Back Pain Doctor
Patellofemoral Arthritis
Patellofemoral arthritis is osteoarthritis of the joint between the underside of the kneecap and the groove in the thighbone that it slides in. It causes pain at the front of the knee, most often felt with stairs, squatting, kneeling and rising from a chair, and is frequently accompanied by grating or crackling as the knee moves.
Assessment focuses on confirming the source of pain and how it behaves, checking kneecap tracking and alignment, and distinguishing patellofemoral arthritis from other causes of anterior knee pain. X-rays help confirm that the arthritis is limited to the kneecap compartment. Contributing factors such as prior kneecap injury, alignment, muscle strength, activity load and body weight are also reviewed, because these influence both symptoms and progression.
First-line care is usually non-surgical — education and activity modification to reduce loading of the kneecap, weight management where relevant, simple analgesia or a short course of anti-inflammatory medication where appropriate, and a physiotherapy program targeting quadriceps strength and kneecap tracking. A corticosteroid injection may help a painful flare. Where symptoms progress despite conservative care, referral for an orthopaedic surgical opinion is the appropriate next step.
Common symptoms
- Pain at the front of the knee, behind the kneecap
- Pain with stairs, squatting, kneeling or rising from a chair
- Grating or crackling (crepitus) when moving the knee
- Stiffness after sitting for long periods with the knee bent
Commonly seen in
Evidence for twelve treatment options in patellofemoral arthritis
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation — diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan — with weight management where that is clinically relevant.
What the evidence shows
Exercise is the core treatment, and it performs as well as the tablets. A network meta-analysis of 152 randomised trials and 17,431 patients found exercise gave the same pain relief and functional improvement as oral anti-inflammatories and paracetamol, with a far better safety profile (Weng, Br J Sports Med 2023). EULAR (Moseng, Ann Rheum Dis 2024) and the American College of Rheumatology (Kolasinski, Arthritis Rheumatol 2020) both make exercise, education and weight management the core of non-pharmacological care. An individual-participant meta-analysis of 31 trials and 4,241 patients is honest about the size of it: the average effect is small and of questionable clinical importance, and those with more pain and worse function at the start benefit most (Holden, Lancet Rheumatol 2023).
Pairing reviewed 2026-09-02.
Where it fits for you
Worth being straight about: the average effect is modest, and it is larger for people who are struggling more to begin with. What it does have over the alternatives is that it is safe to keep doing, and it works on the things a joint injection cannot — strength, capacity and weight.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. No trials in this diagnosis
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with 0.02-0.08% lignocaine is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling — the same technique with nothing injected — is not offered here.
What the evidence shows
Searching trigger point and myofascial needling against patellofemoral osteoarthritis, patellofemoral arthritis, retropatellar pain and chondromalacia patellae returned two records, and neither is a trial: a single case of trigger point acupuncture at this joint (Ye, Acupunct Med 2024) and a massage case report after cruciate reconstruction (Zalta, Int J Ther Massage Bodywork 2008). The large needling meta-analysis that covers the patellofemoral joint studied patellofemoral pain syndrome, which is a different diagnosis from arthritis behind the kneecap, and reported its result on the Kujala score for that condition (Hu, PLoS One 2026).
Pairing reviewed 2026-09-19.
Where it fits for you
Considered only where examination finds a tender band in the quadriceps or lateral thigh reproducing part of your pain. It does not treat the joint surface.
Ultrasound-guided injections Guidance means we can see the needle reach the target. What goes into the needle depends on the diagnosis. Good support
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis — and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Ultrasound improves needle-placement accuracy, but guidance is not a treatment in itself: benefit depends on a valid injectable target and what is injected. Condition reviewed: patellofemoral arthritis.
Evidence source: Oo et al., ultrasound-guided injection systematic review (2024)
Pairing reviewed 2026-08-30.
Where it fits for you
For patellofemoral arthritis, an ultrasound-guided injection is considered only when there is a specific diagnostic question or a separate joint, bursa, sheath or nerve target. The injectate and purpose are stated before treatment.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible — no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits for you
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Only if relevant
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue — including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Shockwave reviews in myofascial pain report a possible benefit but mix protocols and often mix radial pressure wave with focused shockwave; that evidence cannot be transferred to the underlying diagnosis. Condition reviewed: patellofemoral arthritis.
