Patellofemoral Pain Syndrome

Patellofemoral pain syndrome is sometimes also known as Anterior Knee Pain or Patella Mal-tracking. It is sometimes also referred to as runner’s knee – but so is IT band syndrome, so make sure you clarify which one you are talking about!

The symptoms of patellofemoral pain include an aching pain around the front of the knee which is often hard to pin-point and is worst after exercise. Sometimes there are sharper pains which can be felt around the edge of the kneecap – usually medially (to the inside). A typical complaint is that pain is particularly bad when walking down hills and stairs. Exercises like lunges and squats may also cause pain. The knee may click when bending and straightening it and the kneecap may feel loose, unstable or as though it might pop out.Patellofemoral pain syndrome

What is it?

Patellofemoral pain is caused by excessive movement of the knee cap. On the front of the knee there is a groove in which the knee cap is supposed to run when bent and straightened. Due to factors including biomechanical problems and muscle imbalances, the knee cap may deviate from this groove. This can cause pain and inflammation, as well as degeneration of the hyaline cartilage which lines the back of the patella.

Who suffers from it?

Patella pain is most common in women. This is because women have wider hips and so this creates a larger angle at the knee – known as the Q angle. This affects the biomechanics (movement patterns) of the knee. It is particularly prominent in teenage girls and women who run. It can occur in men, it is just less common.

 Patellofemoral Pain Treatment

The treatment of this condition varies from person to person depending on the factors which are contributing to their pain. Rest is the first step to take. It doesn’t have to be complete rest, but rest from anything which aggravates the condition, making the pain worse – either at the time or later on.

The next step is to try to figure out what has caused the condition to develop. A common scenario I find when assessing patients with this condition is the following:

  • Tight lateral thigh musculature
  • Weak hip abductors (such as gluteus medius)
  • Weak Vastus Medialis Oblique (VMO – part of the vastus medialis quad muscle)
  • Overpronation / Flat feet

This combination causes a lateral pull on the patella and the resultant mal-tracking. Think of it as a tug-of-war on the knee cap. The muscles surrounding it should be pulling equally to maintain a central position. But, if the lateral structures are too strong / tight and the medial structures are not strong enough, the knee cap is pulled laterally.

Biomechanical factors can add to this problem. Overpronation at the foot causes a rotatory force to move up through the shin bone to the knee joint. Weak hip abductors mean the knee falls inwards when bent. Both of these dysfunctions can contribute to mal-aligment at the knee joint.

In order to comprehensively treat the condition, you need to address all contibutary causes and correct faulty biomechanics before considering returning to running. Here are some examples of how you can do this.

Strengthening exercises

Strengthening exercises should focus on the hip abductors and VMO.

Strengthening the hip abductors such as VMO can be achieved with various exercises. My favorite is the Clam exercise:

  • Lying on the unaffected side with the top hip directly over the lower one and not rotated back. The knees should be bent to 80 degrees with the feet together.
  • The feet stay in contact as the top knee is lifted up, away from the lower one, as far as feels comfortable.
  • Avoid cheating – rolling the hips back to allow more movement at the hip joint. The idea is to isolate the hip abductor muscles.
  • Make sure the back and pelvis are kept still as you raise the knee. Lower the knee back down, rest and repeat.

The VMO is the Vastus Medialis Oblique. This is part of the Vastus Medialis muscle found on the inner thigh. This section of muscle is particularly important for kneecap stability. It can become weak, or in some cases delayed in firing. This is especially prominent after knee surgery. This muscle can be strengthened and contraction ‘speeded up’ with the following exercise:

  • A rolled up towel in placed underneath the knee joint whilst seated on the floor with both legs straight out in front.
  • Palpate the VMO using two fingers, placed just to the inside and above the kneecap.
  • Press the knee down into the towel and notice how strongly the muscle under your fingers contract.
  • The muscle should also contract the instant the knee is moved. If not – the firing is delayed.
  • If unsure, test this against the other leg – presuming the pain is one-sided!
  • The contraction speed and strength of the VMO can be increased using this exercise. Simply repeat 15-20 times twice a day, really focusing on the area you are feeling and trying to contract the muscle under your fingers.


As mentioned above, common areas of tension in this condition include the outer Quad muscles and lateral retinaculum (fibrous connective tissue on the outer knee).

Stretching the quad muscles can be achieved in a number of ways. Probably the easiest and most commonly used method is the standing quad stretch. This involves bending the knee in a standing position and grabbing the foot with the same hand. Pull the foot towards the buttocks until a stretch is felt in the front of the thigh. Hold for 20-30 seconds, rest and repeat.

The IT band on the very outer thigh itself can’t really be stretched as it is a non-elastic structure. You may also hear of people talking about foam rolling the IT band or getting massage therapy on it. Research shows this is also not effective and so generally a painful waste of time! Your time is much better spent working on strengthening the hips.

Overpronation / Flat Feet

Pronation is a normal movement found at the subtalar joint (joint between the Talus (ankle bone) and the foot. Pronation is the movement where the foot rolls inwards and the arch of the foot lowers. This helps the foot to mold to the surface of the floor and absorb shock.

Overpronation occurs when this movement occurs in excess. This can be a bad thing as when the foot pronates excessively the Tibia (shin bone) rotates outwards which translates up to the knee, placing an abnormal force on the joint and contributing to mal-tracking.

Flat feet or a fallen arch is a slightly different thing to overpronation although they are often confused. Flat feet occurs when the arch of the foot is naturally lower than it should be. This may be a structural problem or have developed after a foot injury. Whilst it is different to overpronation, it can also cause rotation of the Tibia and the same problems at the knee.

If you have fallen arches, flat feet or overpronate then arch support insoles or orthotics are recommended to help correct this. These can be purchased off the peg or can be custom made by a podiatrist. Insoles should be worn in all footwear and can usually be moved between shoes. Running shoes can be purchased with built in arch support – these are known as motion control shoes.

If you are unsure if this applies to you, visit a sports therapist, podiatrist or specialist running shop for a gait analysis. They should be able to point you in the right direction.

Return to Running

Don’t attempt to return to running too early. You should have rested until completely pain free in day-to-day activities. You should have identified and taken steps to correct any muscle imbalances and biomechanical issues. Ensure you have seen clear improvements in the exercises you are performing, such as an increase in reps or range of motion.

Once you are happy that you have made some headway, try a short run. 10-15 minutes tops. Then rest for 3 days. If you feel no pain during the run or in the three days afterwards, attempt another short run and rest again for 3 days. If all goes well, you can begin to gradually increase your running distance, but make sure it is gradual.

If you feel it would help, try wearing a knee support or taping your kneecap to reduce movement. There are knee supports available which target this particular problem with the help of lateral padding and medial straps to reduce lateral movement. A simple taping technique can be applied using 2.5cm zinc oxide tape to pull the patella medially.

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