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1 · SNAPSHOT

Patellofemoral Pain (PFP) body chart — Illustrative, not diagnostic. Canva body chart for Patellofemoral Pain (PFP).

Who: 10–14 year olds in high-volume sport, runners, jumpers, court athletes, 18–40s. Girls and women more. Peak primary-care incidence is age 13.
What: Diffuse retro- or peripatellar pain. They circle the kneecap with a whole hand. They don't point at one spot.
How it behaves: Aggs: stairs down > up, squat, prolonged sitting, running downhill, jumping, kneeling. Eases: straightening the knee, standing up and walking it off, ↓ km / ↓ hills / ↓ sessions.

The one thing to take from this page:

The best diagnostic information you will get is a question, not a test. Stair-descent pain 3–10/10 + prolonged-sitting pain 6–10/10 → +LR 19.47, post-test probability 95%. Nothing you do with your hands comes close.

Finding	Figure
Stair descent 3–10/10 + prolonged sitting 6–10/10	+LR 19.47 (95% CI 6.36–59.65) · post-test probability 95%
Pooled point prevalence, adolescents	7.2% (95% CI 6.3–8.3)
Female adolescent athletes	22.7% (17.4–28.0)
Primary-care incidence, ages 7–24	3.4 per 1,000 person-years — girls 4.6, boys 2.3
Still had knee pain at 2 years	56%
Still had frequent, intense pain at 5 years	40.5% (35.4–45.6) vs 13.2% (8.2–18.1) of controls

([1], 162 patients with anterior knee pain [2] [3], >300,000 primary-care patients [4] [5].)

⚠️ No Australian guideline for this presentation; anchored to the 2019 JOSPT clinical practice guideline ([6], United States), supported by the 2024 BJSM best practice guide ([7], UK-led). Two warnings that travel with that anchor. The JOSPT body is paywalled and was not read — no graded recommendation is quoted anywhere on this page. And the 2018 consensus [8] was written at a retreat held on the Gold Coast and co-led from UQ and La Trobe. It is an international consensus statement, not an Australian guideline. Don't let the venue fool you.

Patterns > Labels. "PFPS" names a compartment. Loaded knee flexion hurts, and it has for months names the problem.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in the order your course teaches them. Insidious onset, so this runs MAIN PROBLEM → BODY CHART → BEHAVIOUR → HISTORY → SPECIAL QUESTIONS. This is where the diagnosis gets made. The P/E is there to rule out what it isn't.

MAIN PROBLEM

"It's all around the kneecap. Going down stairs is the worst, and I can't sit through a two-hour lecture."

Get the activity, not the ache. Stairs, squatting at work, the last 3 km, sitting in the car. That's your outcome measure and it's what you re-test.

BODY CHART

P1: diffuse, retro- or peripatellar. Whole-hand, circling.
Mark the poles deliberately, because they're your differentials. A single tender point at the inferior pole → patellar tendinopathy. Superior pole → quadriceps tendinopathy. Tibial tuberosity in a 10–15 year old → Osgood-Schlatter.
P2 uncommon. Any distal or dermatomal spread → neuro screen in the P/E.
Bilateral is common. Note which side is worse and why.

BEHAVIOUR

Aggs: stairs down > up, squat, prolonged sitting, running downhill, jumping, kneeling.
Eases: extending the knee, standing up, ↓ load.
24-hr pattern: load-linked, not clock-linked — stairs down and an hour of sitting are the two numbers you write down. Morning stiffness M or none.
Severity: VAS 0–10 at best / at worst / right now.
Coding: usually In — intermittent, load-linked. P (constant, unvarying) is not this pattern. See §4.
Morning stiffness: typically M (<30 min) or none at all. In (>30 min) is not PFP — screen for inflammatory arthropathy.
Irritability, the three parts: resting Sx present or not + vigour of the provoking activity + time to settle. It sets your starting dose. It does not set your diagnosis.
Ask the two questions that carry the +LR 19.47, and write the numbers down. "0–10, how bad is going down stairs?" and "0–10, how bad is sitting for an hour?" 3–10 on the stairs plus 6–10 on sitting → post-test probability 95% in 162 patients presenting with anterior knee pain [1].

