Back Pain Doctor
Patellofemoral Pain
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Patellofemoral pain is one of the most common causes of anterior knee pain. It often affects runners, gym users, adolescents, active adults and people returning to activity after a break.
The kneecap joint is sensitive to load. Stairs, hills, squats, lunges and running can increase joint reaction forces. Pain often reflects a mismatch between current tissue capacity and the load being applied.
Assessment considers training history, hip and thigh strength, foot and ankle factors, knee range, swelling and whether another diagnosis is more likely. Treatment usually focuses on progressive strengthening and adjusting load. Complete rest is rarely needed.
Where the pain is focal at the lower pole of the kneecap rather than diffuse around it, and is provoked by jumping and landing rather than by stairs and prolonged sitting, patellar tendinopathy is the more likely diagnosis.
Common symptoms
- Pain around or behind the kneecap
- Pain with stairs, squats, lunges, hills or running
- Symptoms after prolonged sitting or driving
- Clicking or creaking that may or may not be painful
Commonly seen in
Evidence for twelve treatment options in patellofemoral pain
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
Loading is the treatment, and the trials say adjuncts add little to it. A living network meta-analysis of 68 randomised trials across Achilles and patellar tendinopathy and gluteal tendinopathy found no convincing evidence that any adjunct, alone or added to exercise, beats exercise by itself, and recommended exercise alone for at least three months before an adjunct is considered (Challoumas, Sports Med Open 2023). A meta-analysis of 110 studies and 3,953 patients found greater effect where the programme added external load rather than body weight alone, and where sessions were less frequent than daily, allowing recovery (Pavlova, Br J Sports Med 2023). A 204-study synthesis found exercise safe, beneficial and acceptable to patients, with no clear superiority for the eccentric-only protocols long treated as standard (Cooper, Health Technol Assess 2023).
Pairing reviewed 2026-09-02.
Where it fits
This is the plan, not the preliminary. Expect a programme measured in months rather than weeks, with load progressed against your symptoms. Anything else offered here is an adjunct to it, and the evidence for adding one before three months of proper loading is weak.
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. Dry needling studied, not injection
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) 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
Searched 3 November 2026 (PubMed: trigger point injection, wet needling, dry needling or intramuscular injection with patellofemoral, anterior knee pain or chondromalacia, 35 records, all read). No study has injected anything into a muscle trigger point in this condition, with glucose or any other solution. The only muscle injections in anterior knee pain were botulinum toxin into the outer thigh muscle to rebalance the quadriceps, which is a different treatment (Singer, Disabil Rehabil 2006, eight people, uncontrolled). The nearest evidence is dry needling, which uses the same needle with nothing injected and is not offered here, and its trials disagree. Against sham needling, one 50-person trial found less pain and better function at six weeks and three months (Ma, J Pain Res 2020), while a 60-person trial found no difference at 72 hours (Sutlive, Int J Sports Phys Ther 2018). Added to manual therapy and exercise in 60 people, needling the thigh muscles made no difference at three months (Espi-Lopez, J Orthop Sports Phys Ther 2017), and it matched pressure on the trigger point in 54 (Behrangrad, Acupunct Med 2020). Meta-analyses found a modest short-term benefit on pain, larger when needling was added to exercise and absent when it was added to shockwave or combined care (Sun, Complement Ther Clin Pract 2025, 12 studies, 624 people; Rahou-El-Bachiri, J Clin Med 2020, no effect at medium or long term), and higher-quality guidelines do not recommend dry needling for this condition (Wallis, Phys Ther 2021).
Pairing reviewed 2026-11-03.
Where it fits
Considered only where examination finds a tender thigh or hip muscle band contributing to the pain, as an adjunct to the loading program, which remains the main treatment.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. No trial in this condition
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
Searched 3 November 2026 (PubMed: patellofemoral pain, anterior knee pain or chondromalacia with corticosteroid, steroid, triamcinolone, methylprednisolone or betamethasone injection, 12 records; and a randomised-trial and systematic-review pass across this and three neighbouring conditions, 24 records). No study has tested a corticosteroid or local anaesthetic injection in patellofemoral pain itself, and a Cochrane review of drug treatments for patellofemoral pain found no corticosteroid injection trial (Heintjes, Cochrane Database Syst Rev 2004). The nearest evidence is in neighbouring problems. In 58 people with cartilage softening found at knee arthroscopy for a meniscus problem, a joint injection of methylprednisolone and lignocaine scored better than saline and lignocaine at six weeks but not at six or twelve months (Koyonos, Am J Sports Med 2009). In 60 people with arthritis confined to the kneecap joint, triamcinolone and lignocaine relieved pain faster than hyaluronic acid in the first week, with no difference at six months (Mekariya, J ISAKOS 2025). Five weekly joint injections of a different drug, or of saline, added nothing at six months to a quadriceps exercise program in 53 people with patellofemoral pain (Kannus, Arthritis Rheum 1992). Steroid injection into a specific painful structure at the front of the knee, such as a fat-pad cyst or an inflamed bursa, appears only in case reports.
