Pain at the front of your knee? Here's what's likely going on
If your knee hurts at the front — somewhere around or under the kneecap but you can't touch it — and it flares when you run, walk downstairs, squat, or stand up after sitting for a while, the most common cause is patellofemoral pain — which is like a fancy way of saying 'knee pain'. You'll often see it called "runner's knee," though it affects more than only runner's.
The reassuring part first: this is one of the most common knee problems I see, it's rarely caused by anything serious or structural, and you almost never need a scan to diagnose it. It responds well to the right loading and a bit of patience. It is not a sign your knee is "wearing out."
What you can usefully do today: keep moving, but dial the aggravating activity down to a level your knee tolerates rather than stopping completely. Pain that settles within 24 hours after activity is generally fine to work with. If going downstairs or decline walking is the worst, step down with the painful knee, shorten your walking stride and slow down for now. Resting it entirely can make the knee more sensitive, especially when you suddenly go from rest to your normal activity levels.
What's actually causing it
The honest answer is that patellofemoral pain is usually a load problem, not a damage problem. The joint between your kneecap and thigh bone is taking more load, more often, than it's currently conditioned for — and the tissue around it has become sensitised.
That's it. You may have read that it's caused by your kneecap "tracking badly," weak inner-thigh muscles, flat feet, or your knee "grinding." Those ideas are sticky but largely outdated as explanations. [1][4] Plenty of people have so-called maltracking and no pain; plenty have pain and textbook-perfect tracking. The thing that reliably changes is how much load the joint is being asked to handle relative to its current capacity — which is good news, because capacity is trainable.
Common things that tip the balance: a sudden jump in running volume or hill work, a new training block, returning after time off, a change in footwear or terrain, or a stretch of life stress and poor sleep that lowers your tolerance to everything.
For the clinically curious — the evidence underneath this
Patellofemoral pain is best understood as multifactorial, and the international consensus work (the BJSM consensus statements coming out of the patellofemoral research retreats) has steered the field firmly away from single-structure, "maltracking + VMO weakness" models toward a load-capacity framing. [1][2][3]
What the evidence supports as first-line: exercise therapy [3][5], with the strongest signal for combined hip- and knee-targeted loading over knee-focused work alone — proximal (gluteal) control matters, not just quads. [3][6] Isolated VMO training has no good evidence base over general quadriceps loading. [4] Education and activity/load modification are core, not optional add-ons (Rathleff's adolescent work is a good reference point here). [3][4]
Routine imaging is not recommended — structural findings on MRI correlate poorly with symptoms and tend to generate fear rather than answers. [1][4] Foot orthoses can give some people short-term relief and are a reasonable adjunct, not a fix. [3] Taping and manual therapy are adjuncts at best. [3]
The part people don't say out loud: prognosis isn't reliably benign. A meaningful proportion of people — around 40% in one multicentre cohort — still report an unfavourable outcome at a year [7], and more than half report ongoing symptoms at 5–8 years. [8] This is strongly associated with under-dosing the loading and stopping too early — an argument for getting the rehab right and progressive, not for catastrophising.
How I assess and treat it
I don't guess at this. My approach is to work out where your capacity has run short and/or where your demand has peaked and build it back in a way I can measure.
That usually means a proper subjective and physical assessment, and where it's useful, objective strength and capacity testing on VALD ForceDecks — so we're working from your actual numbers rather than my thumb-feel of "that seems a bit weak." From there the plan is criteria-based: we progress when your knee and your data say you're ready, not when the calendar says so.
The loading itself is staged — starting with what the joint tolerates, building strength and tendon capacity, then layering back the spring and speed your running or sport actually demands. Alongside that, we sort the training load: most patellofemoral pain doesn't need you to stop, it needs the dose adjusted while capacity catches up. If you're a runner, simple gait tweaks like a small cadence increase can meaningfully offload the joint while you build. [9][10]
The goal isn't just "pain gone." It's a knee that's robust enough that it doesn't come back the next time you ramp up.
When to get it checked
Most front-of-knee pain (anterior knee pain) is straightforward, but see a clinician promptly if you have any of these: your pain impacts your training and activities of daily life, the knee locks or gives way repeatedly, it's hot, swollen and you feel unwell, you can't put weight through it after an injury, there was a clear trauma with immediate swelling, or the pain is severe at night and unrelated to activity. These point away from simple patellofemoral pain and warrant a proper look.
Get a clear plan for your knee
I'm based at 19 Backfields Lane in St Paul's, BS2 — a few minutes from Stokes Croft, Montpelier and the city centre, and easy to reach from Bishopston, Cotham, Redland and Easton. If your knee's been niggling for a few weeks and you're tired of guessing whether to push or rest, I'll give you a straight assessment and a plan built around your actual capacity, not a generic sheet of exercises.
See appointment options and pricing →
References
Crossley KM, Stefanik JJ, Selfe J, et al. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. Br J Sports Med. 2016;50(14):839–843.
Crossley KM, van Middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ. 2016 Patellofemoral pain consensus statement... Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med. 2016;50(14):844–852.
Collins NJ, Barton CJ, van Middelkoop M, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018;52(18):1170–1178.
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.
van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SMA, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2015;(1):CD010387.
Santos TRT, Oliveira BA, Ocarino JM, Holt KG, Fonseca ST. Effectiveness of hip muscle strengthening in patellofemoral pain syndrome patients: a systematic review. Braz J Phys Ther. 2015;19(3):167–176.
Collins NJ, Bierma-Zeinstra SMA, Crossley KM, van Linschoten RL, Vicenzino B, van Middelkoop M. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2013;47(4):227–233.
Lankhorst NE, van Middelkoop M, Crossley KM, et al. Factors that predict a poor outcome 5–8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2016;50(14):881–886.
Doyle E, Doyle TLA, Bonacci J, Fuller JT. The effectiveness of gait retraining on running kinematics, kinetics, performance, pain, and injury in distance runners: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2022;52(4):192–203.
Anderson LM, Bonanno DR, Hart HF, Barton CJ. What is the effect of changing running step rate on injury, performance and biomechanics? A systematic review and meta-analysis. Sports Med Open. 2022;8(1):112.
