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 usually sits at the bottom tip of the kneecap on the tendon, flares with jumping and changes of direction, and often eases as the tendon warms up. Patellofemoral pain is pain around or behind the kneecap, often aggravated by squatting, stairs and running. It tends to be more diffuse and often does not warm up in the same way. These patterns overlap and the two can coexist, so an assessment looks at the full history and examination rather than one feature.
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 bends under load. It often reproduces the familiar pain. | Pain around or behind the kneecap, sometimes with the knee falling inward (valgus) or the pelvis dropping on the opposite side. The pain is often 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 bends under load. It often reproduces the familiar pain.
Patellofemoral pain
Pain around or behind the kneecap, sometimes with the knee falling inward (valgus) or the pelvis dropping on the opposite side. The pain is often 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. A useful finding, but not enough on its own: many pain-free athletes are tender there too, so I read it alongside the decline squat and the history.
Single-leg decline squat (25 degrees)
Squatting on one leg on a 25-degree decline board puts more load through the patellar tendon. Clear pain at the bottom of the kneecap during this test fits patellar tendinopathy, although no single test confirms it.
Step-down from a stair, 20 to 30 cm height
Reproducing your familiar pain around or behind the kneecap on a single-leg step-down supports the patellofemoral pattern. I also watch how the knee and pelvis are controlled during the movement. No single test confirms it.
Clarke's sign and patellar compression
Gentle compression of the kneecap against the thigh bone, with and without a quad contraction. Pain behind the kneecap (not below it) can fit patellofemoral pain, but these tests have limited accuracy, so they carry less weight than reproducing your familiar pain during squatting or stepping.
Hip strength screen (abduction and external rotation)
Weakness in the glutes, particularly gluteus medius and the deep rotators, is often found in people with patellofemoral pain, though not in everyone, and pain itself can reduce strength. It can play a part in patellar tendinopathy too.
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 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 pain you can cover with one finger at the bottom tip of the kneecap is a useful first clue. 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 helps narrow it down; when the picture stays mixed, I reassess as the knee responds to the first few weeks of loading. 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 strength can play a part in 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.
When to see a doctor first
- A pop below the kneecap, then sudden inability to straighten the knee or lift the straight leg. Go to emergency or urgent care. A patellar tendon rupture needs early surgical assessment.
- A newly hot, red, markedly swollen knee, with or without a fever. Seek same-day medical care to rule out a joint infection, or go to emergency if you feel unwell. Infection is possible even without a fever.
- A knee that locks and will not fully straighten. See your family doctor promptly.
- A child or teenager with a new limp that has no clear explanation. Get a prompt medical assessment before starting exercises. A hip problem can be felt only in the thigh or knee.
- A limping child or teenager with sudden hip, thigh or knee pain, who cannot put weight on the leg, whose leg looks deformed, or who has a fever and feels unwell. Go to emergency now.
- A suspected slipped growth plate at the hip (slipped capital femoral epiphysis, or SCFE). Do not let the child walk on the leg, and seek emergency assessment today. In a teenager this can show up as a limp with hip, groin, thigh or knee pain, even when they can still walk.
Questions patients ask about telling these apart
Can I have both at the same time?
Yes, and in jumping sports it is a common pattern in younger athletes. The two rehabs overlap heavily, with hip strengthening, quad loading, and load management all doing double duty. What matters 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?
Both going up and going down stairs load the kneecap joint more than level walking. Going down also asks the quads to control the lowering, which many people with patellofemoral pain find harder. That is why stairs down, downhill running, and decelerating are common aggravators, although some people notice going up more.
Does my tracking or alignment actually matter?
Less than older theories suggested, but it is not nothing. Current guidance puts more weight on how much load the knee is handling and on quad and hip strength than on small differences in alignment, and a visible tracking problem is not needed for the diagnosis. Strength, control and training load are things rehab can change, so the plan focuses there.
Is squatting bad for my knees with either condition?
Not usually, provided the load is dosed to what the knee tolerates today. Avoiding knee bending completely can leave both tissues less able to handle load over time. 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?
Many people with patellofemoral pain improve over six to twelve weeks of targeted hip and quad work with sensible load management, although symptoms can persist or come back for some. Patellar tendinopathy is often slower because tendons adapt slowly. A return to jumping sport often takes three to six months or longer of progressive loading, with earlier gains in day-to-day function along the way.
Evidence this page draws on
Sources I lean on when separating these two conditions in clinic.
The guideline recommends combined hip and knee strengthening over knee strengthening alone to reduce pain and improve function in patellofemoral pain.
Willy RW et al., "Patellofemoral Pain" (JOSPT Clinical Practice Guideline), 2019.
In a 12-week trial in 39 men with patellar tendinopathy, heavy slow resistance training and eccentric decline squats both improved symptoms and held at six months, with the most satisfied patients in the heavy slow resistance group. Steroid injection helped short term but deteriorated by six months.
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.
The hallmark features of patellar tendinopathy are pain localised to the inferior pole of the patella and load-related pain that rises with demand on the knee extensors. The diagnosis is clinical, because tendon changes on imaging also occur in people without tendon pain.
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
Staged rehabilitation to help you get back to your sport after injury.
Dry Needling
Thin needles placed in tight, tender bands of muscle. It can help ease pain and muscle tension in the short term.
Joint Mobilization
Graded techniques to restore joint movement and reduce stiffness.
Soft Tissue & Myofascial Therapy
Targeted hands-on techniques to ease muscle tension, tenderness, and stiffness.
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
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