Patellofemoral Pain Syndrome (Runner's Knee): Why Your Knee Hurts—And What Actually Helps
- Julia Cole
- Aug 12
- 4 min read
By Julia Cole, CAT(C) – Proactive Therapy | Athletic Therapy in Victoria, BC
Pain around the front of the knee is one of the most common injuries I see in runners, soccer players, hikers, gym-goers, and active adults. It's often referred to as Patellofemoral Pain Syndrome (PFPS) or Runner's Knee, but despite how common it is, there are still many misconceptions about what causes it and how to treat it.
If you've been told to "just rest," avoid letting your knees go over your toes, or spend all your time stretching, you may be surprised to learn that current research tells a different story.
What Is Patellofemoral Pain Syndrome?
Patellofemoral pain refers to pain around or behind the kneecap (patella). It often develops gradually rather than after one specific injury and is typically aggravated by activities that place higher loads through the patellofemoral joint.
Common aggravating activities include:
Running
Walking downhill
Squatting
Lunges
Going up or down stairs
Jumping
Sitting for prolonged periods (sometimes called the "movie theatre sign")
Although the pain is felt in the knee, the reason it develops is often more complex than simply "a bad knee."
What Actually Causes Patellofemoral Pain?
One of the biggest myths is that the kneecap is "out of place" or "tracking incorrectly."
While movement of the kneecap can contribute in some cases, current evidence suggests patellofemoral pain is usually the result of the joint being asked to tolerate more load than it currently has the capacity to handle.
That increased load can come from many factors, including:
Increasing running mileage too quickly
Returning to sport after time off
A sudden increase in hiking or stair climbing
Reduced strength through the hips or quadriceps
Poor recovery between training sessions
Changes in training intensity or frequency
The important takeaway?
Pain doesn't necessarily mean something is damaged—it often means your knee needs greater capacity for the demands you're placing on it.
Why Rest Alone Usually Isn't the Answer
It's natural to think that if your knee hurts, you should stop exercising completely.
While a short period of reducing aggravating activities may be appropriate, complete rest is rarely the best long-term solution.
In fact, if the knee never gets progressively loaded again, it never develops the strength and capacity needed for running, hiking, soccer, or everyday life.
Instead, the goal is to find an amount of activity your knee can tolerate while gradually rebuilding strength.
Is It Really My Knee?
Sometimes.
But not always.
As an Athletic Therapist, I rarely assess the knee in isolation.
I'll also look at:
Hip strength
Glute control
Ankle mobility
Single-leg balance
Squatting mechanics
Running or sport-specific movement (when appropriate)
Training history and recent changes in activity
Two people can have the same diagnosis but require completely different rehabilitation plans depending on why their symptoms developed.
What Does the Research Say Works Best?
The strongest evidence supports exercise therapy, particularly a combination of hip and knee strengthening exercises. This approach has been shown to reduce pain and improve function in both the short and long term.
Some of my favourite exercises include:
Bulgarian split squats
Split stance hip hinges
Lateral step-downs
Single-leg calf raises
Hip thrusts
Leg press or knee extensions (when appropriate)
The exact exercises matter less than ensuring they are progressively loaded and tailored to your goals.
What About Stretching?
Stretching can feel good, and if you have a specific mobility restriction, it may be part of your treatment plan.
However, stretching alone rarely addresses the root cause of patellofemoral pain.
For most people, improving strength, movement quality, and load tolerance has a much greater impact on long-term recovery than spending more time stretching.
Should I Avoid Letting My Knees Go Over My Toes?
This is another common misconception.
For years, people were told that allowing the knees to travel over the toes was harmful.
In reality, your knees naturally move over your toes during many everyday activities, including walking downstairs, getting out of a chair, hiking, and running.
Rather than avoiding this movement, rehabilitation often involves gradually exposing the knee to it in a controlled and progressive way so the joint becomes stronger and more tolerant.
The key isn't avoiding knee-over-toe movement—it's ensuring your body has the strength and control to perform it comfortably.
Can I Keep Running?
Often, yes.
Many people with patellofemoral pain don't need to stop running completely.
Instead, we modify:
Weekly mileage
Speed work
Hills
Running frequency
A common guideline is that mild discomfort during exercise (up to about 3/10) is acceptable if it settles shortly afterward and isn't worse the next day.
Keeping some running in your program—when appropriate—often helps maintain fitness and makes the return to full training smoother.
How Athletic Therapy Can Help
At Proactive Therapy, I take an active, evidence-based approach to treating patellofemoral pain.
Your assessment may include:
Strength testing
Hip and ankle mobility
Single-leg movement assessment
Squat and lunge mechanics
Running or sport-specific assessment
Training load review
From there, we'll develop a personalized rehabilitation plan that focuses on building strength, improving movement, and helping you return to the activities you enjoy with confidence.
The Bottom Line
Patellofemoral pain can be frustrating, but it's also one of the conditions that responds very well to the right rehabilitation approach.
If you're dealing with knee pain while running, hiking, playing soccer, or simply going up and down stairs, don't assume you just need to rest or stretch more.
Understanding why your knee hurts is the first step toward long-term recovery.
If you're looking for Athletic Therapy in Victoria, BC, I'd be happy to help you get back to doing what you love.
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