HISTORY

Insidious, and almost always traceable to a load change — km, hills, sessions, a new sport, a growth spurt, a new job on the feet.
Duration is the prognostic factor that matters. Long symptom duration was the most consistent predictor of a poor 52-week outcome (KPS β −0.07, 95% CI −0.10 to −0.03, p<0.001), with a worse baseline Kujala predicting outcome at 6, 12 and 52 weeks. Gender, BMI and arch height were generally not associated ([9], 179 RCT participants). Ask duration early. Record it.
What the prospective risk-factor list does NOT contain: age, height, weight, BMI, body fat and Q angle — none of them predicted PFP across 18 prospective studies and 4,818 participants, on strong-to-moderate evidence [10]. Stop measuring the Q angle.
What have they been told? If someone has already told them the kneecap "tracks badly", that belief is now part of what you're treating. See §5.

SPECIAL / SCREENING QUESTIONS

Night pain, rest pain, pain that does not vary with patellofemoral loading, unexplained weight loss, fevers, a mass, an unexplained limp. All of §4, free forever.
The hip, in every adolescent. Knee pain is a hip presentation until you've cleared the hip.
General health, medications, sleep, training volume, and what a high-volume kid is actually eating.

PFP is load-dependent by definition. If it isn't load-dependent, it isn't this pattern — and that's a screening finding, not a subtlety.

Assessing this region? Download the Knee assessment template →

3 · HYPOTHESIS RANKING

Top three competing patterns, one discriminating feature each. Rank them, then rule out the dangerous one first — that one lives in §4.

Rank	Pattern	The one discriminating feature
1	Patellar tendinopathy	Point tenderness at the inferior pole, pain on decline squat and hop, warms up with activity and bites afterwards. Tendon pain does not care about prolonged sitting. PFP tenderness is peri- or retropatellar and sitting is one of its cardinal aggravators.
2	Osgood-Schlatter / Sinding-Larsen-Johansson	Tenderness at the tibial tuberosity (OSD) or the distal patellar pole (SLJ) in a 10–15 year old. And a strength split you can measure: adolescents with OSD had lower knee extension strength (ES 1.25); adolescents with PFP had lower hip extension strength (ES 0.73) ([11], 151 PFP / 51 OSD / 50 controls).
3	Patellofemoral OA	Age over 40 with chronic anterior knee pain. 69% of 224 such people had radiographic PFJ OA, 25% isolated to the PFJ — and even under 50, isolated PFJ OA was 26% [12]. Not a different pattern so much as the same knee, later. See the knee OA page.

And the one that isn't a patellofemoral problem at all: serious pathology — night pain, rest pain, systemic features, an unexplained limp, or pain that doesn't vary with patellofemoral loading. Straight to §4.

Why this ranking leans on the history and not on your hands

Across two systematic reviews covering 47 test evaluations, no special test reaches the conventional usefulness threshold. Patellar tilt tops out at +LR 5.4 with −LR 0.6 — it can't rule out. Squatting gives +LR 1.8, −LR 0.2 ([13], 5 studies, 25 tests). Worse: only 1 of 9 studies was high quality on QUADAS, and the tests with the highest reported diagnostic value came from the studies with the lowest quality scores [14]. Those authors' own conclusion is that identifying the best tests for PFP is still difficult.

"If prolonged sitting doesn't hurt, question the label."

Then check it with your educator. You're naming a pattern and a discriminator, not making a diagnosis.

4 · RED FLAGS — DON'T MISS THIS

Free forever. On the site, this section sits outside the paywall and always will. Safety is never gated.

Anterior knee pain in a young active person is one of the most boring presentations you will see on placement. That is exactly why the misses happen here.

1 · Bone tumour — the one that gets missed by looking ordinary

Median diagnostic delay 7 months (IQR 3–12) — 10 months for the pelvis, 7 for the lower limb. Pain in the affected area was present in 90.6% and limited mobility in 28.1%. X-ray was ordered at the first office visit in only 59.4%, and of those, only 47.4% were referred on ([15], 32 patients, single centre — use it for the delay signal, not for a prevalence).

Screen for:

Night pain and rest pain, especially unremitting or worsening.
Constant, unvarying pain — coding P, not In.
Pain that does not change with patellofemoral loading. PFP is load-dependent by definition.
Unexplained weight loss, fevers, night sweats, a palpable mass, an unexplained limp.

2 · The hip, in every adolescent

Slipped upper femoral epiphysis (SUFE; also called SCFE), Perthes disease and septic hip. Suspected SUFE requires urgent orthopaedic assessment and non-weight-bearing while awaiting assessment (RCH guideline). Referred knee pain is a classic hip presentation and the child will point at the knee. Screen hip ROM — especially internal rotation — and gait, in every adolescent with anterior knee pain. An unexplained limp is a hip until proven otherwise.

