Patellofemoral pain (PFP) is a painful condition that limits running, walking and day to day life. At The Injury Clinic we treat a lot of people with this condition, with prescriptive exercise being the main treatment option.

In the past there has been a focus on building the quadriceps muscle, especially the medial muscle on the inside of the knee due to wasting and disuse. The aim of this is to improve the muscle balance between the forces acting on the knee cap to allow symmetrical balance and improve the way the patella moves. For most this works well and can allow progression of exercise to more challenging activities like squatting and lunges without pain.

Recently this concept has been challenged, with evidence to suggest that improving movement first and allowing some discomfort with more challenging movements the medial quadriceps muscle will develop and rehab can be progressed much faster. Furthermore the imbalance of medial quadriceps muscle activation may be present in many with PFP, but not everyone.

Recent evidence has shown:

  • Exercise prescription without medial quads can improve pain in PFP
  • Involving hip muscle +/- quadriceps can improve function
  • Exercise may be uncomfortable, but 3/10 pain is a good guide during and after exercise

Following these guidelines means the approach must be individualised, can be started at a high level for those with less pain, and does not have to include medial quadriceps training for every person. This promotes a person centred approach to treatment, and helps educate the patient during the rehabilitation phase that pain may be present but not harmful.



Cowan, S. M., Bennell, K. L., Crossley, K. M., Hodges, P. W., & McConnell, J. (2002). Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome. Medicine & Science in Sports & Exercise34(12), 1879-1885.

Crossley, K. M., & Cowan, S. M. (2019). Vastus medialis obliquus (VMO) retraining or graduated loading programme for patellofemoral pain: different paradigm with similar results?.


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