Posts Tagged ‘Knee pain’

Patellofemoral Pain Syndrome (PFPS) is a common condition encountered in orthopaedic practice. PFPS most commonly presents with retro- or peri-patellar pain associated with positions of the knee that result in increased or misdirected mechanical forces between the kneecap and femur. Climbing stairs, running, kneeling, squatting and long-sitting are frequent pain aggravators. Clinicians have come to understand that the cause of PFPS is not always directly at the knee, realizing the importance of surrounding dysfunctions proximal or distal to the site of pain….we must understand that knee pain is not about the knees (most of the time), a holistic approach must be utilized in both assessment and treatment to figure out why one would present with knee pain.

Here is a list of 4 common reasons for knee pain and a subsequent diagnosis of PFPS (which is a crappy diagnosis)

1) Weak Hips

You’ve probably heard it before, but it’s worth repeating: Weak hip abductor and external rotator strength is a key reason for PFPS. It is believed that weak hips cause medial rotation, adduction and valgus collapse of the tibia and femur leading to excessive joint compression and patellar mal-tracking. This is especially true in women due to the larger Q-angle they present with (wider hips), which makes it all the more important to strengthen the hips as part of a comprehensive treatment approach

“Current research reveals that poor proximal neuromuscular control and/or weakness of the hip musculature may lead to limited control of transverse and frontal plane motions of the hip (especially during single-legged stance). Other evidence suggests such dysfunction can result in dynamic malalignment including components of femoral adduction and internal rotation, valgus collapse at the knee, tibial rotation and foot pronation. Findings of deficits in hip abduction, extension and external rotation strength has also been shown with patients with PFPS. Further, multiple studies by Willson and colleagues demonstrate that there is an increased hip adduction angle in PFPS patients compared to healthy controls”

Journal of Orthopaedic & Sports Physical Therapy 2012; 42(1): 22-29.
The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females with Patellofemoral Pain: A Randomized Controlled Trial

American Journal of Sports Medicine 2011; 39(1): 154-163A Proximal Strengthening Program Improves Pain, Function and Biomechanics in Women with Patellofemoral Pain Syndrome

See what I’m talking about?

2) Restricted Ankle Dorsiflexion

I wrote an entire blog post about this a few weeks back. Long story short: If you can’t get the 10-15 degrees of dorsiflexion in your ankle that is needed for proper gait or squatting you will ultimately compensate by falling in on your arches thus pronating through your subtalor joint. Just like with weak hips, if you excessively pronate you will tend to have tibial and femoral internal rotation thus placing the knee in an awkward position when doing such tasks as descending stairs. Muscle imbalances my result along with excessive joint compression at the knee causing PFPS symptoms.

I have not come across a lot of studies that specifically look at the effects of ankle dorsiflexion on knee pain but here is what I’ve read to date:

N Am J Sports Phys Ther. 2009 February; 4(1): 21–28
Treatment of Lateral Knee Pain by Addressing Tibiofibular Hypomobility in a Recreational Runner

J Sports Rehab 2012 May;21(2):144-50.
Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat.

“Altering ankle-dorsiflexion starting position during a double-leg squat resulted in increased knee valgus and medial knee displacement as well as decreased quadriceps activation and increased soleus activation. These changes are similar to those seen in people with PFPS.”

Knee to wall test: How I assess ankle doriflexion

3) Lumbar spine pathology:
Conditions like spinal stenosis, arthritis or a disc herniation from L3-4 (most likely) can refer pain down to the knee. The nerves that exit the lumbar spine at certain levels travel down to the knee to provide motor input and sensory output. Thus, irritation of a nerve root in the lumbar spine can be a chief cause of lateral (L5), anterior (L4) or medial (L3) knee pain. Anecdotally, I have treated a few clients with no back or upper leg pain, but complained of tightness and burning at the knee. Once all knee-specific subjective and objective tests are ruled out, it became apparent via dural mobility testing that the knee pain was a function of a lumbar spine pathology.

Quick tip: If a client has unexplained knee pain and you think it maybe neurologically mediated (well, all pain is neurologically mediated…you get what I’m saying though) then test dural mobility and see if that recreates their knee pain. If so, you have a great outcome measure to see if you made a difference post treatment. If a slump test causes burning lateral knee pain, treat the lumbar spine and re-test the slump. Hopefully it’s better afterwards!

