for reps
moderate reps
(10-15)

1-3 1-3 min Slow to moderate 2-3

1-3 High rep velocity

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 Useful information
Pharmacy Medicines Helpline
If you have any questions or concerns about your medicines, please
speak to the clinical nurse specialist or other member of staff caring
for you or call our helpline.
t: 020 7188 8748 9am to 5pm, Monday to Friday

Your comments and concerns

For advice, support or to raise a concern, contact our Patient Advice
and Liaison Service (PALS). To make a complaint, contact the
complaints department.
t: 020 7188 8801 (PALS) e: pals@gstt.nhs.uk
t: 020 7188 3514 (complaints) e: complaints2@gstt.nhs.uk

Language and Accessible Support Services

If you need an interpreter or information about your care in a different
language or format, please get in touch:
t: 020 7188 8815 e: languagesupport@gstt.nhs.uk

NHS 111
Offers medical help and advice from fully trained advisers supported
by experienced nurses and paramedics. Available over the phone 24
hours a day.
t: 111

NHS Choices
Provides online information and guidance on all aspects of health and
healthcare, to help you make choices about your health.
w: www.nhs.uk
Leaflet number: 3703/VER2
Date published: February 2018
Review date: February 2021
© 2018 Guy’s and St Thomas’ NHS Foundation Trust
A list of sources is available on request

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