Non-Traumatic Anterior Knee Pain

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Patient and contextual information: age and growth stage; sex and gender when clinically relevant; language and communication needs; work or school; caregiving; sport and recreation; and activities, roles and cultural or community practices important to the patient.

Primary concerns

• Context and onset: gradual or sudden onset; recent change in training, running, jumping, kneeling, work or other load; growth spurt; prior knee, hip or low back symptoms; previous patellar dislocation or subluxation; and injury or surgery that may place the presentation outside this pathway.
• Location and pattern: retropatellar, peripatellar, patellar tendon, tibial tubercle or other localized pain; one or both knees; duration, course, severity, irritability and 24-hour pattern; and whether symptoms are improving, fluctuating, persistent or worsening.
• Aggravating and relieving factors: squatting, stairs, prolonged sitting, kneeling, running, jumping, landing, cycling, walking, rising from a chair and sport- or work-specific tasks; response during the activity, later that day and the next day; and response to rest, movement or load change.
• Associated symptoms and participation: swelling, warmth, redness, stiffness, crepitus, catching, true locking, giving way, apprehension, hip or back symptoms, numbness or tingling; and effects on sleep, mobility, self-care, work, school, caregiving, physical activity, sport, recreation and community participation.
• Body systems review: constitutional and infectious; neurological; cardiovascular and peripheral vascular; respiratory; gastrointestinal and genitourinary; reproductive; musculoskeletal and bone health; inflammatory or immune; endocrine or metabolic; skin; haematologic; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, care or referral.
• Health, lifestyle and history: past health conditions; inflammatory arthritis, gout, cancer, infection, blood clot, vascular disease, diabetes, kidney or endocrine disease, low bone strength or low energy availability; injuries, hospitalizations and surgery; current medicines and supplements, including corticosteroids, anticoagulants and hormones; physical activity, training, nutrition and recovery; sleep; smoking; alcohol or substance use; and family history relevant to joint, inflammatory or bone health.
• Social determinants of health: work, school and training demands, education, caregiving, income, housing, food security, discrimination, safety, social support, access to care and ability to modify activity when these may shape health, care or participation (Public Health Agency of Canada, 2026).
• Previous care and responses: advice, rehabilitation, taping, brace, orthosis, medication, injection, imaging or self-management tried; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
• Patient perspective: understanding of the problem, priorities, preferences, concerns about movement or imaging, expectations and previous experiences of care.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use a small set that matters to the patient and is practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: the EQ-5D-5L for adults or the EQ-5D-Y-5L for adolescents, when suitable for the age, language and setting.
• Patellofemoral pain: the Knee injury and Osteoarthritis Outcome Score patellofemoral subscale (KOOS-PF) can track knee symptoms and functioning (Willy et al., 2019).
• Patellar tendinopathy: the Victorian Institute of Sport Assessment-Patella (VISA-P) can track symptom severity and activity (Ophey et al., 2024).
• Symptoms and performance: a pain rating and a small number of repeatable tasks linked to the person’s goals, such as squat, step-down, stairs, sit-to-stand, kneeling, running, hopping, jumping or sport-specific movement, when safe.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful but is not required.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the patient’s presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, draping, pace and support, and confirm ongoing consent.
• Condition-specific safety: defer provocative testing and arrange appropriate assessment when infection, vascular disease, stress fracture, slipped capital femoral epiphysis or another serious condition is suspected.
• Observation and gait: weight-bearing tolerance, gait, stairs, alignment, swelling, muscle bulk, guarding, asymmetry and use of supports. In adolescents with knee pain or a limp, observe foot progression and screen both hips.
• Movement and range of motion: active and passive knee flexion and extension, with hip and ankle movement when relevant; note range, end feel, crepitus, familiar symptoms and whether effusion or true mechanical blockage is present.
• Strength and load tolerance: knee extension and flexion, hip strength and lower-limb capacity as relevant; record pain, force, endurance, control and response during and after loading.
• Functional assessment: select safe tasks linked to the person’s goals, such as sit-to-stand, squat, step-down, stairs, kneeling, running, hopping, jumping, landing or sport- and work-specific movement. Note symptom location, movement strategy, confidence and capacity.
• Palpation and swelling: patellar borders, patellar tendon, tibial tubercle, bursae, fat pad region, joint lines and other relevant structures; assess warmth, effusion and focal tenderness when this helps distinguish a presentation.
• Patellofemoral pain pattern: reproduction of familiar retropatellar or peripatellar pain during a squat or another flexed-knee loading task supports the presentation after competing causes have been assessed. Patellar grinding or compression tests have limited diagnostic value (Crossley et al., 2016; Willy et al., 2019).
• Patellar tendon pattern: localized inferior-pole pain with palpation and tendon loading, such as resisted knee extension or a single-leg decline squat, supports patellar tendinopathy. Patellofemoral pain and tendon pain can coexist (Ophey et al., 2024; Rosen et al., 2022).
• Patellar instability and other knee tests: assess patellar apprehension, mobility, instability history, ligament or meniscal findings, and extensor-mechanism integrity only when these may change the working diagnosis or referral.
• Neurological and vascular examination, when indicated: lower-limb strength, sensation and reflexes; pulses, skin temperature, colour, swelling and other tests guided by the presentation.
• Imaging: not routine for a typical patellofemoral pain presentation. It can investigate serious pathology, recurrent effusion or instability, true locking, another suspected diagnosis, or a result that is likely to change care or referral. For suspected patellar tendinopathy, ultrasound has a limited confirmatory role when clinical uncertainty remains; interpret findings with the symptoms and examination (Ophey et al., 2024; Willy et al., 2019).
• Repeat and adapt the examination when needed to review progress, revisit the working diagnosis or decide whether further assessment or referral is appropriate.

