Is it patellar tendinopathy or patellofemoral pain?
Both sit at the front of the knee and both flare with loaded knee bending. The difference comes down to where the pain points and what triggers it. Patellar tendinopathy is a localised tendon overload problem. The pain sits at the bottom tip of the kneecap on the tendon, flares with jumping and changes of direction, and eases as the tendon warms up. Patellofemoral pain is a loading and tracking problem at the joint surface behind the kneecap. The pain is more diffuse, flares with stairs, prolonged sitting, and running, and does not warm up in the same way.
Written by Kareem Hassanein, Registered Physiotherapist. Burlington, Ontario. This is a guide, not a diagnosis. A brief in-person exam sorts these out reliably.
Side by side
The patterns that separate patellar tendinopathy from patellofemoral pain in clinic. Read across each row and compare.
| Aspect | Patellar tendinopathy | Patellofemoral pain |
|---|---|---|
| Where you point to when asked | One finger directly on the bottom tip of the kneecap, at the top of the patellar tendon. Very localised. | A vaguer arc around the kneecap, often described by circling with the whole hand. People rarely point to a single spot. |
| The "warm-up" phenomenon | Classic. Hurts for the first few minutes of activity, often feels better through the middle, then flares afterwards or the next day. | Pain tends to build with continued loading rather than warm out, and is often worse on descent (stairs down, downhill running). |
| Triggers | Jumping, landing, accelerating, deep squats under load, hill sprints. Sudden volume spikes in jumping sports are a classic setup. | Stairs (often worse going down), prolonged sitting with bent knees ("theatre sign"), running, squatting, and anything that loads the kneecap repeatedly. |
| Sitting with bent knees | Usually fine, unless the knee is deeply bent under load. | Classic aggravator. The so-called 'movie sign', where the knee aches after 20 minutes in a cinema seat or on a long drive, is highly suggestive. |
| Clicking, grinding, or catching | Not typical. The tendon does not usually produce joint noises. | Grinding or clicking behind the kneecap (crepitus) is common, although not diagnostic on its own. |
| Typical sport or activity | Volleyball, basketball, high jump, tennis, soccer, any sport with repeated jumping or cutting. Heavy squatters. | Runners (especially those ramping up volume), cyclists with a saddle too low, desk workers returning to training, recreational athletes. |
| What a single-leg squat shows | Pain at the bottom tip of the kneecap as the knee flexes under load. Usually reproduces the symptom cleanly. | Pain around or behind the kneecap, often with a visible knee-in (valgus) collapse or a hip drop on the stance side. Reproduction is typical but less focal. |
Where you point to when asked
Patellar tendinopathy
One finger directly on the bottom tip of the kneecap, at the top of the patellar tendon. Very localised.
Patellofemoral pain
A vaguer arc around the kneecap, often described by circling with the whole hand. People rarely point to a single spot.
The "warm-up" phenomenon
Patellar tendinopathy
Classic. Hurts for the first few minutes of activity, often feels better through the middle, then flares afterwards or the next day.
Patellofemoral pain
Pain tends to build with continued loading rather than warm out, and is often worse on descent (stairs down, downhill running).
Triggers
Patellar tendinopathy
Jumping, landing, accelerating, deep squats under load, hill sprints. Sudden volume spikes in jumping sports are a classic setup.
Patellofemoral pain
Stairs (often worse going down), prolonged sitting with bent knees ("theatre sign"), running, squatting, and anything that loads the kneecap repeatedly.
Sitting with bent knees
Patellar tendinopathy
Usually fine, unless the knee is deeply bent under load.
Patellofemoral pain
Classic aggravator. The so-called 'movie sign', where the knee aches after 20 minutes in a cinema seat or on a long drive, is highly suggestive.
Clicking, grinding, or catching
Patellar tendinopathy
Not typical. The tendon does not usually produce joint noises.
Patellofemoral pain
Grinding or clicking behind the kneecap (crepitus) is common, although not diagnostic on its own.
Typical sport or activity
Patellar tendinopathy
Volleyball, basketball, high jump, tennis, soccer, any sport with repeated jumping or cutting. Heavy squatters.
Patellofemoral pain
Runners (especially those ramping up volume), cyclists with a saddle too low, desk workers returning to training, recreational athletes.
What a single-leg squat shows
Patellar tendinopathy
Pain at the bottom tip of the kneecap as the knee flexes under load. Usually reproduces the symptom cleanly.
Patellofemoral pain
Pain around or behind the kneecap, often with a visible knee-in (valgus) collapse or a hip drop on the stance side. Reproduction is typical but less focal.
What I check in person to separate them
These are the clinical tests I actually run in the first visit. You cannot do them all on yourself reliably, but understanding what they look for helps explain why an in-person exam sorts these so quickly.
Palpation of the inferior pole of the patella
Pinpoint tenderness right where the patellar tendon attaches to the bottom of the kneecap. This is the single most specific finding for patellar tendinopathy.
Single-leg decline squat (25 degrees)
Squatting on one leg on a 25-degree decline board selectively loads the patellar tendon. Clear pain at the bottom of the kneecap during this test is strongly suggestive of patellar tendinopathy.
Step-down from a stair, 20 to 30 cm height
Reproducing your anterior knee pain on a single-leg step-down, particularly with visible knee-in collapse or hip drop, is a reliable in-clinic trigger for patellofemoral pain.
Clarke's sign and patellar compression
Gentle compression of the kneecap against the femur, with and without active quad contraction. Pain behind the kneecap (not below it) supports patellofemoral pain, although specificity is limited.
