4 Clinical Strategies for Challenging Patellofemoral Pain Cases

Patellofemoral pain (PFP) is something most physiotherapists see a lot. With good education and a structured, progressive exercise program, many patients can improve steadily.

But sometimes there are the tougher cases, the patients who stagnate or get stuck in recurrent flares. They’ve already stopped taking stairs, stopped running, and often stopped doing the things that once made them feel strong. These are the people who need that little extra something, additional to the top-notch education and exercise you’re already giving them. In many cases, some well-chosen interventions can help them get moving again. This blog covers a few options to keep up your sleeve for your next tricky PFP patient.

If you’d like to see exactly how expert physio Dr Natalie Collins manages PFP, watch her full Practical here. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

1. Taping

Taping is never the main event in PFP rehab, but it can be a brilliant adjunct you can test straight away, particularly for patients struggling to tolerate early-stage exercise. When pain reduces, confidence tends to follow. See Natalie demonstrate how to tape in this clip from her Practical:

Medial glide taping can be added when appropriate, especially if the patient responds well to a manual medial glide during your assessment. When done correctly, taping can make stair tasks, squats, and even walking immediately more tolerable. Once patients see they can move with less pain, adherence to exercise will likely improve.
NOTE: Beware of a common pitfall in medial glide taping: don’t apply too much tension, this can compress the joint and lead to irritation!

2. Graded exposure and thoughtful regression

Okay, while these strategies aren’t strictly separate from exercise-based rehab, they’re important to keep in mind when a progressive program just isn’t landing as expected.

Fear avoidance behaviours are incredibly common in PFP. Patients often stop using stairs, stop squatting, or avoid loading one leg because it feels unsafe or painful.

The aim is to break this avoidance cycle through graded exposure, helping them do the very things they’re scared of, but in a controlled, confidence-building way. Take the step up. It’s simple, functional, and one of the most valuable exercises for this population. It’s important to first teach how to do the step up, to give the patient a sense of control rather than fear:

• Stand close to the step
• Place foot firmly on step
• Knee tracks naturally over second toe
• Squeeze buttock as you push up through your heel
• Finish tall

For kinesiophobic patients, begin with a very minimal rise, as small as it needs to be for the patient to feel confident. The goal is exposure, not strength at this stage. Progress happens quickly once confidence increases.

Not all regressions are about fear, though. Some patients simply aren’t ready for certain movements yet. The single-leg squat, for example, is a key exercise in PFP rehab, particularly for runners and jumping athletes, but many patients initially lack the trunk control or hip stability to perform it well. Rather than forcing a movement they can’t coordinate, regress it. See Natalie demonstrate a great regression you can use in the below video from her Practical:

3. Orthotics

Orthotics fall into the same category as taping: not essential for everyone, but can be extremely helpful as an adjunct for the right patient.

The research shows that orthotics can reduce PFP symptoms, especially early in rehab when tissues are sensitive to load. Interestingly, the evidence doesn’t favour custom orthotics over prefabricated ones. Most studies use prefabricated devices – this is good news as it keeps things simple and cost-effective.

A useful starting point is a prefabricated orthotic with the option to modify using wedges. Many clinicians begin with a rearfoot varus wedge, adjusting based on comfort and symptom response. If the patient feels better immediately when walking around the clinic, you’re likely on the right track.

4. Manual therapy

Manual therapy can be a controversial topic, but the reality is that many successful multimodal clinical trials include it as part of treatment.

When used wisely, it can help reduce pain enough for patients to engage in meaningful movement. And you can even teach self-mobilisations to the particularly savvy patients!

Medial glides of the patella are commonly used and can be tailored based on whether you’re targeting stiffness or pain modulation. Gentle soft tissue work around the lateral retinaculum can help desensitise local structures, particularly in patients reporting lateral patellar tenderness.

Another valuable technique covered in the Practical is a dorsiflexion mobilisation-with-movement at the ankle. Limited dorsiflexion can alter hip and knee mechanics during squatting and running, increasing stress on the patellofemoral joint. Improving dorsiflexion can make downstream movements feel more natural and reduce excessive knee load.

Wrapping up

Education and exercise are the foundational components of effective PFP management, but when someone is fearful, overloaded, or just not progressing, the right in-clinic strategies can make a big difference.

Graded exposure, thoughtful regressions, taping, orthotics, and targeted manual therapy all help patients feel safer and more confident during movement. And once confidence improves, rehabilitation becomes far easier and more effective.

Watch Dr Natalie Collins’ full Patellofemoral Pain Management Practical to see exactly how an expert manages a patient in clinic.