Everything You Need to Know About Patello-femoral Pain
Patello-Femoral Knee Pain-What Is It?
There are many causes of knee pain. If you suffer from pain at the front of your knee which is stiff when you’ve been sitting for a prolonged time, aggravated with repetitive squatting, running, stairs or kneeling and sometimes you feel it grinding, you may be suffering from patello-femoral pain syndrome – also known as runner’s knee.
For some people this pain is caused by the repetitive stress of their aggravating activities (squatting, kneeling etc), overuse during training or work and patellar mal-tracking. It is well recognised that patellofemoral pain is multifaceted and there is not one singular cause. Rather, people suffering from this have many contributing factors that all need to be addressed to reach a full result.
The Treatment of Patello-Femoral Pain
Historically, patellofemoral pain syndrome has been treated with orthotics to help abnormal foot position, soft tissue release of tight structures, in particular lateral structures which may contribute to patellar maltracking, and the prescription of strengthening exercises for the knee stabilising muscles. Research has now also looked at the role the hip plays in knee pain.
The role that the hips play in Patello-Femoral Pain
There have been two studies which looked at hip kinematics in females with patello-femoral pain (PFPS) syndrome. One study found that abnormal hip kinematics in women with PFPS was due to diminished hip-muscle performance and less due to altered femoral structure. This shows us that when assessing knee pain you must look at hip strength as a contributing factor (1)
Another study looked at hip internal rotation and found women with PFPS has decreased hip muscle strength, proposing again that hip muscle dysfunction has an association with patellofemoral pain syndrome (2).
Hip Strengthening Exercises & Their Role in The Treatment of Patello-Femoral Pain
The fact that PFPS is associated with hip muscle dysfunction suggests that hip strengthening exercises improve proximal and distal alaignment of the hip and knee and reduce loads on the patello-femoral joint. Lee, souza and Powers looked at the affect of wearing a hip brace on changes in stability with a step down balance task and found that wearing the hip brace improved stability in the knee and reduced centre of pressure displacement. This suggests that the knee is more stable when the hip has greater stability and can be thought that by increasing muscle strength of the hip that this will have a similar result. (3)
So now the researchers know that the hip strength played a role in knee pain, but how does it compare to knee strengthening alone.
One study compared two groups of women with PFPS, one group performing 4 weeks of hip strengthening and the other performing 4 weeks of knee strengthening before completing a 4 week combined program together. At the end of the 8 weeks both groups had improvements in pain and hip strength, but the hip strengthening group had greater initial reductions in pain. This suggests that initially giving hip strengthening exercises and then adding knee exercises may be beneficial for people suffering PFPS. (4)
The Role of Hip Strengthening for Longer Term Patello-femoral Pain Outcomes
Fukada et al compared women with patellofemoral knee pain prescribed with knee only exercises or hip and knee exercises. At three, six and twelve months, it was found that Knee-stretching and -strengthening exercises supplemented by hip posterolateral musculature–strengthening exercises were more effective than knee exercises alone in improving long-term function and reducing pain in sedentary women with PFPS. (5) In a systematic review by Lack et al, it was found that there is strong evidence to support hip combined with quadriceps rehabilitation which decreased pain and improved function in the short term. Moderate evidence indicated that proximal when compared with quadriceps rehabilitation decreased pain in the short-term and medium-term, and improved function in the medium term (6)
Exercise Options for Patello-femoral Pain
When it comes to exercise prescription there are a few options; home exercise program, gym exercise program, Whole body vibration therapy, or a clinical pilates program. Knowing which one is best for you depends on – the time you have available, what kind of exercise you prefer and whether you need to be supervised of not.
Home Program Exercises for Patello-femoral Pain
For an example of several great hip strength exercises click:
- HERE for 4 great exercises with running physiotherapist Brad Beer.
- HERE for a great hip strength exercise for patello-femoral pain.
- HERE for overhead press exercise.
- HERE for a terrific adductor strengthening exercise which will assist with the treatment and prevention of further patello-femoral pain.
- HERE for a terrific glut medius strengthening exercise.
Clinical Pilates for Patello-femoral Pain
Clinical Pilates can be a great way to start your rehabilitation. During clinical pilates you are supervised by a physiotherapist, ensuring that you are performing the exercise routine correctly, your sets and reps are controlled and supervised by the physiotherapist, there is a core strengthening component and it is very safe.
The clinical reformer can be used to strengthen your calves, quadriceps, hamstrings, hip abductor muscles and deep hip external rotator muscles, all necessary when it comes to rehabilitating patello-femoral pain syndrome.
Clinical Pilates Videos: (coming soon)
Double and single leg squat
Standing abduction and skater
Kneeling hip external rotation
Emily Georgopoulos (APAM)
Physiotherapist, Clinical Pilates Instructor
ps. If you are a Gold Coast resident and suffering from knee pain, take the step of getting it comprehensively assessed and correctly daignosed. Say goodbye to pain and injury and hello to your physical best performance by booking your Discover Recover Session today!
(1)Predictors of Hip Internal Rotation During Running Richard B. Souza and Christopher M. Powers Am J Sports Med 2009 37: 579 originally published online December 19, 2008 DOI: 10.1177/0363546508326711
(2) Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain Richard B. Souza and Christopher M. Powers J Orthop Sports Phys Ther 2009;39(1):12-19. doi:10.2519/ jospt.2009.2885 TA;OMEH:I0 bi
(3) Lee, S., Souza, R., Powers, C. (2011) The influence of hip abductor muscle performance on dynamic postural stability in females with patellofemoral pain. Sports Health. 2011 Sep; 3(5): 455–465. doi: 10.1177/1941738111415006
(4) Dolak, K., Silkman, C., McKeon, M., Hosey, R., Lattermann, C. and Ulh, T. (2011) Hip strengthening prior to functional exercises reduced pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized control trial. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70. doi: 10.2519/jospt.2011.3499
(5) Fukuda TY, Melo WP, Zaffalon BM, Rossetto FM, Magalhães E, Bryk FF, Martin RL (2012) Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up.J Orthop Sports Phys Ther. 42(10):823-30.(6) Lack, S., Barton, C., Sohan, O., Crossley, K., Morrissey, D. (2015). Proximal muscle rehabilitation is effector for patellofemoral pain: a systematic review with meta-analysis. Br Jportsmed doi:10.1136/bjsports-2015-094723