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Patellofemoral pain syndrome and your posture

12/29/2013

16 Comments

 
Patellofemoral pain syndrome (PFPS) or "runner's knee" is characterized by pain and discomfort originating from the contact of the posterior surface of the patella (kneecap) and the femur. Patellofemoral pain syndrome usually involves acute or chronic lateral dislocation of the patella. This means the patella is sliding laterally (to the outside) in and out of its groove. This causes thinning and softening of the articular cartilage on the underside of the patella (chondromalacia) and/or on the medial or lateral femoral condyles. 

The lateral dislocation is usually blamed on a weak vastus medialis muscle and overly strong vastus lateralis muscle and typical exercise therapy or physical therapy involves quad strengthening exercises that attempt to correct this imbalance. I agree that this imbalance is often present, but I rarely believe it is the cause of the problem, but rather a symptom of, or compensation for, a much bigger problem.
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Many scientific studies have linked hip muscle imbalances to patellofemoral pain. To understand how weak hip muscles can cause patellofemoral knee pain, lets look at what these muscles do and how weakness affects posture, joint mechanics, and gait. 

The image and accompanying text below expand the "quad imbalance view" to include a weak rectus femuris, a strong tensor fascia lata (TFL) and a tight iliotibial (IT) band that all play a role in the faulty patellar tracking.  The TFL is a strong hip flexor that also abducts and internally rotates the femur and externally rotates the tibia. The TFL via the IT band can thus create internal femur rotation while at the same time creating external tibial rotation and, via the fascia that connects the IT band to the lateral side of the patella, will have the effect of pulling the patella in and out of its groove as the hip and knee flexes and extends. Physical therapists, exercise specialists, and personal trainers who look at this larger picture will include stretching for the IT band and TFL muscle along with the quad strengthening exercises mentioned previously. 
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Research is showing that this approach is still missing a very important component of PFPS and physical therapy, exercise therapy, and rehabilitation should be adapted to include the latest findings. Three high quality studies have come out in 2013 that link hip muscle imbalances to patellofemoral pain, most pointing to weak hip abductor and hip external rotator muscles especially weak gluteus medius muscles. A review of 47 published studies in the British Journal of Sports Medicine examined factors causing PFPS and showed that decreased muscle strength in hip abduction and hip external rotation are important facts associated with PFPS. This means the gluteal muscles (gluteus maximus, gluteus medius, gluteus minimus), which help with hip abduction and external rotation, and the deep six (piriformis, gemellus superior, obturator internus, gemellus inferior, quadratus femoris, and obturator externus), which do lateral or external hip rotation and help with hip abduction, play a really important role in controlling femur position which dictates patellar position and tracking. 
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Now good exercise therapy will take into account all these muscles groups and their respective strength or weakness when developing an exercise routine to combat patellar tracking issues and patellofemural pain syndrome. But could there possibly be anything else involved in dysfunctional movement patterns that create PFPS?

What about the iliacus and psoas muscles? 
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The psoas and iliacus both play a role in controlling excessive internal rotation of the femur just like the deep gluteal muscles and they can play a role in stabilizing the pelvis just like the abductor group, not allowing a hip drop during gait, seen as a Trendelenburg Sign. A Trendelenburg Sign, excessive internal rotation of the femur, or valgus or varus stress at the knee are all signs of likely weakness of ipsilateral psoas and iliacus, contralateral hip abductors, and contralateral external femur rotators.
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The psoas and iliacus are the most powerful hip flexors and when they are weak or dysfunctional, other muscles have to take over there role. What muscles start to take over? The TFL via the IT band and the rectus femoris. With psoas weakness the femur will internally rotate which puts the TFL and IT band into a more forward position to take over as the primary hip flexor. This overuse will create tightness along the TFL and IT band. The rectus femoris and TFL via the IT band, as they are overworked, creates excessive force pulling the patella laterally during gait creating the wear and tear on the surrounding cartilage. 

While walking, climbing stairs, or running your feet and knees should point straight ahead and your hips/pelvis should remain almost level. Weakness in the above mentioned muscles allows excessive movement in the transverse and frontal planes which creates forces on the knee and patella that can pull it out of its groove causing PFPS. 

How does someone with weak hip muscles move from point A to point B? By compensating for the weak muscles and creating compensatory movement throughout the entire body as can be seen below. The woman on the left is showing proper movement patters. The woman on the right is showing dysfunctional movement caused by weak and imbalanced hip musculature which is creating compensatory movements throughout her body. Those compensatory movements create muscle imbalances up and down the entire body. 
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Movement is posture in motion. We can look at static standing posture to understand why we see what we do during movement. The static standing posture of the two women above is shown below:
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The woman on the left shows proper posture with correct alignment of all eight of her major load joints - ankles, knees, hips, and shoulders. They are all vertically and horizontally aligned. This means she has good muscular balance throughout her body. This allows her to walk, run, squat, lift, and climb stairs without losing proper bone alignment and joint movement patterns. 

