What treats runner's knee (pain around the kneecap)?
Knee strengthening, plus hip work if needed, with education throughout; orthoses, taping or running retraining as add-ons. Short-term trials only, not runner-specific.
Main caveat: Short-term only. Every adequately tested intervention was tested at under 3 months.
Neal, Lack, Bartholomew and Morrissey updated their 2015 best-practice guide for patellofemoral pain by combining three data streams kept apart until the synthesis: their own systematic review with meta-analysis of high-quality RCTs (PEDro score >7; search to May 2022), thematic analysis of interviews with 12 people with patellofemoral pain and 19 multidisciplinary clinical experts, and three new focus groups with 9 experts on how and in whom to apply each intervention.
An intervention entered the guide if it was adequately tested and efficacious, or — when it had not been adequately tested — if patients advocated it and experts recommended it; adequately tested interventions that were not efficacious or added nothing were labelled inappropriate outside a clinical trial.
The strength of recommendation started from the best GRADE certainty and was raised one category for patient advocacy plus expert recommendation and one more for a clear application from the focus groups.
Knee-targeted exercise therapy came out on top ("very high": short-term pain SMD 1.16, high certainty; function SMD 1.19, moderate), followed by hip-and-knee-targeted exercise and prefabricated foot orthoses ("high", from very low to low certainty raised by patients and experts), lower-quadrant manual therapy and exercise plus perineural dextrose injection ("moderate", trials only), and running retraining and taping ("low", never adequately tested).
Education is not graded as a separate intervention; the guide says it should underpin every intervention. Dry needling (alone or with exercise), vibration therapy, hyaluronic acid injection with exercise, and adding prefabricated orthoses to a multi-part package were judged inappropriate outside trials.
Our reading: the guide makes exercise therapy plus education the clinician's default for patellofemoral pain, which the base's knee row in SYNTH-73 lacks; its runner content is limited to examples, every effect is short-term, and the base's one trial in runners (REF-917, 69 runners: education alone did as well as education plus exercise or plus gait retraining over 20 weeks) is a runner-specific counterpoint, not a contradiction of the population-level evidence.
Protocol
Design: convergent segregated synthesis of a published systematic review with meta-analysis, patient interviews, expert interviews and new expert focus groups; the meta-analysis results did not shape the interview topic guides. AGREE II used to formulate and present the guide; qualitative work reported to SRQR. Ethics: Queen Mary Ethics of Research Committee (QMERC/2018/48,036).
Systematic review: MEDLINE, Web of Science and Scopus from inception to May 2022, keywords only (no MeSH), English, plus Google Scholar citation search; RCTs of non-surgical interventions in people with patellofemoral pain. Two authors rated PEDro; >7 = high quality and retained; RoB 2 applied.Random-effects pooling; SMD small ≤0.59, medium 0.60-1.19, large ≥1.20; OR small 1.0-1.99, medium 2.0-4.99, large ≥5.0. Arms with n < 22 (from minimal detectable changes of 2 points on a numerical pain scale and 10 on the Kujala scale) counted as inadequately tested. Follow-up: short <3 months, medium >3 to <12, long >12. GRADE for certainty.
Trials found: 5740 records screened, 170 RCTs appraised, 65 high-quality RCTs retained (n = 3796), giving 11 adequately tested interventions or combinations, all at short-term follow-up only.
Patients: n = 12 with insidious-onset patellofemoral pain and an episode of care in the past 6 months; 7 women, 5 men; 26.5 ± 4.7 years; symptoms 43.3 ± 42.3 months; England 8, rest of Europe 1, North America 3.
Experts (interviews): n = 19 with more than 5 years' clinical experience and direct research involvement — 9 physiotherapists, 4 podiatrists, 3 orthopaedic surgeons, 1 athletic trainer, 1 general practitioner, 1 sports physician; UK 13; 18.6 ± 8.6 years' experience.
Focus groups: three online 90-min groups in February 2023 with n = 9 experts (5 had also been interviewed; 22.1 ± 9.3 years' experience); coded by one author and verified by a second.
Recommendation rule: start at the highest GRADE certainty (inadequately tested interventions start with no strength); +1 category for patient advocacy and expert recommendation together; +1 for a clear approach to application from the focus groups; final strengths by consensus of three authors (BSN, SL, DM) on a five-step scale (very high, high, moderate, low, very low).
