Patellofemoral Pain: Running Gait Retraining Explained

Patellofemoral pain (PFP) is one of the most common musculoskeletal conditions in runners.
Evidence-based guidelines emphasise exercise therapy, education, and addressing movement patterns, but many patients continue to struggle despite prior physiotherapy.

In his Case Study, expert PFP physiotherapist Dr Bradley Neal shares the story of a runner who came to him as a last resort to return to pain-free running. This blog highlights the running retraining strategies Bradley used, so you can apply them in your own practice.

If you want to see exactly how expert PFP physio Dr Bradley Neal assessed and managed a real patient with PFP, check out his 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.

Background

The patient was a 31-year-old female runner with a two-year history of right-sided anterior knee pain.

Her symptoms gradually appeared with increases in running volume. She had recently been advised to “forget about returning to running” following a specialist’s diagnosis of chondromalacia patellae. At the time she came to see Bradley, she had not run for six months and reported relatively low pain levels (3/10) and an Anterior Knee Pain Scale (AKPS) of 72/100 (where 100 indicates no pain).

On assessment, there were no significant strength differences in hip or knee musculature, no signs of hypermobility, or clinically relevant foot biomechanics issues. So what next?

Bradley usually categorises second-opinion PFP patients into three groups: misdiagnosed, mistreated, or those who truly have a poor prognosis. Importantly, many people can fall in the latter group, with approximately 50% of people with PFP remaining symptomatic 5–8 years post-diagnosis, Bradley was hoping this was not the case with his patient.

The objective assessment confirmed the PFP diagnosis and ruled out any clinically relevant deficits that could explain her symptoms. The final piece of the puzzle was a detailed analysis of her running mechanics through objective gait assessment.

Gait analysis and retraining

First of all, objective gait analysis does not always require complex equipment, watch Bradley explain how he conducts a treadmill gait analysis in this clip from his Case Study:

It’s important to note that while strength training has many benefits, it does not change running kinematics. If a gait pattern is contributing to the problem, running retraining is the most effective approach. Watch Bradley explain what he observed in his patient in this snippet from his Case Study:

Bradley outlines some of the most common approaches to gait retraining for PFP, including:

1. Hip adduction retraining: subtle, difficult to observe, but can help reduce medial knee stress.
2. Transition to forefoot running: visible in video analysis, though 25% of runners may develop secondary calf or Achilles issues.
3. Minimalist footwear adaptation: biomechanical changes are evident, but again secondary issues can occur.
4. Increasing step rate: a reliable, low-risk intervention to address overstride mechanics.

Step rate retraining

Bradley selected step rate retraining to address his patient’s overstriding without risking secondary problems. He explains some of the benefits of this approach in the below video from his Case Study:

Before retraining began, education was the first priority. This usually involves a tailored approach, aiming to:

1. Challenge inaccurate beliefs.
2. Explain that pain does not always correlate with tissue damage.
3. Outline the recovery journey and expected timelines.
4. Promote autonomy, confidence and reduce fear.

The retraining was conducted on a treadmill at the same speed used during assessment. Bradley implemented a 12-week program which gradually increased running load, while reducing the patient’s reliance on metronome feedback. It looked like:

1. Weeks 1–7: Intermittent run-walk sessions, gradually increasing continuous running while reducing use of metronome.
2. Week 7-12: Metronome removed, continuous running with consolidated step rate mechanics. Gradually increasing distance.

The results were excellent. After seven weeks of the program, the patient reported an AKPS of 96/100 and pain of just 1/10 during running sessions! And after the full program, she was able to run long distance, no longer needing to “forget about returning to running”.

Wrapping up

This case provides a window into the clinical reasoning of an expert physiotherapist, demonstrating how thorough assessment and thoughtful problem-solving can uncover the root causes of persistent PFP.

It also highlights the powerful impact that targeted gait retraining can have when applied appropriately, even when strength deficits or structural issues are minimal, reinforcing its value as a practical tool for helping runners return to pain-free activity. By combining evidence, clinical reasoning, and patient-centred strategies, physios can guide runners with long-standing PFP safely and successfully back to running.

Want to see exactly how Dr Bradley Neal managed this case? Watch his full Case Study HERE.