An Overview of the Patellofemoral Pain Best Practice Guide

Patellofemoral Pain (PFP) is an incredibly common condition seen by physios, and for this reason there is a large and ever-growing body of research, alongside a wide range of clinical approaches.

Being so common, there’s no shortage of opinions on how best to manage it. For a condition that can significantly impact quality of life, it’s important we’re not just following habits, but actually aligning with the best available evidence.

Experts in the field, Dr Simon Lack and Dr Bradley Neal, have worked with a team to develop a best-practice guide (1) that combines high-quality research with expert clinical reasoning and lived experience. This blog gives an overview to bring physios up to speed with the guide.

If you want to learn exactly how these recommendations were developed and how to apply them clinically, you can watch the full Masterclass with Dr Simon Lack and Dr Bradley Neal here.

How were they developed?

The guide is based on a synthesis of high-quality systematic reviews alongside qualitative input from both expert clinicians and people with PFP. Only the highest quality evidence was included, with qualitative work layered on top to ensure the recommendations reflected both clinical expertise and lived experience.

What interventions are important?

Looking purely at the research, a few consistent patterns emerge.
Hip-targeted and knee-targeted exercise produce similar outcomes. Foot orthoses also show comparable effects to hip-focused exercise. See Bradley explain some of the key evidence-based findings in this snippet from his Masterclass:

On the flip side, a number of commonly used additions don’t appear to offer meaningful benefit. Adding dry needling, vibration therapy or injections such as hyaluronic acid to a well-structured exercise programme does not improve outcomes.

Across the meta-analysis, six interventions were found to be better than doing nothing:

1. Knee-targeted exercise.
2. Combined interventions (patellar retinacular soft tissue work + taping + neuromuscular stimulation + exercise).
3. Foot orthoses.
4. Lower quadrant manual therapy.
5. Hip-and-knee targeted exercise.
6. Knee-targeted exercise combined with perineural dextrose injection.

However, this only tells part of the story. Many interventions commonly used in practice, such as education, running retraining and psychological approaches, haven’t been adequately tested in high-quality trials. This is where expert opinion and lived experience came in.

When everything was combined, a clearer structure emerged. Education underpins management. Knee-targeted exercise is prioritised. Hip and knee exercise, along with foot orthoses, sit as useful options depending on the patient. Manual therapy, movement or running retraining, and taping can be used where appropriate, but are not essential for everyone. Combined interventions were excluded from the guide, as they were not commonly used and lacked clarity on how to implement them in practice.

Where does education fit?

Education is positioned as a foundation of best practice, even though the research evidence alone isn’t strong enough to justify that decision.

A 2020 systematic review (2) found that education delivered by a health professional, when combined with exercise, produced similar outcomes to education alone. However, the certainty of this evidence was low, and there are no high-quality trials comparing education to no treatment, making it difficult to quantify its standalone effect.

Despite this, both clinicians and patients consistently highlight its importance. In practice, this means being deliberate with education. It’s not just reassurance or generic advice, but helping patients understand their symptoms, set realistic expectations, and engage with rehabilitation in a meaningful way.
See Simon explain how he integrates education in this video from his Masterclass:

Exercise prescription

Exercise remains central, but how it’s prescribed matters.

A key takeaway is accepting that no single approach works for everyone. Even knee-targeted exercise, despite being a cornerstone, won’t be effective for all patients. This reinforces the need for tailored programmes.

The guide provides some structure around knee-targeted exercise, but the real skill lies in applying this to the individual. Exercises should be selected based on symptoms, goals and response to loading, rather than applying the same template across every patient with PFP. Progression should be guided by each individual patient’s response.

See Bradley explain how to approach exercise prescription in this clip from his Masterclass:

Wrapping up

The best-practice guide doesn’t introduce a completely new way of treating PFP, nor should it be seen as a recipe. What it does is provide clarity around what matters, and a structure to support clinical reasoning in practice.

Education forms the foundation, knee-targeted exercise is a priority, other interventions such as hip strengthening, orthoses and manual therapy can be used selectively. Perhaps most importantly, more treatment is not necessarily better treatment.

For clinicians, this guide provides a useful foundation to understanding what to prioritise, what to leave out, and how to tailor management to the individual in front of you.

If you want to see how the guide was developed and how to apply it clinically, watch the full Masterclass from Dr Simon Lack and Dr Bradley Neal here.