Funding and interests: a Private Physiotherapy Education Foundation Scheme A2 research grant awarded to BSN, SL and DM; the funding body had no input into the design, execution or dissemination. Competing interests: none declared.Affiliations as printed include Queen Mary University of London, the University of Essex, Barts Health NHS Trust and Pure Sports Medicine, London (SL). The guide builds on the authors' own 2015 guide and 2022 meta-analysis, and DM is also the first author of the plantar heel pain guide built the same way (REF-1382).
Key Results
Intervention synthesis (Table 1 and Results; short-term follow-up; positive SMD or OR favours the intervention; A = advocated by patients, R = recommended by experts, Y = application clear in focus groups):
| Intervention | Trial evidence (certainty) | Patients / experts / focus groups | Strength of recommendation |
|---|---|---|---|
| Knee-targeted exercise therapy (primary efficacy) | pain SMD 1.16 (95% CI 0.66 to 1.66), high; function SMD 1.19 (0.51 to 1.88), moderate | A / R / Y | Very high |
| Hip-and-knee-targeted exercise therapy (secondary efficacy, compared with knee-targeted exercise) | pain SMD 1.02 (0.58 to 1.46), very low; function SMD 1.03 (0.61 to 1.45), low | A / R / Y | High |
| Prefabricated foot orthoses (primary efficacy) | positive short-term outcome on the global rating of change, OR 4.31 (1.48 to 12.56), low | A / R / Y | High |
| Lower-quadrant manual therapy (primary efficacy) | function SMD 2.30 (1.60 to 3.00), moderate; pain SMD 2.19 (−1.02 to 5.41), no significant effect | not discussed / no clear application | Moderate |
| Exercise therapy plus perineural dextrose injection (secondary efficacy; "knee-targeted" in Table 1, "hip-and-knee-targeted" in the Results text) | pain SMD 1.34 (0.72 to 1.95); function SMD 1.12 (0.60 to 1.82); moderate | not discussed | Moderate |
| Movement/running retraining | inadequately tested by meta-analysis | A / R / Y | Low |
| Taping | inadequately tested by meta-analysis | A / R / Y | Low |
| Hip-and-knee exercise + vastus medialis oblique biofeedback + soft-tissue stretching + McConnell-style patellar taping (primary efficacy) | pain SMD 0.79 (0.26 to 1.29); function SMD 0.98 (0.47 to 1.49); very low | not discussed | Very low |
| Education | not a meta-analysed intervention; a theme of both patients and experts | — | not graded; "should underpin any/all interventions" |
Judged inappropriate outside a clinical trial (adequately tested; no effect or no added benefit):
| Intervention | Effect (certainty) |
|---|---|
| The four-part combination above plus prefabricated foot orthoses | positive outcome OR 0.75 (0.16 to 3.58), very low, no additional benefit |
| Dry needling vs sham needling | pain SMD −0.19 (−0.73 to 0.35); function SMD 0.02 (−0.51 to 0.55); low |
| Vibration therapy added to hip-and-knee exercise | pain SMD −0.07 (−0.42 to 0.28); function SMD 0.76 (−0.85 to 2.37); very low |
| Dry needling added to hip-and-knee exercise | pain SMD −0.95 (−2.68 to 0.78), low; function SMD −1.26 (−3.38 to 0.85), moderate |
| Hyaluronic acid injection added to hip-and-knee exercise (vs sham saline) | pain SMD −0.21 (−0.64 to 0.21), very low; function SMD −0.57 (−1.00 to −0.13), low; not advocated by patients |
Time frame: "no high-quality RCTs adequately testing any intervention beyond" short-term follow-up; nothing in the guide rests on a medium- or long-term trial result.
How to apply (Figure 2 and text): understand the person (population, e.g. in-season athlete or sedentary worker; aetiology, e.g. symptoms starting after an increase in exercise frequency; history; where they sit between patellofemoral pain and early patellofemoral osteoarthritis); establish why they sought care and their goals; examine hip and knee strength, movement pattern (e.g. single-leg squat or treadmill running), tissue tolerance (pain provocation tests, effusion) and joint structure (patella alta, hypermobility); then deliver knee-targeted exercise therapy, add hip exercise especially when loaded knee flexion is poorly tolerated, put education under everything, and choose supporting interventions.