Hip strength screen (abduction and external rotation)
Weakness in the glutes, particularly gluteus medius and the deep rotators, is strongly associated with patellofemoral pain. It can be a contributor to patellar tendinopathy too, but it is a more consistent finding in patellofemoral cases.
Which pattern fits you better?
Plain-language routing. This is not a diagnosis, and real patients often sit between the two, but the language below is a reasonable starting point.
Patellar tendinopathy
Your pattern more closely matches patellar tendinopathy if you can put one finger on the bottom tip of the kneecap where it hurts, the pain warms up as you keep going and flares afterwards, jumping and changes of direction reliably bring it on, and sitting with a bent knee is fine. A recent spike in training volume, a new sport, or a preseason return are common setups.
Read the patellar tendinopathy pagePatellofemoral pain
Your pattern more closely matches patellofemoral pain if the pain is more diffuse around or behind the kneecap, going down stairs and sitting with bent knees for a while both bother it, and you notice a feeling of the knee giving or buckling going downhill. It often starts after a running ramp-up, a life change that added a lot more stairs or walking, or after a period of detraining.
Read the patellofemoral pain pageIf you still cannot tell
These genuinely overlap and they can coexist, so a brief assessment matters. I localise the tenderness first, because one finger on the inferior pole of the patella is worth a lot of diagnostic weight. Then I run the single-leg decline squat and the step-down, check hip strength, and look at your running or squat mechanics if relevant. That usually sorts it. Where they coexist, I dose the tendon work and the patellofemoral rehab in parallel rather than arguing about which is primary.
When both are going on
It is common to see both in the same knee, particularly in jumping athletes who also sit at a desk all day. Hip and trunk weakness feeds both. Chronic patellofemoral pain can also alter loading at the patellar tendon over time, and a grumbling tendon can change how you squat, which feeds the patellofemoral side. The rehab for both has a lot of shared elements, so the plan is rarely either-or.
Questions patients ask about telling these apart
Can I have both at the same time?
Yes, and in jumping sports it is probably the most common pattern I see in younger athletes. The good news is that the two rehabs overlap heavily, with hip strengthening, quad loading, and load management all doing double duty. The key is dosing both tissues within their current tolerance rather than pretending only one is the problem.
Why does my patellar tendon hurt more the day after training, not during?
That is the classic tendon pattern. Tendons often tolerate load during the session because they warm up, then flare 24 to 48 hours later as the tissue responds. If your post-session and next-morning pain is rising over several sessions, the tendon is telling you the load has exceeded its current capacity. The fix is changing the dose, not stopping completely.
Why do stairs down hurt more than stairs up with patellofemoral pain?
Going down loads the kneecap more. The quads work eccentrically to control descent, and the compressive force behind the kneecap is substantially higher going down than going up. That is why stairs down, downhill running, and decelerating are the classic aggravators.
Does my tracking or alignment actually matter?
Less than older theories suggested, but it is not nothing. What matters more in current evidence is strength and control. Hip abductor and external rotator weakness, poor trunk control, quad weakness, and sudden spikes in training load are bigger drivers than small anatomical differences. The rehab focuses on the pieces you can change.
Is squatting bad for my knees with either condition?
No, provided the load is dosed to what the knee tolerates today. Complete avoidance of knee flexion usually makes both conditions worse over time because the tissue loses capacity. The real questions are depth, load, tempo, and frequency. I adjust those to keep you training without flaring the symptom.
How long does each usually take to settle with physiotherapy?
Patellofemoral pain typically improves meaningfully over six to twelve weeks of targeted hip and quad work with sensible load management. Patellar tendinopathy is slower because tendons are slower tissues. Expect three to six months of progressive loading before full return to jumping sport, with earlier wins in day-to-day function along the way.
Evidence this page draws on
Sources I lean on when separating these two conditions in clinic.
Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving function in patellofemoral pain.
Willy RW et al., "Patellofemoral Pain" (JOSPT Clinical Practice Guideline), 2019.
Progressive heavy slow resistance training produces equivalent or superior outcomes to eccentric-only protocols for patellar tendinopathy.
Kongsgaard M et al., "Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy." Scandinavian Journal of Medicine & Science in Sports 2009; 19(6): 790-802.
Pinpoint tenderness at the inferior pole of the patella and pain on a single-leg decline squat have the best clinical value for identifying patellar tendinopathy.
Malliaras P, Cook J, Purdam C, Rio E. "Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations." JOSPT 2015; 45(11): 887-898.
Treatments that commonly sit inside either plan
The specific mix depends on the assessment and your goals. These are the pieces I draw from most often for both conditions.
Exercise Therapy
Personalized exercise programs designed to restore strength, flexibility, and function.
Sports Rehabilitation & Return to Sport
Evidence-based recovery programs for athletes to safely return to sport after injury.
Dry Needling
Precise needle therapy targeting trigger points for effective pain relief and improved muscle function.
Joint Mobilization
Graded techniques to restore joint movement and reduce stiffness.
Soft Tissue & Myofascial Therapy
Targeted hands-on techniques to address muscle tension, pain, and movement restrictions.
Book an assessment
If this page has helped you narrow things down, or if it has left you wanting a proper exam, I see patients at Endorphins Health & Wellness Centre in Burlington. Direct insurance billing is available, and a physician referral is not required.
4631 Palladium Way, Unit 6
Burlington, ON L7M 0W9
Direct billing. No referral needed.
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