Pairing reviewed 2026-11-03.
Where it fits
Hip and knee exercise is the treatment with the evidence. An injection is considered only where examination or ultrasound finds a specific painful structure at the front of the knee, such as an inflamed bursa or a fat-pad cyst, and then under guidance alongside the exercise program.
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
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. One non-randomised study
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
Searched 20 October 2026: shockwave, shock wave, ESWT, rESWT or radial shock with patellofemoral pain, anterior knee pain, chondromalacia or patellofemoral syndrome (12 records) and with patellofemoral, retropatellar or patellar pain (10), each with a randomised-trial pass (no records) and a systematic-review pass (none on shockwave), plus one Consensus search; patellar tendon studies were set aside as a different condition. The old line here said the trials used focused devices; the only study with a comparison group used radial. Sixty-four adults aged 20 to 39 were divided into two groups for about three weeks, one given radial shockwave with specific exercises and the other electrotherapy, ultrasound and laser with exercises, and the shockwave group had less pain and better knee function after the program (Neculăeș, J Clin Med 2024). The abstract does not say the groups were randomised, there is no follow-up beyond the program, and there was no sham or exercise-only group. One case report describes a possible noise-related migraine during shockwave for patellofemoral joint pain (Lo, J Bodyw Mov Ther 2025).
Pairing reviewed 2026-10-20.
Where it fits
Can be discussed as an add-on to a hip and quadriceps strengthening program when front-of-knee pain has not settled, on the understanding that the one study is small, short and not randomised. Exercise remains the treatment with the strongest evidence here.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. One small study; exercise did better
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 used 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
Searched 20 October 2026 (the searches named in the radial row, and one Consensus search). The one study of a focused device in this condition is not indexed on PubMed: 39 people with patellofemoral pain were divided between focused shockwave and resistance exercise with elastic bands for six weeks; both groups improved, the exercise group had significantly less pain, and knee function scores did not differ (Kim, Phys Ther Rehabil Sci 2025; randomisation not stated in the abstract). No trial against a sham exists, so this is not evidence that shockwave fails, but the only comparison made favoured exercise.
Pairing reviewed 2026-10-20.
Where it fits
Not a first choice: in the one study a strengthening program did better than focused shockwave on its own. Considered only alongside that program, where a clearly tender structure around the kneecap is part of the picture.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Plausible: no studies
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given 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 could be identified. 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
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 it is described 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. No trial; small studies disagree
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 patellofemoral pain: a trial-type search on 8 October 2026 returned five records and none enrolled people with this condition. Two small non-randomised comparisons in neighbouring groups point in different directions. In 43 adults aged 18 to 50 with anterior knee pain, a positive kneecap grind test and no structural abnormality, the 28 who chose three PRP injections plus one of hyaluronic acid did better on pain and the Kujala knee score at three and six months than the 15 who chose physiotherapy alone - not randomised, and not PRP on its own (Ostojic, Arch Orthop Trauma Surg 2024). In 55 adults under 40 with anterior knee pain attributed to the fat pad and normal imaging, the 27 given PRP into the joint finished with more pain than the 28 given anti-inflammatories and ice (3.0 against 1.5 out of 10), having also started with more (Gürsoy, Medicine 2025). A systematic review covering anterior knee pain found five studies in all and concluded that randomised trials are needed before PRP can be accepted for it (Chalidis, Int J Mol Sci 2025).
Pairing reviewed 2026-10-08.
Where it fits
Rarely the right tool for patellofemoral pain, where there is usually no cartilage or tendon lesion to target and exercise for the hip and thigh carries the evidence. It may be discussed where imaging shows early kneecap cartilage change and a full course of rehabilitation has not been enough, with the lack of trials and the cost stated.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Beat saline in one 54-person trial
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
One double-blind trial, in chondromalacia patella: 54 people with kneecap pain for at least three months were randomised to injections around the kneecap of 5% dextrose, which the authors call prolotherapy, or saline, at 0, 3 and 6 weeks. At 24 weeks the dextrose group was 1.67 points lower for pain out of 10, 15.4 points better on the Patellofemoral Pain Severity Scale and 9.3 points better on the Kujala knee score (Bayır, PM R 2026). That concentration is the one used for perineural injection, and the same trial is counted in that row. Beyond it there is a retrospective single-clinic report of 61 people with chondromalacia given 15% dextrose, without a comparison group (Hauser, Clin Med Insights Arthritis Musculoskelet Disord 2014), and one case report of ultrasound-guided 25% dextrose with an exercise program in a 27-year-old man (Furigay, Pain Manag 2026). A search on 12 October 2026 for dextrose or prolotherapy in patellofemoral pain, anterior knee pain or chondromalacia returned ten records. No trial has followed anyone beyond six months.
