Anterior knee pain (AKP) encompasses a range of sometimes overlapping conditions, characterised by pain localised to the anterior aspect of the knee. It is highly prevalent in adolescents, young adults, and athletes. Early identification and management are crucial to prevent it becoming chronic and causing functional impairment, especially in sports but also everyday life such as walking, sitting and standing.
AKP is multifactorial and can result from:
- Patellofemoral Pain Syndrome (PFPS) – Maltracking or increased stress on the patellofemoral joint.
- Overuse and Repetitive Stress – Activities such as running, jumping, or squatting can overload the knee, sudden increases in activity
- Muscle Imbalances or Weakness – Weak quadriceps, hip abductors, hamstrings
- Soft Tissue Tightness – Quadriceps Iliotibial band, hamstrings, and gastrocnemius tightness increasing patellofemoral pressure.
- Lower Limb Structural Abnormalities – Patellar malalignment, flat feet (pes planus), or increased Q-angle.
- Trauma or Previous Injury – Direct impact or history of knee injury, osteoarthritis
Clinical Presentation
People attend with differing symptoms but most can be summarised as follows:
- Pain Characteristics: Diffuse, dull ache localized anteriorly; often exacerbated by knee flexion under load (“theatre sign”).
- Aggravating Activities: Squatting, stair ascent/descent, running (especially downhill), prolonged sitting.
- Associated Findings: Crepitus, occasional swelling, or pseudo-giving way due to pain inhibition.
Understanding the Cause
Identifying the cause of AKP can be difficult and requires a full history and physical and not simply looking at the knee itself. Often this is enough to confirm a diagnosis, however sometimes imaging is needed:
- X-rays: Evaluate for patella alta, lateral tilt, or osteochondral lesions, osteoarthritis.
- Ultrasound: For most soft tissues including ligaments, fat pad and muscles.
- MRI: Indicated for suspected cartilage, meniscus injury, cruciate ligaments,
Treatment
Normally conservative treatment (First-line) is all that is needed (no surgery, injections). This can include activity modification: Reducing high-impact activities, gradual reintroduction.
- Analgesia is often useful for the short- term relief, for example: ibuprofen.
- Physical Therapy is almost always part of the solution including specific quadriceps, hip abductor and external rotator strengthening. Stretching of the IT band and hamstrings is also often useful.
- Self-mobilisation of the patella and taping can be used especially if activity is being limited.
- For lower limb structural issues orthotics are very often a good on-going management option especially where over pronation or other foot/ankle issues are present.
- As we move up the treatment order there is the use of braces (a topic in itself).
- I also use Shockwave therapy (see the website) for some of the conditions presenting at the anterior knee including patella tendinosis and fat pad syndrome
- Surgical Intervention is usually left for those situations where conservative intervention has failed or initial the examination identifies an issue such as a torn meniscus, cruciate ligament injury or severe arthritis.
Prognosis
Most patients improve with structured rehabilitation within 6–12 weeks. Persistent pain is often linked to poor adherence to the rehabilitation and often trying to get back to top form too quickly.