Supporting interventions, when (expert reasoning): prefabricated foot orthoses for people who respond to a treatment-direction test (e.g. symptoms improve during a functional task with orthoses in), customised for comfort; taping and manual therapy when severity, irritability or fear of movement hold rehabilitation back; movement/running retraining when symptoms are reasoned to be tied to task-specific mechanics (e.g. a higher step rate in a runner with excessive stride length).Review assessment and engagement if there is no favourable outcome after a realistic period, minimum 6 weeks.
Against earlier consensus: the authors found stronger support for knee-targeted exercise alone than the hip-and-knee preference in earlier consensus and guidelines, which they attribute to the qualitative streams; and their manual-therapy finding conflicts with the most recent consensus, which did not support isolated manual therapy.
Returning to running: the guide gives no return-to-running criteria, timeline or pain limit.
Mechanisms
Measured: short-term pain and function in the pooled trials; no mechanism was measured in this synthesis.
Authors' interpretation: education should challenge inaccurate beliefs, explain that pain does not track damage (especially with long-standing symptoms), set the recovery journey and time frames, help manage load and reduce fear.Hip exercise may help by a route other than hip strength: a cited mediation analysis found that rising hip strength did not mediate short-term pain relief, while quadriceps weakness has a prospective association with developing patellofemoral pain.
Authors' interpretation: pooling trials as "knee-targeted" or "hip-and-knee-targeted" followed the trial aim and the joint with the greatest excursion (a leg press counted as knee), though knee exercises load the hip and vice versa; a different split could have changed the recommendation.
Inference: a higher step rate is the retraining the experts quote; it lowers energy absorbed at the knee in healthy runners (REF-620, B), but in runners with patellofemoral pain gait retraining showed no evidence of added benefit over education (REF-917, B+) — consistent with the guide's "low" grade for retraining.
Practical Application
What treats runner's knee (pain around the kneecap)? Knee strengthening, plus hip work if needed, with education throughout; orthoses, taping or running retraining as add-ons. Short-term trials only, not runner-specific.
Exercise therapy is the default, education its frame: knee-targeted exercise is the one intervention with high-certainty trial evidence (short-term pain SMD 1.16) and the guide's top recommendation; hip exercise is added, and leads when loaded knee bending is poorly tolerated (A-, best-practice guide, short-term trials). Education underpins every intervention, but it was graded from patients' and experts' views, not from trials.
Graded by evidence vs by people, in the guide's own terms: trial-graded — knee-targeted exercise (high/moderate certainty), hip-and-knee exercise (very low/low), prefabricated foot orthoses (low), lower-quadrant manual therapy (moderate, function only), exercise plus perineural dextrose (moderate), the four-part combination (very low); supported by patients and experts only, never adequately tested — running retraining, taping, and education; where and in whom each add-on fits came from the expert focus groups.
Add-ons by need, not by default: foot orthoses if a squat or task feels better with them in; taping when pain blocks the exercise; running retraining (e.g. a higher step rate for an over-striding runner) only when the clinician links the pain to how the person runs. Not worth doing outside a trial: dry needling, vibration therapy, hyaluronic acid injection.
For the knee row of [SYNTH-73]: that row offers cutting the recent load jump, education (REF-917) and step rate as an option, and no exercise therapy. This guide makes knee ± hip exercise therapy with education the primary treatment and agrees that retraining is an option (graded low).Give both: exercise therapy with education is the clinician's usual first line; in the one trial of runners in the base, education on symptoms and training load alone did as well over 20 weeks (REF-917, B+, 69 runners).
Not from this paper; the base's own practice: the assistant repeats what the athlete reports, never names a condition and uses a clinician's diagnosis as given; not improving within about two weeks of sensible changes, or recurring, means a clinician (SYNTH-73). The guide's own review point is for clinicians who are already treating: a realistic period, minimum 6 weeks.
Coming back to running: the guide holds no return-to-running criteria, timeline or pain limit; running appears only as goals and expectations (5 km; a marathon in six weeks).
