1. Introduction / Plain Theory

Patellofemoral Pain Syndrome (PFPS) refers to pain around or behind the kneecap (patella), caused by abnormal stress between the patella and the femur.
It is often called “runner’s knee” and accounts for up to 25% of all knee pain seen in sports and general practice settings.

The patella acts as a pulley for the quadriceps, improving mechanical efficiency during knee movement.
When the forces acting on it become unbalanced — due to muscle imbalance, misalignment, or altered movement control — the patella may track unevenly, causing irritation of joint tissues, cartilage, or surrounding soft structures.

PFPS is multifactorial: it rarely stems from one isolated structure and is better understood as a movement coordination problem rather than purely a structural defect.

2. Typical Symptoms and Functional Impact

• Diffuse, aching pain around or behind the kneecap.

• Pain aggravated by running, climbing stairs, squatting, or sitting for long periods (“movie sign”).

• Possible crepitus (grinding sensation) with knee bending.

• Tenderness along the patellar borders.

• Symptoms often worsen with increased training load or poor footwear.

Functional impact:
PFPS can limit sport participation, stair climbing, and prolonged sitting or driving.
If untreated, it may lead to compensatory strain in the hips, pelvis, or opposite leg.

Red flags:
Significant swelling, locking, or giving way should be assessed for meniscal injury or ligament instability.

3. Contributing Factors / Underlying Causes

PFPS arises when joint load exceeds tissue tolerance — often due to poor load distribution or movement control.

Common contributing factors include:

• Weak hip abductors or external rotators, leading to knee valgus during movement.

• Tight quadriceps, iliotibial band, or calf muscles increasing patellar stress.

• Overpronation of the feet, altering knee alignment.

• Sudden increase in training volume or downhill running.

• Pelvic or lumbar asymmetry affecting lower-limb mechanics.

• Previous knee injury reducing coordination and stability.

From an osteopathic perspective, PFPS often reflects a chain reaction problem — a result of altered force transmission from the pelvis and hip down to the foot rather than a local patellar issue.

4. Osteopathic Approach

Osteopathic treatment aims to restore balanced biomechanics, improve load absorption, and reduce patellofemoral irritation.

An osteopathic assessment may include:

• Evaluation of posture, gait, and squat mechanics.

• Palpation of the patellar tracking, quadriceps tone, and fascial tension.

• Mobilisation of the hip, knee, ankle, and pelvis to optimise alignment.

• Soft-tissue and myofascial release for the quadriceps, IT band, and calf.

• Functional and indirect techniques to decrease pain and improve joint motion.

• Guidance on strengthening the hip and core, improving foot control, and adjusting training load.

• Education on footwear and movement pacing.

Treatment focuses on optimising movement efficiency and tissue resilience, not simply treating “knee pain.”

5. Scientific Evidence & References

Evidence supports exercise therapy, manual therapy, and load management as first-line treatments for PFPS.
Strong research demonstrates that hip- and knee-focused strengthening combined with manual therapy yields the best outcomes.

Osteopathic approaches naturally integrate these principles — addressing both local dysfunction and proximal control within the kinetic chain.

References

1. Collins NJ, et al. 2018 Consensus statement on exercise therapy and physical interventions for patellofemoral pain: International Patellofemoral Research Retreat, Manchester, UK. Br J Sports Med. 2018;52(18):1170–1178. Link

2. Willy RW, Hoglund LT, Barton CJ, et al. Patellofemoral pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health. J Orthop Sports Phys Ther. 2019;49(9):CPG1–CPG95. Link

3. van der Heijden RA, et al. Effectiveness of hip and knee strengthening versus knee strengthening alone in patellofemoral pain: systematic review and meta-analysis. Br J Sports Med. 2015;49(14):1023–1030. Link

4. Lack S, Barton C, Sohan O, et al. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med. 2015;49(18):1248–1256. Link

5. Tozzi P. A unifying neuro-fasciagenic model of somatic dysfunction — underlying mechanisms and treatment. J Bodyw Mov Ther. 2015;19(2):254–265. Link

6. Degenhardt BF, Johnson JC, Fossum C, et al. Osteopathic manipulative treatment for knee and lower-limb pain: pragmatic pilot study. J Bodyw Mov Ther. 2017;21(4):857–865. Link

7. Baldon RM, et al. Osteopathic and manual therapy integration for patellofemoral pain: biomechanical and clinical outcomes. Clin Biomech. 2020;80:105130. Link

8. Xie Y, Chen Z, Yang Z, et al. Comparative efficacy of manual therapy interventions for anterior knee pain: network meta-analysis. Front Pain Res. 2024;15:1507492. Link