Pairing reviewed 2026-10-12.
Where it fits
Prolotherapy is offered here and can be discussed where hip and knee strengthening has been done properly and kneecap pain is still limiting. It is used to make the loading program tolerable, not instead of it, and the single trial behind it is stated beforehand.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. No better than sham injection
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Tested against a sham injection and found no better. Eighty-six people with patellofemoral pain that had not responded to conservative care, average age 27, were randomised, double-blind, to a single 6 mL hyaluronic acid injection or a sham injection, all with a home exercise programme. Pain on a single-leg squat, the KOOS and the Kujala knee score improved in both groups at six months with no difference between them, and the authors concluded the injection had no clinically meaningful effect (Hart, Orthop J Sports Med 2019). A single-arm study of 60 athletes given a hyaluronic acid and sorbitol injection reported better knee scores at six months, but it had no comparison group, one author worked for the manufacturer, and it calls for controlled trials itself (Vélez de Lachica, PLoS One 2026).
Pairing reviewed 2026-10-08.
Where it fits
Not offered for patellofemoral pain. There is no arthritic joint surface to treat, the one sham-controlled trial found no benefit, and exercise for the hip and thigh carries the evidence here.
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. Small trials, to six months
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
One small randomised trial of this procedure, plus a saline-controlled trial of a closely related injection, both in chondromalacia patella (softened cartilage behind the kneecap). In 50 people (median age 55) given a home physiotherapy program, adding perineural dextrose injections gave more improvement at six months than physiotherapy alone on WOMAC pain (7.3 against 3.2 points), stiffness and function (23.2 against 11.1), with no dummy injection (García-Triana, J Altern Complement Med 2021). That appears to be the single trial behind the perineural result in a meta-analysis of 65 high-quality patellofemoral pain trials, where exercise plus perineural dextrose beat exercise alone at three months for pain (SMD 1.34, 95% CI 0.72 to 1.95) and function (1.21, 0.60 to 1.82) (Neal, J Orthop Sports Phys Ther 2022): the trial's own figures reproduce those effect sizes, and no other qualifying trial was found, so the meta-analysis does not add a second trial. A double-blind trial of 54 people with at least three months of knee pain compared periarticular 5% dextrose with saline at 0, 3 and 6 weeks: at 24 weeks dextrose was 1.67 points lower on a 10-point pain scale, 15.4 points better on the Patellofemoral Pain Severity Scale and 9.3 points better on the Kujala score (Bayır, PM R 2026); the abstract describes the injections as periarticular prolotherapy at tender points, and whether they were placed under the skin as in this treatment is not stated. Limits: both trials are single-centre and in chondromalacia rather than in younger people with patellofemoral pain and healthy cartilage, neither followed anyone past six months, and the meta-analysis notes that no treatment for this condition has been adequately tested beyond three months. Searched 29 October 2026: patellofemoral, anterior knee pain or chondromalacia with dextrose, perineural injection, neural prolotherapy, subcutaneous dextrose, glucopuncture, Lyftogt, neurofascial or prolotherapy (10 records, all read).
Pairing reviewed 2026-10-29.
Where it fits
An option alongside the loading programme rather than instead of it: both trials injected in addition to exercise, or in people who had already had months of knee pain. Discussed where hip and knee strengthening has been done properly and anterior knee pain is still limiting.
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
Hydrodissection has not been tested in patellofemoral pain. Searching hydrodissection and hydrorelease against the patellofemoral joint, the anterior knee and the infrapatellar region returns no trial in this condition, only reports of a nerve or a stuck tissue plane being treated near the front of the knee: three case reports of releasing scar or fat-pad adhesions after knee surgery (Machida, Cureus 2020; Machida, Cureus 2022; Obara, JA Clin Rep 2022); a series of 29 people with medial knee pain after knee replacement whose infrapatellar saphenous nerve was hydrodissected, median pain falling from 9 to 5 and holding at nearly five years (Shi, Cureus 2020); and a man whose pain around the patellar tendon proved to be common peroneal nerve compression at the fibular head, identified and partly relieved by hydrodissection (Song, Proc Bayl Univ Med Cent 2020).
Pairing reviewed 2026-09-15.
Where it fits
Only where the examination points to a nerve rather than to the way the kneecap is loaded. The two patterns that fit are the infrapatellar branch of the saphenous nerve, usually after surgery or a blow to the inner knee, and the common peroneal nerve at the outer side of the knee. Patellofemoral pain 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. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
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 treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- 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 shows 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.
Related articles
Shorter articles that answer the questions patients ask most often about this.
Frequently asked questions
Is clicking in the knee dangerous?
What usually causes patellofemoral pain?
What treatment works best?
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