The knee is the largest joint in the body. With no bony stability, it is entirely supported by muscles and four major ligaments: anterior cruciate, posterior cruciate, medial collateral and lateral collateral. Patellofemoral Pain Syndrome (PFPS) occurs as the muscles of the knee overcompensate due to the lack of strength and/or stability in the hip. The activities most commonly creating pain with PFPS include kneeling, squatting, running, getting in and out of a chair, and ascending and descending stairs. PFPS has also been associated with sitting for prolonged periods of time, causing tightness of the hip flexors and hamstrings. All activities that reproduce pain should be modified or avoided until the joint is pain free.
Unfortunately, the most commonly accepted treatment for PFPS is strengthening of the VMO (vastus medialis oblique), which is an attempt to reinforce the medial stability and correct any patellar tracking problems caused by tight lateral muscles and ligaments.(1) However, this does not address the core issue of PFPS: muscle imbalances and poor alignment of joints. Exercise should focus on the hip, knee and ankle/foot, and how each can affect the other to produce problems. According to Dr. Christopher Powers at the University of Southern California, “Results suggest that increased motor unit activity of the vastus medialis appears to be associated with abnormal patellar kinematics in women, but it is not necessarily a cause of abnormal patellar kinematics.”(2)
A client that presents with pain on or around the kneecap (patella) should be referred to a medical professional to find the cause of the pain. If it is found that the client has PFPS, the focus of personal training should be stretching the tight muscles and strengthening the weak muscles. Strengthening ought to concentrate on the gluteus medius, gluteus maximus, quadriceps and hamstrings. Stretching should focus on the hamstrings, hip flexors (iliopsoas and rectus femoris) and iliotibial (IT) band. Ankle and foot biomechanics should be addressed by specialty stores selling a variety of supportive shoes and/or over-the-counter orthotics. In some cases custom orthotics are necessary.
Focusing on strengthening the muscles listed above will help stabilize the pelvis/hip and help decrease stress on the knee. Stabilization of the pelvis is the first priority, followed by proper alignment of the ankle and foot to the knee. This program along with the use of orthotics has been shown to decrease or resolve PFPS.(3) If alignment issues are not addressed, the body will find a way to use unintended muscles, which will perpetuate the painful cycle.
To summarize, modify the exercises that are re-creating the knee pain. Incorporate a few simple exercises to strengthen and stretch the appropriate muscles. Finally, refer your client to a running specialty store for proper fitting of shoes to address ankle and foot alignment issues.
The knee joint is comprised of two bones, the tibia and femur. The kneecap or patella sits within the quadriceps tendon and glides on a smooth cartilaginous surface between the medial and lateral femoral condyles. As the knee flexes, the patella tracks inferior-laterally. As the knee extends, it tracks superior-medially to sit back in the femoral groove. The quadriceps muscle crosses the knee and attaches to the tibial tuberosity via the patellar tendon.
There are multiple muscles that control the movement of the hip. The gluteus maximus primarily extends the hip and laterally rotates the femur. It also has fibers that extend into the tensor fascia latae (TFL). If the gluteus maximus is weakened, the TFL begins to compensate and increases strain on the knee joint. Strengthening the gluteus maximus is important to prevent tightness in the TFL and iliotibial band. The IT band has an indirect insertion point on the patella and can become tight, causing a lateral pull on the patella. The TFL works in synergy with the gluteus maximus and medius to support the pelvis with the femur and the femur on the tibia. The gluteus medius is the primary hip abductor muscle. It also helps to control the contralateral hip during unilateral stance activities. Weakness of the gluteus medius causes the IT band to overwork, leading to tightness and patellar tracking issues. It is important to understand that one weak or tight muscle can affect the whole leg.
Those who experience PFPS most commonly report pain behind the patella and may have point tenderness along the medial and lateral borders. The pain associated with PFPS is often reproduced when using stairs, squatting, kneeling, and getting out of a chair after sitting for a prolonged period of time. PFPS is sometimes referred to as “movie goer’s knee” due to the increased time spent with the knee in a flexed position. In many cases, little to no swelling is observed, but the client may complain of tightness.
Proper shoes and orthotics
Research has shown that the use of foot orthoses can be an effective treatment for people with patellofemoral pain syndrome. Over-the-counter orthotics are an easy and inexpensive way to help properly align the foot, thereby reducing or relieving pain. Most commonly, you may find off-the-shelf, full-length or three-quarter-length orthotics. The most common foot alignment problem associated with PFPS is overpronation or “flatfeet.” Wearing properly fitting and supportive shoes is an additional way to address knee pain stemming from any possible foot and ankle malalignment.
When to seek a healthcare professional
If at any time a client has knee pain, it is important to refer him or her to a health professional. There are many causes of knee pain; without a proper differential diagnosis and diagnostic imaging, a fitness professional could cause more damage. Many clients can be under the care of an orthopedist and/or a physical therapist while training with their fitness professional. It is important to communicate with the healthcare provider regarding the cause of knee pain and follow his/her guidelines or protocols until there is pain-free movement. Keeping the health of your client at the forefront of your training is of utmost importance, as is knowing when to seek medical advice. Understanding how to modify irritating activities, as well as learning the areas to strengthen and stretch, can help decrease the incidence of PFPS. In some cases, surgical intervention is needed to release the lateral structures around the patella. AF
See page 2 for Exercises and Stretches
Jeffrey M. Woods, MSPT, COMT, CSCS, CFT, received his master’s degree in physical therapy from the University of Miami. Currently he’s the director of a physical therapy clinic in Baltimore. He is an instructor for AFAA, teaching both the Personal Trainer Certification and Injury Prevention seminar. Woods specializes in orthopedics, sports medicine, vestibular dysfunctions and manual techniques.
Nicholette Panas is a physical therapist assistant (PTA) student from Baltimore. She graduated in 2009 from the University of Rhode Island with a B.S. in kinesiology. Panas is currently completing her full-time clinic placements for an A.A. degree in PTA in the fields of orthopedics and traumatic brain injury.
1. BOLGLA, L.A. AND BOLING, M.C. “AN UPDATE FOR THE CONSERVATIVE MANAGEMENT OF PATELLOFEMORAL PAIN SYNDROME: A SYSTEMATIC REVIEW OF THE LITERATURE FROM 2000 TO 2010.” INTERNATIONAL JOURNAL OF SPORTS PHYSICAL THERAPY, 6, NO. 2 (JUN 2011): 112-25.
2. POWERS, C.M. “PATELLAR KINEMATICS, PART I: THE INFLUENCE OF VASTUS MUSCLE ACTIVITY IN SUBJECTS WITH AND WITHOUT PATELLOFEMORAL PAIN.” PHYSICAL THERAPY, 80, NO. 10 (2000): 956-64.
3. ENG, J.J. AND PIERRYOWSKI, M.R. “EVALUATION OF SOFT FOOT ORTHOTICS IN THE TREATMENT OF PATELLOFEMORAL PAIN SYNDROME.” PHYSICAL THERAPY, 73, NO. 2 (1993): 62-68.
SUTLIVE, T.G., ET AL. “IDENTIFICATION OF INDIVIDUALS WITH PATELLOFEMORAL PAIN WHOSE SYMPTOMS IMPROVE AFTER A COMBINED PROGRAM OF FOOT ORTHOSIS USE AND MODIFIED ACTIVITY: A PRELIMINARY INVESTIGATION.” PHYSICAL THERAPY, 84, NO. 1 (2004): 49-61.