Patellofemoral Pain Syndrome: Why it is more than just knee pain

examination of knee pain
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Acumen Sports & Shoulder Clinic

This blog was republished with permission from Acumen Sports & Shoulder clinic, located in Edmonton, Alberta. You can check out more great tips and advice from them at acumensportsandshoulder.com.

Patellofemoral Pain Syndrome or PFPS as it is commonly known, is a fancy way of saying that there is pain in and around the patella (kneecap) caused by the muscles around the femur (your quads or hip flexors). Most often, this is either due to abnormal patella (kneecap) tracking, weak abductors & external rotators, lower extremity misalignment, and/or lack of flexibility to name a few (Selhorst, Rice, Jackowski, Degenhart & Coffman, 2018). It is mostly common but not limited to adolescents. Many adults that have recently increased their level of activity also seem to face PFPS, in most cases, this is due to muscular imbalance or internal rotation of the tibia (shin bone) which puts a lot of stress on the medial aspect of the knee (Scali, Roberts, Mcfarland, Marino, & Murray, 2018)

Knowing the exact cause of patellofemoral pain is often hard to do but there are various telltale signs when certain movements are done and all these relate to the causes that were mentioned in the paragraph above.

Abnormal patella tracking

This is when the knee cap doesn’t stay in the groove created by the femoral condyle throughout various movements like flexions and extension. This can be caused by various muscular imbalances in the quads, meaning that instead of the quads firing as one unit to cause knee extension, one muscle fires first causing a misalignment. This is why quad extensions are often recommended to treat PFPS but knowing which muscles fires first or doesn’t fire is important so that the rehab exercises are done the right way.

Weak abductors/external rotators

Your abductors are the muscles on the lateral side of your hip that work to bring your leg up to the side. They fire whenever we stand on one leg whether it is during walking or running or whether we are doing single leg exercises like lunges or Bulgarian Split squats. If these muscles are working properly, the hips will not have to compensate and direct force to the wrong muscles. However, if these are not working properly whether it is lack of strength or not often used, the hips will compensate for this and send the work to other muscles in the leg that aren’t built for that resulting in a lot of stress being put on the knee. Most often, this is because the adductor longus activates more than the glute med resulting in the knee going into valgus.

Your external hip rotators are the muscles in your hips that cause your knees to drop or rotate outwards whether your knees are bent or not. Your hip rotators can be found underneath and around your glute muscles as we constantly sit on them. Constant pressure on these muscles can cause them to tighten up resulting in them not being as efficient when they have to be activated.

Lower extremity malignment

The body has various lines and angles that it is supposed to be at to function properly. When this is the case, the muscles are at their proper length so they can fire efficiently and properly while maintaining an efficient joint alignment. When one muscle in these movements alignments is off, it is going to affect not only the ones around it but all the muscles that are involved in various patterns round it.

For the knee, the most common one is tight hip flexors. Your hip flexors are various muscles that attach in and around your pelvis and they bring your knee up towards your chest. This is the same action that happens when we sit for long periods of time or the one that hockey players are in for a long time while skating. Being in this constant position, causes the hip flexors to shorten and adapt causing a shift or a strain in every movement that doesn’t include immediate hip flexion (i.e – standing up for a long amount of time can cause more pressure to be placed on the lower back or the knees as the hips are not able to provide the support that is needed)

Decreased flexibility

Flexibility is an important aspect of being pain free and mobile. Without it, we are not able to do any of the basic movements that we all take for granted. Being able to touch your toes is may more than just hamstring flexibility, it’s about lower back flexibility and hip flexibility. Just the way being able to bend your knees is more than just knee joint flexibility – it’d about the hip flexor’s ability to stretch so that the hamstrings can contract fully. Or the hip’s ability to extend within its normal ranges. Without flexibility, our body compensates for various movements and at first, this might seem like it isn’t causing any damage but over time, the incorrect pattern causes wear and tear on the body resulting in pain or tension in the areas that break first.


Training to prevent patellofemoral pain syndrome would include tackling the reasons above and doing so in a smart way. As an athletic therapist and a strength coach, there are various ways to see if someone is putting a lot of pressure on their knee and these don’t always have to be very extensive tests. Often, it can be seen in something as easy as them sitting down on a chair or standing up. How does their body adapt to the movement? Do they bend their chest forward a lot? Do they put their hands on their quads as they do so? Do they bend their knees more than they bend their hips as they do so? These little movements are normal in our society because we all know someone who sits like that – whether it is consciously due to an injury or subconsciously. However, these are the little things that can make one susceptible to knee pain.

Tips on how to change that in your daily life

  1. When sitting, bend your hips more and try and keep your knee and heel aligned – this is almost like a squat. This shifts the weight from your quads to your hips/glutes forcing them to work more.
  2. Don’t press your arms to your legs when you’re about to sit down, this is you not engaging your core – again forcing your hip flexors to stabilize your body. Since some of your hip flexors become your quads, this ends up putting a lot of strain on your knee cap either limiting your flexibility or affecting how your patella tracks.
  3. When squatting, make sure that your knees do not cave in – they should be facing forward, this makes sure that your abductors and external rotators are working as they should.
  4. Clamshells – clamshells are an exercise that targets your abductors and hip rotators. Since weakness in these muscles is a precursor to knee pain, training those muscle to work properly is essential. For clamshells, you are laying down on your side with your knees and hips bent to about 45 degrees each, from here, you’re going to try and lift the top knee from the bottom one while keeping your ankles together. 3 sets of 12/side is a good place to start.
  5. Stretch, stretch, stretch – I know that we talk so much about the importance of stretching but no matter how many times that is said, it is not applied as much as it should. Limited flexibility is one of the first indication of a wrong movement pattern before pain even settles. Try and make time – proper stretching takes about 10 minutes of you day. Stretching your quads, hip flexors and lower back are all great places to start. Holding each stretch for about 40 seconds – 1 minute/side

If you have PFPS or ongoing knee pain, talk to an Athletic Therapist near you today.


Selhorst, M., Rice, W., Jackowski, M., Degenhart, T., & Coffman, S. (2018). A sequential cognitive and physical approach (SCOPA) for patellofemoral pain: A randomized controlled trial in adolescent patients. Clinical Rehabilitation,32(12), 1624-1635. doi:10.1177/0269215518787002

Scali, K., Roberts, J., Mcfarland, M., Marino, K., & Murray, L. (2018). Is Multi-Joint Or Single Joint Strengthening More Effective In Reducing Pain And Improving Function In Women With Patellofemoral Pain Syndrome? A Systematic Review And Meta-Analysis. International Journal of Sports Physical Therapy,13(3), 321-334. doi:10.26603/ijspt20180321

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