Working clinical presentations

• Presentations can overlap or change. Use the history and examination, and imaging when it will change care. Do not infer a tissue diagnosis from pain location, one provocative test or an imaging finding alone (Ophey et al., 2024).
• Patellofemoral pain: retropatellar or peripatellar pain reproduced by squatting, stairs, running, hopping, jumping or another activity that loads a flexed knee, after competing causes have been assessed. Crepitus, pain after prolonged sitting or patellar-edge tenderness can occur but are not required (Crossley et al., 2016; Willy et al., 2019).
• Patellar tendinopathy: focal, load-dependent pain at the inferior patellar pole, often during jumping, landing, running or resisted knee extension, with localized tenderness and pain during tendon loading (Ophey et al., 2024; Rosen et al., 2022).
• Growth-related apophyseal pain: in a skeletally immature adolescent, localized load-related pain and tenderness at the tibial tubercle suggests Osgood-Schlatter disease. Reassess an atypical, severe or progressive presentation (Neuhaus et al., 2021).
• Localized superficial or anterior soft-tissue pain: focal pain, swelling or tenderness over a bursa, fat pad or plica region may be linked to kneeling, repeated compression or movement. Warmth, redness, marked swelling or systemic symptoms require Red Flags assessment.
• Patellofemoral instability: apprehension, recurrent giving way, subluxation or dislocation suggests a presentation distinct from patellofemoral pain and may need shared care (Crossley et al., 2016).
• Anterior knee pain without a confirmed specific presentation: the symptoms appear musculoskeletal after serious, traumatic and referred causes have been assessed, but the available findings do not support a more specific pattern. Record the working impression and revisit it as the course and response to care become clearer.

Develop care with the patient. Choices reflect the working presentation, safety, goals, preferences, culture, access, other health conditions, previous responses and the burden of care. Respect the patient’s right to accept, decline, limit or stop any part of care.

