Runner’s Knee (PFPS): Best Treatments and What to Avoid
In this deep dive installment on Runner’s Knee or patellofemoral pain syndrome (PFPS), the next logical question is how do you treat it? We have already established that runner's knee is difficult to treat with over 50% of cases lasting 18+ months and another 50% of people having a recurrent episode within a year. Part of this problem may be due to a history of misinformation, poor previous treatments, and passive approaches that contributed to lasting symptoms. In this blog, I will review these outdated methods or what to avoid for runner’s knee treatment. I will then provide a guide on the current best practices and treatment approaches to help solve your runner’s knee for good.
The DON’Ts of Runner’s Knee Treatment
DON’T: Waste your time (or money) on passive therapy
Although passive therapies may feel good temporarily, we currently have no evidence to show they help in the treatment of PFPS. This would include treatments such as dry needling, vibration therapy, hyaluronic acid injections, and massage. Dry needling has gained mainstream popularity to treat a variety of conditions recently. However, it has not been shown to be effective with PFPS. Multiple high quality meta-analyses and large research studies show dry needling, alone or with exercise, does not improve treatment outcomes. So for now, it is recommended to save your money on the passive therapies and put your time towards ones that work.
DON’T: Obsess on how to fix patellar tracking
As discussed in our last blog, we no longer need to fixate on patellar tracking in order to “fix” runner’s knee. Targeted exercises for the VMO have consistently been shown to produce worse outcomes compared to general hip/knee strengthening. Even with use of patellar taping, be aware of the reasoning behind it. The tape is not able to “realign” how your kneecap moves, but it may provide some temporary relief. Keep reading to find out more about taping.
DON’T: Fall into the boom or bust cycle
Trying complete rest and immobilization is rarely ever the best treatment for running injuries and this would hold true for PFPS. When you allow for complete rest or immobilization this further reduces your capacity or envelope of function (see last blog for more) which increases knee sensitivity even more. Further, trying to ramp back to 100% once your knee feels a little better is not the way to go either. We want to avoid high activity peaks, and periods of inactivity when managing PFPS.
DON’T: Make drastic footwear changes
High stack height, soft shoes may seem like they protect knees but in reality they do more harm than good for those with runner’s knee. We have studies showing that max cushion shoes increase knee joint forces by up to 20% per step! This high impact can contribute to the excessive loads on the knee that may be causing symptoms in the first place. However, this does not mean to go jumping straight into a pair of minimalist shoes. A gradual transition between shoe types is key to avoid secondary injuries.
DON’T: Ignore the rest of your body
No pain, no gain? I think not. Your body is more than just a knee that hinges to let you move. You are a person who has stress at work and home, fears about your knee and when you'll be able to return to normal, and a sleep schedule that never allows you to fully recover. All of these must not be ignored if you want to fully treat your runner's knee.
The DO’s of Runner’s Knee Treatment
DO: Gain Understanding of your pain
Understanding your knee pain is the first key to creating a path towards recovery. Pain in the knee does not always equal damage. Think of the pain as an alert system, it is telling the brain it feels something but it is not saying that damage is occurring. Sometimes this alert system can become recalibrated to send very intense pain signals when in reality there is nothing significant happening. Further the sounds of clicking, popping, and grinding are quite normal for the knee joint. These sounds are most likely due to the helpful fluid in your joint lubricating it rather than cartilage wearing away or bone on bone damage.
DO: Prioritize a progressive hip and knee strength program
Strength training is a must with runner’s knee. At some point, there was a mismatch between what you were doing and what your body could handle. Strength training for the hip and knee is used to build up what your body can handle. Combined practice of knee exercises on machines and weight bearing along with hip exercises have shown to be the most effective ways to build leg capacity. In our next blog we will go into more specific as to which exercises may be the most helpful at different stages in treatment.
DO: Use temporary tailored Helpers to manage symptoms
As hinted at earlier, patellar taping can be useful for the acute management of PFPS but should only be viewed as a temporary helper not a fix. The tape can help provide a sense of further knee support especially in those with high sensitivity levels. Minor adjustments to gait such as increasing cadence by 10%, increasing forward trunk lean, and running “softer/quieter” are also recommended for temporary management. These simple changes may keep you running while implementing the “capacity builders” previously discussed
DO: Follow a graded return to activity plan
A graded activity plan is one that slowly builds based on your current level of function. Each person will start at a different level depending on their knee symptoms, sensitivity levels, and activity tolerance. So this means, you must find out what your body can tolerate and function just below the line of symptom flare up. A good rule of thumb is pain greater than 4/10 should be avoided while anything below it can be tolerated. This will allow your body to slowly build its capacity while avoiding excessive load too early which could cause a flare up.
DO: Address lifestyle factors
Sleep is arguably the most cost effective and tissue healing treatment for runner’s knee. Proper sleep allows the body time to rebuild tissue that may be injured, improve tissue tolerance to load and help increase your pain tolerance levels. Other factors such as anxiety, depression, and pain catastrophizing are necessary to manage in order to treat PFPS. Seeking the right medical provider depending on your situation is key. Finally, proper nutrition that focuses on anti-inflammatory foods and supplements like omega-3 can further speed up your recovery process.
The best treatment for PFPS may not always be doing more treatment. Sometimes it is slowing down to allow for more sleep, modifying current activity, and selecting the right exercises for your current tolerance level. Building your body's capacity through consistent activity and graded progression will always trump quick fixes and passive treatments.
If you live in the CSRA and are ready to have personalized guidance to get back to running, schedule a call today!
Disclaimer: This information is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or health-related goals.
References
Esculier, J.-F., Maggs, K., Maggs, E., & Dubois, B. (2020). A contemporary approach to patellofemoral pain in runners. Journal of Athletic Training, 55(12), 1206–1214. https://doi.org/10.4085/1062-6050-0535.19
Gragnani, B. C., Hart, H. F., Forsyth, A., Barton, C. J., & De Oliveira Silva, D. (2026). Patellofemoral pain is a multifactorial complex condition; are we missing a multidisciplinary approach to its management? Time for a paradigm shift. Open Access Journal of Sports Medicine, 16, 517971. https://doi.org/10.2147/OAJSM.S517971
Neal, B. S., Lack, S. D., Bartholomew, C., & Morrissey, D. (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
Nielsen, R. Ø., Parner, E. T., Nohr, E. A., Lind, M., & Rasmussen, S. (2014). Excessive progression in weekly running distance and risk of running-related injuries: An association which varies according to type of injury. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 739–747. https://doi.org/10.2519/jospt.2014.5164
Rathleff, M. S., Graven-Nielsen, T., Hölmich, P., 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
Teng, H.-L., & Powers, C. M. (2014). Sagittal plane trunk posture influences patellofemoral joint stress during running. Journal of Orthopaedic & Sports Physical Therapy, 44(10), 785–792. https://doi.org/10.2519/jospt.2014.5249