Evidence source: Wu et al., shockwave for myofascial pain review (2022)
Pairing reviewed 2026-08-30.
Where it fits for you
For patellofemoral arthritis, radial pressure wave may be considered for a distinct superficial muscle or fascial component. It is not used as evidence of benefit for the primary diagnosis.
Focused shockwave (ESWT) A true shock wave converging at depth — for tendon, joint, ligament and bone. Plausible — no studies
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form we use for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
The osteoarthritis evidence for shockwave is in the KNEE (Silva, Clin Rehabil 2022; Liao, Clin Rehabil 2019). There is no trial evidence at this joint.
Pairing reviewed 2026-08-30.
Where it fits for you
Reasonable to consider on the same mechanism, with the gap stated. Not a substitute for the loading and weight-management work that has the better evidence in arthritis generally.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Painless, no contact. Plausible — no studies
What it involves
You sit with the applicator positioned over the area for a short session. Painless, no gel or contact required, and usually delivered as a course — commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that we can point to. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative — a randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why we describe it this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Plausible — no studies
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
No randomised trial of PRP in this condition. The PRP evidence sits in lateral epicondylitis, patellar tendinopathy, rotator cuff and gluteal tendinopathy, plantar fasciitis and knee osteoarthritis.
Pairing reviewed 2026-08-30.
Where it fits for you
Can be discussed on the same rationale, with the absence of direct trials, the cost and the fact that it is not a first-line option all stated.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Plausible — no studies
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
The prolotherapy osteoarthritis evidence is overwhelmingly in the KNEE, where it is strong (Chen, Clin Rehabil 2022; Liao, Int J Mol Sci 2023). There are no comparable trials at this joint.
Pairing reviewed 2026-08-30.
Where it fits for you
Reasonable to consider on the same rationale, with the gap in the evidence stated. Discussed alongside the loading work rather than instead of it.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Plausible — no studies
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
The viscosupplementation trials are overwhelmingly in the knee, and even there the guideline bodies disagree. There are no comparable data at this joint.
Pairing reviewed 2026-08-30.
Where it fits for you
Rarely relevant here. Discussed only where the knee-based rationale is explained along with the gap.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve—not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Worth discussing
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
The closest direct trial is in chondromalacia patella rather than established patellofemoral osteoarthritis: 54 people randomised to periarticular 5% dextrose or saline were 1.67 points lower on pain and 9.3 points better on the Kujala score at 24 weeks (Bayır, PM R 2026). Around it sits a systematic review of periarticular-perineural dextrose in knee osteoarthritis — eight studies and 599 participants, every one reporting less pain and better function, and results equal to or better than non-injection treatments in the short and medium term — but the review rates the studies as low methodological quality and declines to draw a conclusion (Arias-Vázquez, J Integr Complement Med 2026). The knee osteoarthritis studies do not separate the patellofemoral compartment from the rest of the joint.
Pairing reviewed 2026-09-09.
Where it fits for you
Worth discussing where the pain is anterior and load management, quadriceps and hip work have been given a fair run. Presented as a pain treatment with short to medium-term evidence, not as something that changes the cartilage.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Only if relevant
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
Nothing has been published on hydrodissection for patellofemoral arthritis specifically. Knee osteoarthritis appears in this literature, but as fluid spread around or into the joint rather than as nerve treatment: a scoping review of 21 included studies pools hydrodissection with hydrodilatation and calls the evidence early and heterogeneous (Leahy, Front Pain Res 2026), and the only prospective knee work is an uncontrolled series of ten people given three monthly posteromedial fascial injections of 5% dextrose, with WOMAC scores roughly halved at twelve months and the authors themselves noting that placebo and natural fluctuation cannot be excluded (Lam, Diagnostics 2026).
Pairing reviewed 2026-09-15.
Where it fits for you
Only where the assessment finds a nerve contributing separately to the front-of-knee pain, most often the infrapatellar branch of the saphenous nerve. The arthritis itself is treated by the options higher up this page.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So we do not build treatment plans around it. Where an injection is the right call, we review the specific diagnosis and target, discuss what is being injected and why, keep the number low, and pair it with the loading work that changes the longer-term course.
When we would still consider it
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal — a trip, a procedure, a return to work
- Diagnostic use, where the response tells us where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other knee conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
How is patellofemoral arthritis diagnosed?
What does treatment involve?
Will I end up needing a knee replacement?
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