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Patellofemoral pain syndrome

Updated: Jun 22, 2020

hands holding knee with red highlight on knee

Patellofemoral pain syndrome (PFP-S) is one of the most common conditions that affects cyclists at any level. It manifests gradually rather than from a specific injury and is characterised by pain felt anywhere around the front of the kneecap.

In simple terms it is pain that is arising from any of the structures associated with the kneecap (patellofemoral) joint. It is classified as an overuse injury as in most cases it arises without any inciting traumatic episode or crash - though this can also be a cause of persistent knee pain symptoms.

What causes Patellofemoral pain syndrome?

In simple terms the cause of patellofemoral pain can be associated with any of the structures around the kneecap (patellofemoral) joint. The repetitive motion of the kneecap can lead to overloading on these strucutres which can lead to sensitivity or inflammation. However it is very common not to find any 'pathology' on an MRI scan of a knee PFP. Clinically it is established as a diagnosis of exclusion - i.e. if there are no other plausible diagnoses from examination then PFP is the most likely source of the problem.

Risk Factors

  • Patella alta (a high riding patella)

  • Trochlear dysplasia (essentially a too shallow groove for the kneecap to sit in)

  • It is more common in females (twice as common)

  • Quadriceps and gluteal muscle weakness

  • Changes in training load such as increasing volume or intensity without adequate time for the body to adapt can lead to overstrain at the knee.

  • Unsuitable bike fit or set up is also a key concern in developing this problem. A rider can often cope with a set-up that is sub-optimal when training volume is lower but as soon as they start to build up (for race season, a sportive, cycling holiday) the problems can start to arise.

What are the symptoms?

  • Pain at the front of the knee around the kneecap, it can be vague in early stages but often becomes very sharp.

  • Clicking or catching is often described though it is well evidenced that this is rarely if ever the cause or related to the pain itself and it is not indicative of knee damage.

  • Pain during the downstroke (power phase) of pedaling, walking down stairs, or performing a squat on one leg.

  • Occasionally there is swelling but more so in chronic cases where the symptoms have been ignored and training loads have continued to be maintained.

How can I manage Patellofemoral pain syndrome?

Activity Modification

  • In most cases you will need to dial back either riding intensity or volume, or both. It is best to try and reduce intensity first as you may be able to continue to maintain some of your training volume with less intense efforts. However, if there are still symptoms when hard efforts are removed then it is crucial to drop overall volume, introduce rest days and start to look for other ways to maintain cardiovascular fitness without aggravating your knee symptoms - swimming is often a great low impact way to do this.

  • When there is a drop in intensity in cycle specific training it is a good idea to look for this elsewhere - the silver lining here is that it can be the perfect opportunity to place your focus on an area of your training you have been ignoring - eg strength training, core stability, flexibility etc.

Bike Fit

  • Incorrect saddle height is the primary bike fitting or positional fault that will be leading many cyclists to developing PFP. In amateur cyclists it tends to be a saddle that is slightly too low whether as in more experienced cyclists we often see the reverse.

  • The other issue that crops up regularly is a reach that is too long or a drop to the handlebars that is too low. Both of these factors can pull the rider forward to the point where they are not only pedaling using there knees but also supporting their body weight - the result of which will quite quickly be PFP.

  • Bike Fit is a complex relationship of multiple variables and it is important to remember that changing the position of one component will have knock on effects on all other areas.

  • As always, seeing a competently trained professional bike fitter that is able to look at all of the possible variables associated with your current set up is vital. In addition to that it is important that your fitter has an understanding of cycling injuries as they significantly influence fitting decisions.

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  • Strength Training Cyclists and endurance athletes alike tend to avoid strength training like the plague for fear they will bulk up and the have to carry around this excessive weight. This belief is wide of the mark as while you will be able to make significant changes in your strength it is unlikely you will bulk up too much due to the effect endurance training has on muscle bulk gain. Strength training is an absolute must for nearly all cyclists suffering with patellofemorl pain. Most cases of patellofemoral pain will demonstrate common patterns of muscle weakness. In order of priority they are quads, glute medius, glute max, and hamstrings.

  • Taping Various forms of taping can be quite useful in modifying the symptoms around the front of the knee and are a great option in the short term BUT, they will not cure the issue.

  • Sports Massage A skilled sports masseur or physiotherapist can make a big difference to the tension and discomfort felt at the front of the knee by working on the quads. As one of the major workhorse muscle groups in cyclists they often become over burdened. This can leave the quad muscles on the front of the thigh feeling tight, stiff, and uncomfortable. Again, as a standalone treatment it is unlikely to be the solution to the problem.

  • Foam Roller The evidence base for the therapeutic benefit of these devices is admittedly not great but there continues to be a swell of support for their use anecdotally. They will never replace the abilities of a good massage therapist but they can be a good stop gap in applying some post exercise stimulation to the quads.

  • Flexibility It is rare to see a true loss in range of motion at the knee joint with PFP. Despite this, one of the most commonly described symptoms that cyclists with PFP report is ‘tightness’. As such they often carry out extensive stretching programmes to little effect. Having said that, ensuring satisfactory flexibility forms part of a comprehensive treatment approach.

Injection Therapy

There are various injections considered to be helpful in cases of PFP that do not settle with conservative measures. However, each need to be carefully considered as they are not without side-effects and should never be delivered as a stand-alone treatment for PFP. The most common injections offered are:

  • Corticosteroid Injection​

  • Hyaluronic Acid (e.g Ostenil, Durolane etc)

  • Platelet Rich Plasma (PRP)


  • Many surgical interventions for PFP are not well supported in the literature, largely due to t​o the fact that there is often very little in the way of demonstrable (via imaging such as MRI) structural tissue change or 'faults' that can be corrected.

  • However there are a number of underlying anatomical risk factors that may precipitate to PFP such as a shallow trochlear groove (the groove the knee cap sits in), patella alta (a high patellar position). There may be a role for surgery in cases where these factors have been identified and are considered to be contributing to the clinical presentation where conservative measures have not succeeded.

What else could it be?

If you are having issues with your knee and want to get in touch about booking a consultation or a bike fit then please email us:



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