3 · The apophysitides you cannot separate with your hands

OSD and SLJ do not differ much in clinical presentation, and imaging is what separates them ([16], clinical review, no accuracy data — use it for the prompt, never for a number). If the distinction changes your plan, image it. Don't guess it and call the guess a diagnosis.

4 · The wrong label at the other end of the age range

Not dangerous, but the commonest error over 40: 69% radiographic PFJ OA, 25% isolated [12]. Do not accept "anterior knee pain in a 45-year-old" as PFP without considering patellofemoral OA.

And the ones that mean it's a different knee entirely

Acute trauma, a real effusion, true locking, true giving way. Not this pattern — reassess.
Progressive neurological symptoms → neuro exam, and escalate.
Systemically unwell. This stops being a load problem.

Escalate, don't sit on it: GP or sports physician, and tell your clinical educator the same day. Nothing on this page authorises you to make a diagnosis — it gives you a pattern, a discriminator and a reason to ask.

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Guideline anchor

No Australian guideline for this presentation.

Anchored to JOSPT Clinical Practice Guideline, Patellofemoral Pain (Willy et al. 2019, PMID 31475628), supported by the BJSM best practice guide (Neal et al. 2024, PMID 39401870)

PubMed

No Australian guideline exists for patellofemoral pain. No ACSQHC clinical care standard, no RACGP guideline. The anchor is a United States CPG plus a UK-led best practice guide. The 2018 consensus statement (Collins et al., PMID 29925502) was written at the 5th International Patellofemoral Research Retreat held on the Gold Coast and is co-led from UQ and La Trobe — it is an INTERNATIONAL consensus statement and must never be presented as an Australian guideline.

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Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 32

