Bridging the Gap: A Systematic Evidence and Gap Map of Risk Factors and Preventive Strategies for Patellofemoral Pain

OBJECTIVE: To systematically review, map, and appraise the existing prospective evidence on risk factors for, and preventive strategies against, the development of patellofemoral pain (PFP), and to identify key gaps. DESIGN: The study design was a systematic evidence and gap map (EGM). LITERATURE SEARCH: Nine electronic databases (PubMed, CINAHL, PEDro, Scopus, SPORTDiscus, Embase, Cochrane, Web of Science, CENTRAL) were searched from inception to the end of March 2024. STUDY SELECTION CRITERIA: Published prospective observational studies and randomized controlled trials (RCTs) investigating the development of PFP in individuals without baseline PFP were included. Studies of other knee conditions, older adults (mean age > 45), or retrospective designs were excluded. DATA SYNTHESIS: Evidence was mapped across the following domains: sociodemographic, neurobiological, anthropometric, psychological, biomechanical, and behavioral. RESULTS: From 57,897 identified records, 36 studies were included: 24 prospective observational studies and 12 RCTs. Most studies focused on biomechanical risk factors (n=22), with limited exploration of psychological (n=1), behavioral (n=2), and neurobiological (n=1) domains. Preventive interventions involved orthoses (n=4), exercise (n=3), bracing (n=2), gait retraining (n=1), stretching (n=1), or running intensity/volume modification. Nonbiomechanical strategies such as education or graded exposure were rarely tested. Risk of bias was low to moderate for most prospective observational studies and moderate to high for most RCTs. CONCLUSION: This EGM reveals an overreliance on biomechanical perspectives within the context of PFP risk factor research, with limited attention to psychosocial, behavioral, and load-related risk factors. Preventive trials are few, often low in quality, and narrowly focused. Addressing these evidence gaps is essential for developing effective, multifactorial prevention strategies for PFP. J Orthop Sports Phys Ther 2026;56(2):85-97. Epub 15 December 2025. doi:10.2519/jospt.2025.13489