The woman on the right shows many postural imbalances: dropped right shoulder, right lateral head tilt, torso offset to left, right elevated pelvis/hip, valgus knee position, externally rotated right femur, everted feet right more than left. If all these imbalances are not corrected, strengthening the vastus medialis and gluteus medius and stretching the IT band will have very little if any long term benefit. The body is a unit and when treated as one patallofemoral pain syndrome and any other musculoskeletal pain can become a thing of the past. 
Related articles:
Knee joint osteoarthritis
Preventing ACL injuries
Meniscus surgery ineffective
  1. Lankhorst NE, Bierma-Zeinstra, SMA, and van Middelkoop, M. Factors associated with patellofemoral pain syndrome: a systematic review.  Br J Sports Med.  2013;47:193–206.
  2. Barton CJ, Lack, S, Malliaras, P, and Morrissey, D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013; 47:207–214.
  3. Selkowitz, DM, Beneck, GJ, and Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther. 2013; 43(2):54-64.
16 Comments
Ty Walll link
10/9/2014 09:15:59 am

Great article! I learned a lot about this condition, esp. with the 2013 studies. What exercises would you recommend to strengthen the psoas and iliacus? I've had symptoms for a few months now and have been going to PT, with light alleviation.

Areas we've targeted: Soft tissue work (quads, adductors, all calf muscles, TFL, glutes), strengthening internal rotators and adductors. Added more hamstring work to my strength training program.

My knees track fine over my feet, I'm not having issues with that. I haven't been able to do any deep knee flexion for a few months without issues. Just last week I started Rear foot elevate split squats, and they actually feel great (as my tibia stays vertical).

Open to any ideas, thanks! :)

Reply
Matt Whitehead link
10/13/2014 05:50:20 am

Hi Ty, I'm glad you learned something from the article. There are many exercises that strengthen the psoas and iliacus, the important part is figuring out which ones would be beneficial to your posture, mechanics, and level of strength and function. It's hard for me to know exactly what is causing your pain and limitations without looking at your posture, but here is what I'm gathering from the info you provided. Soft tissue work is usually targeted to tight, restricted, knotted, or scared tissues with a goal of releasing hypertonic muscles or rearranging fascia. So your quads, adductors, calves, TFL, and glutes are overworked? The question is why? Your PT has you doing strengthening for internal rotators, adductors, and hamstrings so they are weak? Seeing as your PT is having you do exercises for rotators and adductors leads me to believe you do/did have a tracking issue with your knees, but maybe not. What has stopped you from being able to do deep knee bends? Pain? Weakness? Tightness? Where? Typically people who cannot do deep knee bends it is because restricted range of motion of the ankles and/or hips along with an inability to use your hip flexors. This will show up as your knees going forward excessively, your spine flexing excessively, your heels lifting, and loosing balance. I'd be more than happy to give you a free posture evaluation and that would give me some ideas of what is causing your problems and what you need to do to correct them.

Reply
Nick link
6/8/2015 09:49:52 am

Great article Matt! Refreshing to see such a complete and comprehensive explanation of knee pain! You guys are dead on about treating the body as a whole to resolve one of the symptoms! Glad I found your site!

Reply
Matt Whitehead link
6/8/2015 10:04:18 am

Hi Nick, Glad you found the article informative. If you have any specific questions, feel free to contact me: matt@oregonexercisetherapy.com or 971-279-2189

Reply
nicky
5/24/2016 07:58:31 am

Hii Matt... Excellent article I have come across so far...

. I have pfps since past 5 years... Patella in my both knees are tilted and shifted medially slightly. My right gluteus Maximus is weak and left gluteus medius is weak. My left hip is hiked up causing lateral pelvic tilt. I also have anterior pelvic tilt. And my pelvis is twisted to the left and shifted to the right slightly. My right shoulder drops. I have mild scoliosis... Slight curvature to the left in lumber spine region and slight curvature to the right in upper spine near neck. I have internally rotated femurs and externally rotated tibia ( external tibial torsion ). My feet have fallen arches.

In short... Lots of muscle imbalance in my body is causing back spasm.


I have seen more than a dozen PTs. Since last 4 years I was doing knee strengthening exercises especially vmo strengehtening and lateral retinacular stretches which gave no positive outcome. Psoas and lilacs ....I have never paid attention to them so far.

I have done a lot of struggle since my body mechanics changed. Visited so many physios and doctors with poor outcomes. Your article has given me a fresh new hope towards correcting all imbalances in my body. I will pay attention to psoas now.

Recently, I came across egoscue exercises for posture alignment.

Do you think those methods can correct my posture and muscle imbalances??


I just came across exercises like static back, gravity drop, airbench and more etc.

Thnx..:)

Reply
Matt Whitehead link
5/24/2016 10:27:20 am

Hi Nicky,

I'm glad you found the article informative and thought provoking. I think you've run into the problem many of my clients have with PT and other specialists: they focus on the symptom/area of the symptom and use their typical protocol without really looking at the whole body and function of the individual in front of them.

You have identified much of what is the underlying reason for your PFPS: muscle and posture imbalances up and down your body. Since your body is a unit and everything is connected, your shoulders and spine have as much to do with your knee pain as your knees do. And your feet and lower legs have as much to do with your back spasms as your spine does.