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2024Mostafaee et al. (2024). Examining the diagnostic accuracy of common physical examination and functional tests in the diagnosis of patellofemoral pain syndrome among patients with anterior knee pain. Physiotherapy theory and practice, 40(4), 843-855. https://doi.org/10.1080/09593985.2022.2158053
2018Smith et al. (2018). Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis. PloS one, 13(1), e0190892. https://doi.org/10.1371/journal.pone.0190892
2023van Leeuwen et al. (2023). Patellofemoral pain in general practice: the incidence and management. Family practice, 40(4), 589-595. https://doi.org/10.1093/fampra/cmad087
2016Rathleff et al. (2016). Is Knee Pain During Adolescence a Self-limiting Condition? Prognosis of Patellofemoral Pain and Other Types of Knee Pain. The American journal of sports medicine, 44(5), 1165-71. https://doi.org/10.1177/0363546515622456
2019Rathleff et al. (2019). Five-year prognosis and impact of adolescent knee pain: a prospective population-based cohort study of 504 adolescents in Denmark. BMJ open, 9(5), e024113. https://doi.org/10.1136/bmjopen-2018-024113
2019Willy et al. (2019). Patellofemoral Pain. The Journal of orthopaedic and sports physical therapy, 49(9), CPG1-CPG95. https://doi.org/10.2519/jospt.2019.0302
2024Neal et al. (2024). Best practice guide for patellofemoral pain based on synthesis of a systematic review, the patient voice and expert clinical reasoning. British journal of sports medicine, 58(24), 1486-1495. https://doi.org/10.1136/bjsports-2024-108110
2018Collins et al. (2018). 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. British journal of sports medicine, 52(18), 1170-1178. https://doi.org/10.1136/bjsports-2018-099397
2010Collins et al. (2010). Predictors of short and long term outcome in patellofemoral pain syndrome: a prospective longitudinal study. BMC musculoskeletal disorders, 11, 11. https://doi.org/10.1186/1471-2474-11-11
2019Neal et al. (2019). Risk factors for patellofemoral pain: a systematic review and meta-analysis. British journal of sports medicine, 53(5), 270-281. https://doi.org/10.1136/bjsports-2017-098890
2020Rathleff et al. (2020). Pain, Sports Participation, and Physical Function in Adolescents With Patellofemoral Pain and Osgood-Schlatter Disease: A Matched Cross-sectional Study. The Journal of orthopaedic and sports physical therapy, 50(3), 149-157. https://doi.org/10.2519/jospt.2020.8770
2014Hinman et al. (2014). Is patellofemoral osteoarthritis common in middle-aged people with chronic patellofemoral pain?. Arthritis care & research, 66(8), 1252-7. https://doi.org/10.1002/acr.22274
2013Nunes et al. (2013). Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine, 14(1), 54-9. https://doi.org/10.1016/j.ptsp.2012.11.003
2012Cook et al. (2012). Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy, 98(2), 93-100. https://doi.org/10.1016/j.physio.2011.09.001
2023Kotrych et al. (2023). Delay in Diagnosis and Treatment of Primary Bone Tumors. Ortopedia, traumatologia, rehabilitacja, 25(1), 9-22. https://doi.org/10.5604/01.3001.0053.4026
2023Ziskin et al. (2023). Anterior knee pain in young athletes: Osgood Schlatter or Sinding-Larsen-Johansson disease?. JAAPA : official journal of the American Academy of Physician Assistants, 36(10), 1-3. https://doi.org/10.1097/01.JAA.0000977724.84515.ff
2022Rathleff et al. (2022). The 45-second anterior knee pain provocation test: A quick test of knee pain and sporting function in 10-14-year-old adolescents with patellofemoral pain. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine, 53, 28-33. https://doi.org/10.1016/j.ptsp.2021.11.002
2021Collins et al. (2021). Patellofemoral alignment, morphology and structural features are not related to sitting pain in individuals with patellofemoral pain. The Knee, 28, 104-109. https://doi.org/10.1016/j.knee.2020.10.009
2025van Paassen et al. (2025). Knee alignment and patella shape are not associated with the persistence of patellofemoral pain. Journal of ISAKOS : joint disorders & orthopaedic sports medicine, 12, 100849. https://doi.org/10.1016/j.jisako.2025.100849
2021Ho et al. (2021). Selective Atrophy of the Vastus Medialis: Does It Exist in Women With Nontraumatic Patellofemoral Pain?. The American journal of sports medicine, 49(3), 700-705. https://doi.org/10.1177/0363546520982244
2021Alsaleh et al. (2021). Local neuromuscular characteristics associated with patellofemoral pain: A systematic review and meta-analysis. Clinical biomechanics (Bristol, Avon), 90, 105509. https://doi.org/10.1016/j.clinbiomech.2021.105509
2014Rathleff et al. (2014). Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. British journal of sports medicine, 48(14), 1088. https://doi.org/10.1136/bjsports-2013-093305
2020Winters et al. (2020). Comparative effectiveness of treatments for patellofemoral pain: a living systematic review with network meta-analysis. British journal of sports medicine, 55(7), 369-77. https://doi.org/10.1136/bjsports-2020-102819
2022Neal et al. (2022). Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy, 52(11), 750-768. https://doi.org/10.2519/jospt.2022.11359
2023Hansen et al. (2023). Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial. British journal of sports medicine, 57(20), 1287-1294. https://doi.org/10.1136/bjsports-2022-106197
2019Rathleff et al. (2019). Activity Modification and Load Management of Adolescents With Patellofemoral Pain: A Prospective Intervention Study Including 151 Adolescents. The American journal of sports medicine, 47(7), 1629-1637. https://doi.org/10.1177/0363546519843915
2020de Oliveira Silva et al. (2020). Patient Education for Patellofemoral Pain: A Systematic Review. The Journal of orthopaedic and sports physical therapy, 50(7), 388-396. https://doi.org/10.2519/jospt.2020.9400
2008Collins et al. (2008). Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. BMJ (Clinical research ed.), 337, a1735. https://doi.org/10.1136/bmj.a1735
2014Barton et al. (2014). Patellar taping for patellofemoral pain: a systematic review and meta-analysis to evaluate clinical outcomes and biomechanical mechanisms. British journal of sports medicine, 48(6), 417-24. https://doi.org/10.1136/bjsports-2013-092437
2019Bramah et al. (2019). A 10% Increase in Step Rate Improves Running Kinematics and Clinical Outcomes in Runners With Patellofemoral Pain at 4 Weeks and 3 Months. The American journal of sports medicine, 47(14), 3406-3413. https://doi.org/10.1177/0363546519879693
2019Bartholomew et al. (2019). Altered pain processing and sensitisation is evident in adults with patellofemoral pain: a systematic review including meta-analysis and meta-regression. Scandinavian journal of pain, 20(1), 11-27. https://doi.org/10.1515/sjpain-2019-0079
2019Crossley et al. (2019). Rethinking patellofemoral pain: Prevention, management and long-term consequences. Best practice & research. Clinical rheumatology, 33(1), 48-65. https://doi.org/10.1016/j.berh.2019.02.004

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