Pain in the front of your knee during squats? You may have Patellofemoral Pain Syndrome

What is Patellofemoral Pain Syndrome?

Patellefemoral Pain Syndrome (PFPS) is pain underneath your knee-cap (or patella) that tends to come on or worsen with running or any activity that puts a high amount of stress on your bent knees – squats, lunges, or even sitting occasionally.

The pain can be mild to severe, causing you to stop your activity.

Who gets Patellofemoral Pain Syndrome?

PFPS is much more common in young women, occurring more than twice as often in women as men (Boling, 2010).

It is seen in those who do frequent exercise that puts a high amount of stress on the knee – such as running, jumping, squats, or lunges.

What causes Patellofemoral Pain Syndrome?

PFPS is caused by imbalance in the sliding of the patella over the end of your femur. Many studies have shown that people with PFPS have knees that bend towards each other too much (AKA knee valgus or knock-knees).

It is often thought that women suffer from this condition more because we have wider hips.

Our femurs start farther apart at the hips but end up a similar distance away from each other at the knees as men so the bones of your knees bend inward more than they should (AKA hip adduction or bending inward – the opposite of abduction or bending outward).

Since your quadricep muscles start out wide at your hips, they pull your patella out wide despite the end of your femur being closer in. This puts a lot of stress in the area between your patella and the grove of your femur where the patella slides.

Over time, this area becomes inflamed and painful.

Another component is weakness in the hip abductor muscles. These muscles pull the femur bone outward and prevent your knees from leaning in towards each other. Our sedentary lifestyle causes weakness in the hip abductors since we use them so infrequently.

Overall, PFPS is caused by weak hip abductors which cause excess hip adduction (bending inward) and subsequently knee valgus (knock knees).

Patellofemoral Pain Syndrome Proper Knee Tracking is over toes, not caving in

As if the pain from PFPS wasn’t enough, several studies have shown that the same knee valgus is associated with significantly higher rates of ACL injuries (April, 2015; Hewett, 2005) so it’s not something to ignore.

How to know if I have Patellofemoral Pain Syndrome?

Usually a doctor or physical therapist can diagnose you with this problem.

But the way it is diagnosed by physicians is easy to do on yourself.

There are three parts to the diagnosis:

  1. If you suffer from pain directly under your knee cap during activities that put a lot of stress on your knees or during at least two of the following activities: ascending/descending stairs, hopping/jogging, prolonged sitting, kneeling, and squatting.
  2. Pain when pushing on either side of the patella
  3. No large swelling of the knee, no fevers, no unintentional weight loss, no excess range of movement of the knee in any direction, and no locking of the knee.
Patellofemoral Pain Syndrome has pain at both sides of knee cap

If you fit all three of these things, I would confirm with your primary physician but it is overall pretty likely that you have PFPS.

How to fix Patellofemoral Pain Syndrome?

The treatments are pretty straightforward but they do take time.

Hip Abductor Retraining

One of the best ways to treat PFPS is to retrain your body to maintain proper knee alignment. This often involves strengthening your hip abductor muscles.

By far the best way to accomplish this is with a trained physical therapist. A physical therapist will be able to gain the better perspective of your knees and body position during movement and will be able to tailor advice specifically to you.

Outside of physical therapy, a great way to retrain and strengthen your hip abductors is by using a mini resistance band focusing on pushing your legs into the band while performing various exercises.

The best solution is using resistance band and focusing on pushing legs out into band

A study by April, et al. in 2005 showed almost complete resolution of knee valgus when using the mini resistance band and focusing on pushing legs out into the band during jump squats.

  • This study showed that just using the band didn’t help so it is important to retrain your brain as well by actively thinking about pushing your legs into the band while performing the exercise
  • This works well for squats, deadlifts, box jumps, jump squats, crab walks, etc.

Over time you will build up the hip abductor muscles and retrain your brain to automatically fire those muscles during all activity so you won’t even have to think about it (Petersen, 2014).

This is the best treatment overall on which to focus your energy since it will resolve the inciting problem of hip adduction.