What it is good for as a source: the ranking of treatments for diagnosed patellofemoral pain, with the certainty behind each and which ones rest on patient and expert views. What it does not show: anything beyond 3 months, an effect in runners specifically, how to dose the exercise, whether a knee brace helps (not part of the synthesis; for prevention see REF-1386), or how to return to running.
Limitations
Short-term only. Every adequately tested intervention was tested at under 3 months; the guide cannot say what lasts, in a condition where the authors cite persistent pain in over 50% more than 5 years after diagnosis.
Not a runner guide. The trial populations are not described here, and there is no runner subgroup; runners appear only in examples.
The ranking is the authors'. The rule that patients plus experts raise a recommendation by a category, and a clear application by another, is predefined by the authors and applied by consensus of three of them; it lifts very-low-certainty hip-and-knee exercise and low-certainty orthoses to "high" and lets two never-tested interventions (retraining, taping) into the guide. The authors warn that "not all recommendations include level 1 evidence from multiple RCTs".
Thin qualitative base. 12 patients (mostly UK) and 19 experts (13 UK); one coder for the focus groups; the author team is UK-based and, in its own words, biased towards the male gender.
Search and pooling. Keywords only, English only, not updated after May 2022; the knee vs hip-and-knee split is a judgement the authors say could change the recommendation.
Reporting inconsistencies. The dextrose combination is "knee-targeted" in Table 1 and the Results summary but "hip-and-knee-targeted" in the Results paragraph and the application section; the abstract says six interventions were recommended, while Table 1 gives a positive strength to eight rows.Hyaluronic acid's function effect (SMD −0.57, −1.00 to −0.13) lies wholly below zero, which on the guide's sign convention points to worse than sham saline plus exercise (our reading); the guide calls it non-efficacy.
Funding and interests: a Private Physiotherapy Education Foundation research grant to three authors, with no funder input; competing interests none declared. No device maker, federation or data platform is named. The authors grade their own earlier meta-analysis.
How this entry was checked and changed
Why this level
the efficacy layer is a systematic review with meta-analysis of RCTs graded with GRADE, the rubric's A design; held at A- because every adequately tested intervention was tested at short-term follow-up only (<3 months), the certainty runs from high (knee-targeted exercise, pain) to very low, the meta-analysis was not updated after its May 2022 search, and two of the eight positively graded interventions (running retraining, taping) plus the education that underpins all of them rest on patients' and experts' views, not on trials; a four-author best-practice guide, not a governing-body consensus. Read from the full text (the journal's online-first PDF in the University of Essex repository, listed by OpenAlex)
Full text (checked 2026-10-28)
Data from 65 high-quality RCTs involving 3796 participants informed 11 meta-analyses of interventions; interviews with 12 people with PFP led to 3 themes and interviews with 19 clinical experts led to 4 themes (full text)
Knee-targeted exercise therapy: high certainty evidence for short-term pain reduction (SMD 1.16, 95% CI 0.66, 1.66) and moderate certainty for short-term function improvement (SMD 1.19, 95% CI 0.51, 1.88); strength of clinical recommendation Very high (full text)
Hip-and-knee-targeted exercise therapy: very low certainty for short-term pain reduction (SMD 1.02, 95% CI 0.58, 1.46) and low certainty for short-term function (SMD 1.03, 95% CI 0.61, 1.45) (full text)
Prefabricated foot orthoses: low certainty evidence for a positive short-term outcome on the global rating of change scale (OR 4.31, 95% CI 1.48, 12.56) (full text)
Movement/running retraining and taping were inadequately tested by meta-analysis but advocated by patients and recommended by experts; strength of clinical recommendation Low (full text)
The 65 high-quality RCTs gave 11 adequately tested interventions at short-term follow-up, with no high-quality RCTs adequately testing any intervention beyond this time point (full text)
If favourable outcomes are not observed after a realistic period (minimum 6 weeks), clinicians should revisit assessment findings (full text)
Patients: 7 women, 5 men, mean age in years 26.5±4.7, mean symptom duration in months 43.3±42.3 (full text)
Funding: a Private Physiotherapy Education Foundation Scheme A2 research grant awarded to BSN, SL and DM; the funding body had no input into the design, execution, or dissemination of the study; competing interests none declared (full text)