How to Apply Best Practice Guidelines for Patellofemoral Pain

Patellofemoral pain (PFP) is a condition physios see frequently, and many feel relatively comfortable assessing and managing. We know exercise works, we know to target the knee and hip, and we’ve all seen patients improve.

But outcomes aren’t always consistent. Some patients do really well, while others plateau or flare despite doing “all the right things”. Often, the difference isn’t whether we prescribe exercise, but how well we apply our knowledge of PFP to the individual in front of us.

Dr Simon Lack shows exactly how he applies the recently developed best practice guidelines for PFP (1) in the clinic. This blog provides a snapshot of how these guidelines can be used in a practical, clinically useful way, from subjective assessment through to exercise prescription.

If you want to see exactly how an expert physio assesses and manages PFP, watch Dr Simon Lack’s full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

Subjective assessment

Simon’s patient is a 23-year-old female presenting with anterior knee pain that has been on and off for two years, now worsening, with pain reaching 6/10 at its worst. She has stopped running entirely due to her symptoms.

At face value, this is a typical PFP presentation. But the role of the subjective isn’t just to confirm the diagnosis, it’s to start identifying what may be driving the pain and what might limit recovery.

Pain severity is already a key feature. A worst pain of 6/10 suggests a relatively high symptom load, which is likely to influence both exercise tolerance and early progression.

Her goals are just as important. She isn’t simply aiming to be pain-free in daily life, she wants to return to regular running. That immediately sets the level of capacity we need to build.

Rather than collecting information in isolation, the subjective helps map the problem against a best practice framework. Which factors are likely to be relevant, and where are the main limitations likely to sit?

See how Simon applied the framework to the subjective interview in this video from his Case Study:

Objective assessment

Within this framework, the objective assessment focuses on several key areas, including pain, strength, movement patterns, tissue tolerance, and patellofemoral joint-related resilience.

Simon often starts with movement pattern assessment. Tasks such as a single leg squat or double leg squat can give you a quick sense of how the patient is loading the limb in functional tasks.

See how he approaches this in the video below from his Case Study:

However, as Simon highlights, movement quality alone doesn’t tell you about strength. Strength needs to be assessed separately, and ideally in a consistent, standardised way. Both hip and knee strength are important, particularly given the strong evidence supporting combined proximal and quadriceps rehabilitation.

From there, it’s important to consider the broader picture. Foot biomechanics and patellofemoral joint function may influence how load is distributed through the joint. Structural factors such as patellofemoral alignment or femoral anteversion can also play a role, and in some cases may place a ceiling on how much improvement is achievable.

Tissue tolerance is another key piece of the puzzle. Reproducing symptoms with palpation can give you a sense of how sensitive the joint is and how much load it’s currently able to tolerate. Bringing all of these findings together is what allows you to move from assessment to decision-making. See how Simon did this in the clip below from his Case Study:

Exercise-based management

We know that exercise is effective for PFP. There is strong evidence supporting both knee-targeted and hip-targeted strengthening, and combining the two is considered best practice. But simply prescribing strengthening isn’t always enough.

Simon approaches exercise prescription in a structured, systematic way, guided by four key considerations.

First is structure. Factors such as potential chondral changes or patella alta may influence how much load the joint can tolerate. This doesn’t mean avoiding load altogether, but it does mean taking a more graded and structured approach to progression.

Next is biomechanics. The movement pattern and strength findings from your assessment should directly inform exercise selection. The aim isn’t just to strengthen in isolation, but to improve how load is controlled and distributed through the limb.

Volume, frequency, and intensity are also important. Many patients either do too much too soon or stop loading altogether. The goal is to keep them exercising, while modifying load to reduce stress on the patellofemoral joint early on, and then progressively building it back up.

Finally, everything sits within a psychosocial context. Barriers to exercise, beliefs about pain, and confidence all influence adherence and outcomes. If these aren’t addressed, even well-designed programmes can fall short.

The key question isn’t just what exercises to prescribe, but how those exercises target the mechanisms driving the patient’s symptoms.

Wrapping up

Patellofemoral pain is a multifactorial condition, and while exercise remains the cornerstone of management, outcomes depend on our clinical reasoning and how well we tailor our management to the individual.

The subjective assessment helps identify what matters, while the objective assessment clarifies which factors are contributing and guides your management plan. Using a best practice framework supports this process and helps structure your clinical reasoning in practice.

Want to see exactly how an expert applies it to a real patient case? Watch Dr Simon Lack’s full Case Study here.