Patellofemoral Pain Syndrome (Runner's Knee): Causes, Symptoms & Treatment in Burlington

What Is Patellofemoral Pain Syndrome (Runner's Knee)?

You head out for your usual run along Spencer Smith Park, and somewhere around the 4 km mark you feel a dull ache creep in around the front of your kneecap. Maybe it shows up walking down the stairs at home, or after sitting through a long meeting and then standing up. It's not sharp. It's not catastrophic. But it's there, and it isn't going away. If that sounds familiar, there's a good chance you're dealing with patellofemoral pain syndrome — better known as runner's knee — and it's one of the most common reasons people walk into our clinic this time of year.

Patellofemoral pain syndrome (PFPS) is pain that comes from the joint between your kneecap (patella) and your thigh bone (femur). When you bend and straighten your knee, the kneecap glides through a groove on the front of the femur. When the load going through that joint exceeds what the surrounding tissues can handle, you start to feel it. The pain is usually felt directly behind, around, or just below the kneecap, and it tends to flare up with activities that load the knee in a bent position — running (especially downhill), squatting, going up and down stairs, and that famously annoying "movie-goer's sign" where your knee aches after sitting still for too long.

At Pursuit Physiotherapy, patellofemoral pain syndrome treatment in Burlington is a core part of what we do, and we see PFPS constantly in spring. Burlington runners are ramping up their mileage for summer races, cyclists are getting back on the road, and recreational athletes are jumping back into pickleball, basketball, and soccer after a quieter winter. The sudden spike in load is exactly when this condition shows up.

Why Patellofemoral Pain Develops

There's no single cause of PFPS. It's almost always a combination of factors that push the knee past its current capacity. Understanding what's driving it matters — because the right treatment depends on identifying the right contributors.

• Training errors — A sudden jump in running volume, adding hill repeats too aggressively, or starting a new sport without building a base. The tissues haven't had time to adapt.

• Hip and glute weakness — Weak hip abductors and external rotators (think glute medius and glute max) let the thigh collapse inward when you load the leg, which changes how the kneecap tracks. This is one of the most consistent findings in the research on PFPS.

• Quadriceps strength deficits — The quads control how the kneecap glides. When they're weak or fatigued, the joint takes more load than it should.

• Movement patterns — How you land when you run, how deep your knee caves in during a squat, how your foot strikes the ground. These patterns are trainable, but they don't change without deliberate work.

• Footwear and surface changes — Switching shoes, adding road miles after a winter on the treadmill, or running too many kilometres on the same hard surface.

• Female anatomy — A wider pelvis changes the angle the quad pulls on the kneecap. It's not destiny, but it does mean women statistically develop PFPS at higher rates and tend to respond especially well to targeted strengthening.

For most of our Burlington patients, it's a mix of two or three of these working together — often a training spike on top of a hip strength deficit they didn't know they had.

Signs and Symptoms to Watch For

Where the pain shows up

• Aching pain around or behind the kneecap, often hard to point to with one finger

• Pain that builds during activity rather than starting sharp and sudden

• Discomfort that lingers after sitting with the knee bent for a long stretch (driving, movies, desk work)

• Pain going down stairs that's worse than going up

• Sometimes a grinding or clicking sensation under the kneecap (this on its own isn't dangerous)

What's usually NOT PFPS

• Pain on the inside or outside of the joint line — that points more toward meniscus or ligament involvement

• Sharp, locking sensations or the knee giving way

• Significant swelling that comes on suddenly after a single event

If your symptoms fall in the second category, you need an assessment to rule out other diagnoses before assuming it's runner's knee. That differential matters — treating PFPS as if it's a meniscus tear (or vice versa) wastes time and money.

What the Research Says

A 2025 systematic review and meta-analysis published in BMC Sports Science, Medicine and Rehabilitation pooled 12 randomised controlled trials covering more than 1,300 patients with patellofemoral pain. The conclusion was clear: muscle strengthening produced statistically significant reductions in pain at both 4–6 weeks and 8–12 weeks compared to other conservative treatments. The effect was most pronounced in women, where the mean difference in pain reduction was nearly three times larger than the overall pooled effect. (Ruisi et al., 2025. BMC Sports Sci Med Rehabil, 17(303).)

• Strengthening — particularly of the hip and quadriceps — consistently outperforms passive treatments like ice, ultrasound, or rest alone.

• Hip strengthening produces meaningful improvements in pain and function, and the effect appears to compound when paired with knee-focused work rather than substituting for it.

