Going back over my notes, I originally had extruder max speed at 3600, then subsequently fiddled with it. I've just rebuilt my config entirely and all seems well.
I do still have an issue with the MFM reporting too little movement (<40%) with pressure advance on, though I'm homing in on whether it's slipping itself or whether there is actually some under extrusion going on. My feeling so far is it's struggling to react to rapid moves, but only some slow motion footage will be able to confirm that. I can't hear any skipping and the filament feels like its movement matches the extruder. My prints usually run around the 80-110% mark and I've had the MFM set 70% - 120% for as long as I can remember.