Education, self-management and participation

• Explanation and shared understanding: explain the working clinical presentation, what findings mean, the limits of tests and imaging, and how symptoms and load can change without implying that pain always means tissue damage (Neal et al., 2024).
• Activity and load: identify the activities and recent load changes linked to symptoms. Options include temporary changes to volume, frequency, intensity, speed, hills, stairs, jumping, kneeling or recovery, followed by gradual exposure toward meaningful activity (Neal et al., 2024; Rosen et al., 2022).
• Participation: pacing, task changes, knee protection for kneeling, school or workplace accommodations and communication with coaches or teams can help maintain valued roles while capacity is rebuilt.

Physical activity and exercise

• Patellofemoral pain: knee-targeted exercise can form the base of care, with hip-targeted exercise added when it fits the assessment. Weight-bearing and non-weight-bearing options can be used. Type, dose and progression reflect irritability, capacity, goals and response (Neal et al., 2024; Willy et al., 2019).
• Patellar tendinopathy: progressive tendon loading and planned changes to jumping, running or other high tendon loads can form part of care. Isometric, isotonic, eccentric and heavy slow resistance approaches are possible loading formats; no single format suits every person (Ophey et al., 2024; Rosen et al., 2022).
• Growth-related apophyseal pain: symptom-guided activity change, lower-limb strengthening and flexibility work can be used while growth-related irritability settles. Evidence comparing specific programmes is limited (Neuhaus et al., 2021).
• Movement and running retraining: task practice or a temporary change in running or landing strategy can support a specific goal when the assessment identifies a modifiable loading pattern. Keep changes simple and review their effect (Neal et al., 2024).

Hands-on and symptom-relieving care

• Patellar taping: tailored taping can be tried with exercise for short-term symptom relief when it makes a meaningful task easier (Neal et al., 2024; Willy et al., 2019).
• Prefabricated foot orthoses: a short trial can be paired with exercise for patellofemoral pain when assessment and immediate response indicate a likely fit. Comfort and benefit guide continued use (Neal et al., 2024; Willy et al., 2019).
• Manual therapy and soft-tissue techniques: can be used as short-term adjuncts when they improve symptoms or make active care easier. They do not replace education, load management and exercise (Neal et al., 2024).

Psychological, social and interdisciplinary support

• Persistent pain or movement concern: psychologically informed education, graded exposure and support for confidence can be integrated when fear, distress or uncertainty is limiting activity or participation (Neal et al., 2024).
• Coordinated support: communication with primary care, sports medicine, physiotherapy, school, workplace, coaching, dietetic or mental health services can address needs outside one clinician’s scope, including low energy availability, repeated instability or barriers to participation.

Medication and procedural shared care

• Medication questions: coordination with primary care or pharmacy can be useful when pain is limiting sleep or participation. Prescribing, dosing and injection decisions remain with an authorized clinician and are guided by the specific diagnosis, age, other health conditions and current medicines.

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, swelling, relevant neurological or vascular findings, functioning, participation, benefits, harms, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the clinical presentation, differential diagnosis, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: the course varies by presentation and by person. Patellofemoral pain can improve, persist or recur and is not always self-limiting, including in adolescents. Patellar tendinopathy and growth-related apophyseal pain can also take time to settle as load tolerance is rebuilt. No universal timeline applies (Neal et al., 2025; Rathleff et al., 2016; Ophey et al., 2024; Neuhaus et al., 2021).
• Factors associated with a less favourable course: for patellofemoral pain, longer symptom duration and greater symptoms or lower functioning at baseline have been associated with poorer group outcomes. Prognostic evidence is heterogeneous, and physical, psychological or demographic findings do not determine an individual’s course (Matthews et al., 2017; Neal et al., 2025).
• Potential supports for recovery: a clear explanation, feasible load changes, progressive exercise, confidence in movement, supportive relationships and teams, suitable school or workplace accommodations, access to care and timely shared care may support functioning and participation.
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using goals, repeated outcomes and the observed response over time. Do not use one test, imaging finding or prognostic factor as a fixed prediction.