Exercises for Knee Pain caused by Patello-Femoral Syndrome

Miranda, in London, England asks:

"I get knee pain when I attempt to exercise and my physio says it is Patello-Femoral syndrome. She has tried taping it, but I still get pain. Are there any exercises that will take my pain away?"

Marc R. Bernier, MPT CSCS responds:

"Patello-Femoral Stress Syndrome (PFSS) is a generic term that is often used to describe generalized knee pain that centers around the kneecap (patella). The pain that is associated with this condition is thought to be the result of either abnormal tracking (movement) of the patella during flexion/extension of the knee, or excessive stress being placed on the patello-femoral joint during functional activities. Over the years, many theories have been proposed as the primary cause of this condition:

Quadriceps / Vastus Medialis Oblique (VMO) muscle weakness
Muscular tightness
Iliotibial band (IT Band) tightness
Hyper-pronation of the foot
Bone structure abnormalities

"As a result, treatment methods typically focused on the following:

Strengthening of the quadriceps (more specifically, the VMO)
Stretching of the quadriceps, hamstrings and IT Band
Orthotics to control hyper-pronation
Patellar taping to correct abnormal tracking of the patella

"Unfortunately, despite our best efforts, the above treatments seemed successful only 50-60% of the time.

"The latest research into this condition has led to an increased focus on the proximal (anatomy closer to the trunk) influences on the patello-femoral joint, mainly the role of the Gluteus Medius muscle of the hip. This muscle is located at the top of the buttocks and can usually be palpated just above the back hip pocket. This muscle is responsible for both abducting (raising out to the side) and externally rotating the leg. However, it's more important function is its role when the leg is in a weight-bearing position. During running, cutting and planting maneuvers it prevents the thigh from 'buckling' and rotating inwards, which is the 'position of danger' for knee injuries (especially Anterior Cruciate Ligament injuries). It is also a position that causes significant stress to the patello-femoral joint, as the Patella will have a tendency to be pulled laterally (towards the outer side), causing stress to the Patello-Femoral joint and soft tissue that surrounds it.

"Several studies have shown that weakness of this muscle may be a primary cause of PFSS, especially in females. A study performed on long distance runners with Ilio-Tibial Band syndrome revealed a 90% success rate by implementing a Gluteus Medius strengthening program alone. I have also seen a very high correlation between hip weakness and PFSS incidence in females, and implementation of a hip strengthening program has resulted in a drastic increase my success rate in resolving this condition.

"The program I implement with my patients (especially the female athletes) is a two phase program, and is based on the premise that the hip will control the position of the knee. The first phase focuses solely on Gluteus Medius strengthening. Strengthening of this aspect of 'the core' will better enable the patient to control the lower extremity and keep the knee out of the 'position of danger'. Once this baseline strength has been established (2-3 weeks minimum), the second phase of Quadriceps/Hamstrings/Gastrocnemius strengthening can be initiated. It must be emphasized that implementing a general lower extremity strengthening program before resolution of the hip weakness will result in continued knee pain."

Side Lying Abduction