95 patients with tibial fractures undergoing intramedullary nailing randomized to one of two approaches: the conventional medial parapatellar surgical approach (CMPP), or a suprapatellar semi-extended approach (SPSE). The study was conducted in order to determine if the use of the suprapatellar semi-extended approach significantly reduced anterior knee discomfort, through a newly developed kneeling test measure, compared to the conventional approach. Patient-reported pain, satisfaction and functional outcomes were also assessed. Findings indicated a significant difference in favour of the SPSE group over the CMPP group in the kneeling test for anterior knee discomfort at 6 and 12 months. Differences between groups in pain and functional outcomes were reported to not be statistically significant.