Temporary solutions:

Many other treatments can treat the pain while the support is in place on the knee. These are great to use temporarily while working on hip abductor retraining as above.

NSAIDs

The actual pain comes from inflammation of the cartilages improperly rubbing on each other with high pressures during intense knee flexion.

NSAIDs such as ibuprofen, Motrin, Advil, Aleve, aspirin, etc. all work to decrease pain by decreasing inflammation.

Be sure to follow the directions on the back of the box/bottle for how much to take.

These medicines are definitely useful especially in the moment when you are having this type of pain.

Taping Knee Cap

Applying tape that pulls the knee cap medially or inward has been shown in many studies to help with pain (Petersen, 2014). This makes sense because it counteracts the quads muscles from pulling the patella outward.

How to Tape Knee for Patellofemoral Pain Syndrome Infographic

All of the studies only show temporary relief of pain which also makes sense because as soon as the tape is removed, the patella will return to its lateral position.

It will decrease some inflammation from happening during intense activity while taped so it can have a good effect but only if used consistently longterm.

It’s much more effective to retrain your muscles to align your body properly so you don’t have to rely on this method all the time.

Patellar Braces

Similarly, patellar braces pull the patella medially or inward while it is being worn.

Draper, et al in 2009 showed that a patellar brace works effectively to keep the patella tracking medially during movement but patella knee sleeves did not have any effect.

Again, patellar braces will decrease inflammation from building up during activity and so can work if used consistently long term.

Personally, I would much rather not rely on having to remember to use external supports.

I believe it’s much more effective and safer to retrain your muscles as above.

Patellar Brace works much better for Patellofemoral Pain Syndrome than Patellar sleeve

Foot orthotics

Many studies have tried shoe inserts or foot orthotics that function to turn the ankles outward. The thought is that this would help push the knees outward.

Most studies have shown no statistically significant improvement in pain but trends in the data tend to show possible improvement (Barton, 2011; Petersen, 2014; Vicenzo, 2008; Wiener-Ogilvie, 2004)

I wouldn’t recommend this option but it may be a last resort if none of the above options work for you in the mean time while you are working to retrain your hip abductor muscles.

Sources

April, S. M. (2015). The use of resistance bands and a verbal cue on the frontal plane knee kinematics and kinetics during a drop vertical jump task (Order No. 1526413). Available from ProQuest Dissertations & Theses A&I. (1681987212). Retrieved from http://libproxy.temple.edu/login?url=https://search.proquest.com/docview/1681987212?accountid=14270

Barton CJ, Menz HB, Crossley KM (2011) Effects of prefabri- cated foot orthoses on pain and function in patients with patel- lofemoral pain syndrome: a cohort study. Phys Ther Sport 12(2):70–75

Boling M, Padua D, Marshall S, Guskiewicz K, Pyne S, Beutler A (2010) Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports 20(5):725–730

Draper CE, Besier TF, Santos JM, Jennings F, Fredericson M, Gold GE, Beaupre GS, Delp SL (2009) Using real-time MRI to quantify altered joint kinematics in subjects with patellofemoral pain and to evaluate the effects of a patellar brace or sleeve on joint motion. J Orthop Res 27(5):571–577

Hewett, T.E., Myer, G.D., Ford, K.R., Heidt, R.S., Colosimo, A.J., McLean, S.G., … & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine, 33(4), 492-501.

Petersen, W., Ellermann, A., Gösele-Koppenburg, A., Best, R., Rembitzki, I. V., Brüggemann, G. P., & Liebau, C. (2014). Patellofemoral pain syndrome. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 22(10), 2264–2274.

Vicenzo B, Collins N, Crossley K, Beller E, Darnell R, McPoil T (2008) Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: a randomised clinical trial. BMC Musculoskelet Disord 9:27–34

Wiener-Ogilvie S, Jones RB (2004) A randomised trial of exercise therapy and foot orthoses as treatment for knee pain in primary care. Br J Podiatry 7(2):43–49

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