• Improvements are visible within 4–6 weeks of consistent loading, with continued gains through 8–12 weeks.

• Recovery isn't passive. The patients who get better are the ones who actually do the work between sessions.

This is why our approach to PFPS leans heavily on exercise prescription — not because exercise is trendy, but because it's what the evidence supports. Manual therapy and acupuncture have a role for short-term pain relief, but they're tools that buy you time and comfort to load the tissue properly. The strengthening is the part that fixes it.

How Physiotherapy Treats Patellofemoral Pain Syndrome in Burlington

Most patients who walk into Pursuit Physiotherapy with anterior knee pain have already tried something — rest, ice, a brace from the pharmacy, maybe a few sessions of generic exercises pulled off Instagram. When those things don't move the needle, it's usually because the program wasn't matched to the specific drivers of their pain. That's where a proper assessment changes things.

Getting the Diagnosis Right

The first session is built around figuring out exactly what's going on. We rule out meniscus involvement, patellar tendinopathy, IT band syndrome, and referred pain from the hip or low back. We assess hip and quad strength, look at how you squat and step down, and (when relevant) watch you run. The goal isn't to label you with a diagnosis and send you home with a sheet of exercises — it's to map out which contributors are driving your specific case.

Load Management

If you're running through pain that's getting worse week over week, no exercise program will outpace the damage. We modify training volume in the short term — not stop it, but adjust it — so the tissue can settle while we build capacity. This usually means temporarily reducing mileage, swapping hill repeats for flat work, and using cycling or pool running to maintain fitness if you're training for something specific.

Strengthening That Actually Targets the Drivers

• Hip-focused work — Side-lying clams, monster walks with a band, single-leg bridges, hip thrusts, step-downs with attention to control. These target the abductors and external rotators that influence how the femur (and therefore the kneecap) moves.

• Quad strengthening — Loaded squats, split squats, leg press, terminal knee extensions, and Spanish squats. Loaded properly, these are usually well tolerated even when symptoms are present.

• Movement retraining — Step-down mechanics, landing patterns, running cadence adjustments. We pair the strength work with how you actually use the leg.

• Progressive return to running — A graded plan back to your previous training load, with clear thresholds for what's acceptable pain and what isn't.

An important nuance from the research: over 90% of patients with PFPS respond favourably to exercise-based treatment when the program is targeted and consistent. Surgery is almost never required for this condition.

Where appropriate, we add manual therapy for short-term pain relief and to improve tolerance of loading, and medical acupuncture for patients who present with significant local muscle tone or guarding around the joint. These are adjuncts, not the main event.

What to Expect at Your First Appointment

Every assessment at Pursuit Physiotherapy is a 60-minute one-on-one with Javier. No assistants running you through a checklist. No three-patients-at-once scheduling. We take the time to understand your training history, your goals, and what you've already tried — then put you through a full physical assessment of the hip, knee, and ankle so we can identify exactly what's driving your symptoms. By the end of the first session, you'll have a working diagnosis, a clear plan, and a starting set of exercises matched to where you are right now.

Self-Management Tips Until Your First Session

1. Don't stop moving entirely. Complete rest deconditions the tissue further. Reduce, don't eliminate. If running is making it worse, switch to cycling or pool running for a week or two while you settle things down.

2. Modify what aggravates it. Take stairs one at a time, avoid deep squatting on the painful side, and break up long periods of sitting with knees bent.

3. Start basic hip and quad work. Side-lying clams, glute bridges, and wall sits are low-risk starting points. Two sets of 12–15 reps daily.

4. Check your training log. If you've increased mileage by more than 10% in any given week, that spike is likely contributing. Drop back to your previous baseline for now.

5. Don't rely on a brace as a long-term solution. A patellar strap can help short-term symptoms, but it doesn't fix the underlying capacity problem.

6. Skip the "stretching it out" approach. Quad and IT band stretching is not what fixes PFPS. Strength is.

When to See a Physiotherapist

If your knee pain has been going on for more than two to three weeks, isn't responding to rest and basic modifications, or is starting to limit activities you care about, it's time for an assessment. PFPS that's left to drag on tends to get more entrenched — pain pathways become more sensitive, you lose strength from avoiding the leg, and the longer you wait, the longer the rehab takes. We treat patients with runner's knee from across Burlington, Oakville, Hamilton, Waterdown, and Milton, and the pattern is the same: the ones who come in early get back to their sport faster.

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