4) Hallux Valgus or 1st MTP restriction:
Just like at the ankle, if the 1st toe can’t extend or dorsiflex like it should the foot  will fall into more pronation through midstance to toe off (the big toe has to find a way to get to the ground and it does so by forcing the subtalor joint into pronation). This again leads to dynamic knee valgus and the possibility of PFPS…Knee pain? Check the big toe!

Good ROM


  • Knee pain is often multifactorial and keeping in mind regional interdependence yields a more comprehensive assessment and treatment approach
  • Knee pain can have components of articular restriction, dural irritation, tendonopathy or a combination of many things (usually the case)
  • When someone comes in with insidious onset unilateral knee pain and the prescription from their G.P says “overuse injury, treat with ROM, strengthening and stretching of the knee” (what I had last week) you MUST explain to the patient that unilateral overuse with bilateral activity (running etc) is probably impossible.
  • Treat the joints above and below and even on the contralateral side if needed

Ok, here it is…part 2 of it’s all in the hips. In my last post I discussed the importance of strong gluts for the prevention of knee pain. I explained what the glut muscles do and what happens when they go wrong. Suffice to say, there would be a lot less “pattelofemoral” pain patients in the world if we all worked on strengthening our hips!

Before I begin I want to say that the following exercises are for beginner to intermediate athletes and for those who have knee pain that COULD be attributed to the hips. Like I said in my last entry, there are other factors to knee pain but in any case, there is nothing wrong (or unsafe) about training the hips so I’m confident I wont hurt anyone by giving them some tips and videos. PLEASE note: don’t assume that these exercises will “cure” you of knee pain. I will always always always recommend getting a specific assessment by a trained professional such as a physiotherapist or chiropractor to determine the exact cause of your problem…you knew that was coming lol

Here is a list of exercises I like to give my patients with weak hips that are causing knee and low back pain:

1) The single leg bridge:

This exercise is great for 2 reasons. First and foremost, it strengthens the glut max (butt muscle) on the weight bearing side very well if done correctly. Secondly, this exercise is single leg and as such, the glut medius and minimus are working to control the non weight bearing hip from dropping down to the side. If this exercise is too hard to do..i.e you cant lift up high enough to make your hips level, you can do the double leg bridge…same idea as this, but you use 2 legs to bring your butt up instead of just one.

2) The “telephone” book exercise:

This exercise is tricky and is hard to explain in writing. Basically, you stand on a step (or telephone book lol) with one foot. You drop the other foot that is not on the step down my lowering the hip on that side. You then have to focus on contarcticing the glut med muscle on the weight bearing side to hike up the hip on the non weight bearing side. It’s best to hike the hip up higher then the hip on the weight bearing side for maximal benefit…don’t bent the knee on the weight bearing side much because that is cheating

3) Side lying hip abduction:

This one Is self explanatory…but here are a few key points to know:
a) When raising the leg up, do NOT let the hips roll back. You must try and keep the shoulder, hip and knee parallel. Keep your hand on your hips to sense if they are falling back or not…or do the exercises in front of a mirror if possible.

b) People with weak gluts will cheat in this exercise by using the hip flexor muscle tensor fascia lata (TFL) to raise the leg up instead of using the glut med. You will know this is happening because instead of keeping the leg straight out beside you (or even a little bit extended is best) the leg will come forward…you will flex the hip while abducting the leg because the TFL will do the work for the lazy gluts!

In the video, he uses a plastic band around the ankles to increase resistance. That is a good idea, but poorly executed. The band should ideally be just below the knees for maxiaml effect…having the band around the ankles is a) too hard and b) promotes the use of the TFL over the gluts

4) The Bird Dog:

The dude in this clip actually does a good job of explaining the exercise and common mistakes that are made. Just watch the clip and do what he says 😉
I know the video says this is a killer abs exercise (and it is)…BUT, this exercise is also a great glut max exercise and glut med stabilization exercise. It’s kind of advanced but I thought I’d throw it out there.
To make it easier—Don’t involve the arms. Just extend the legs out one at a time. Hold the leg out in an extended position for 10 seconds, bring it back down, and then do the other leg. This will still target the gluts but won’t do as much for the abs or back..

Do each of these 4 exercises 10 times. That is one set. Do 3-4 sets per day of each. If you develop pain while doing ANY of these exercises, STOP right away!! No need to hurt yourself here haha

As always, feel free to ask any questions you want. There are many more great glut exercises out there (squats, deadlifts etc), but these are the ones I find work well for the majority of people I see. For a personalized exercise program see a trained professional!

Thanks for reading!