I have been using and teaching Egoscue Postural Alignment Therapy for over 15 years and seen amazing success with it. Yes I do think it can greatly help you. The key is getting a good assessment of your posture to figure out what are your primary dysfunctions that need to be addressed and getting a personalized e-cise menu(s) to correct them.

I would be happy to do a free posture assessment for you. Call or email me: 971-279-2189 matt@oregonexercisetherapy.com

Reply
Kim
7/19/2016 11:01:01 am

I love having found this article right when I noticed a fitness instructor with a knee brace who is an avid runner. I'm not a PT I don't get into the nitty gritty of what muscle is working and not and how to approach it. I'm a PAS1.

In Pain Free, Pete recommends supine groin stretch in the menu rather than the progressive. From what I understand in this article, it would make more sense to do the supine groin progressive to affect the internal rotation.

Many Thanks Matt. Your articles are incredibly informative.

Reply
Matt Whitehead link
7/19/2016 12:02:11 pm

Hi Kim,

In Pain Free, I'm assuming you are talking about the menu for Internal Rotation? Pete recommends the Supine Groin Stretch on Towels in this menu. He states the reason why like this:

"What's going on is that the muscles of the pelvic girdle are weak, which makes the pelvis stay in flexion (posterior pelvic tilt is what he's talking about), losing its ability to extend. As a result the femur is rotated inward with each step, as adductor muscles pull the leg back toward the trunk of the body. As a result of the lost extension of the pelvis, the femur doesn't have sufficient counterrotation."

This is how the menu works: Standing Gluteal Contractions externally rotate the femur via the glutes.
Sitting Heel Raises teaches the pelvis to be more anterior/less posterior via the hip flexors.
Isolated Hip Flexor Lifts on a Towel teaches the pelvis to be more anterior/less posterior via the hip flexors.
Supine Groin Stretch on Towels keeps the pelvis in it's new neutral position (rather than defaulting back to it's posterior tilt it was used to before) while teaching normal length and tension to all the muscles surrounding the spine, pelvis and leg. This also teaches the femur to be neutral rather than internally rotated as it had become accustomed to.

Make sense? The reason Supine Groin Stretch on Towels is used instead of Supine Groin Progressive is that towels don't allow the pelvis to go posterior (where this person's pelvis has been living) where the Progressive would allow the pelvis to be more posterior.

Hope that helps!

Reply
angela
5/1/2017 01:32:32 am

Hi, what is the best posture to bend and pick up objects. Information out here is soooo confusing. Is this the Egoscure way? Thanku kindly. What are the best exercises to begin with strength training for this. Plus weights are they beneficial does Ergoscure recommend them?

Reply
Matt link
5/11/2022 10:25:13 pm

Hi Angela,

When your posture is balanced, you won't have to think about how you pick up objects, because your body will naturally do it in the most efficient and safe way.

Yes weight lifting can be very beneficial and I do recommend weights to many clients. The key is to get pretty good alignment before you start weight lifting so you are strengthening good alignment and not strengthening your imbalances.

Reply
Dominique Williams
8/26/2019 06:27:36 am

I dont usually comment on websites to be honest, however, the theory of internal rotation of the femur AND external rotation of the tibia via the ITB is an absolute game changer.

Have to give it to you on that one, I never ever considered that!

Reply
PM
2/17/2020 12:36:28 am

Hi Matt,

You mention the vertical and horizontal alignment of all eight of the major load joints - ankles, knees, hips, and shoulders, which really makes sense, especially when they're misaligned due to wrong posture and can be worked upon to improve. However, what if the misalignment is due to one leg being slightly longer than the other? It would also result in a elevated hip, can this be improved through exercise and training?

Reply
Matt link
5/11/2022 10:28:00 pm

Hi PM, Good question. When one leg is truly longer than the other there are several things I'd recommend. First, getting a good whole foot lift to even out the legs is a good idea.
Second, doing Egoscue ecises to maintain balance in the body is more essential than ever because the leg length imbalance is going to continue creating imbalance in the body. So I'd recommend getting a good menu and doing it daily to counteract those imbalances.

Reply
samantha scott link
8/20/2020 11:48:38 am

What a great blog. This gave me an idea with regards to what is the right thing to do to align body posture.

Reply
richmondhipandknee.com link
1/27/2021 09:07:00 pm

Keeping our posture right help in avoiding various problem away.This blog guide us by stating various strengthening exercises that attempt to correct this imbalance.
Very informative article!

Reply
Susan Griffith
9/21/2022 11:29:54 am

I have had lateral patellar pain ever since I had a hip replacement 8 months ago. My operated leg is now about a centimeter longer than the other leg. Would the muscle weakness from surgery be causing this? My surgeon seems puzzled by my symptoms. Any particular exercises you would recommend for a post op situation?

Reply



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    About Matt Whitehead

    I'm an Egoscue Institute certified Postural Alignment Specialist (PAS) and Advanced Exercise Therapist (AET), certified personal trainer, PatchFitness performer, FiveFingers wearer, trail runner, mountain biker, dad, music lover, environmentalist, and wanna-be slam dunk champion. I will be providing you with the latest posture exercises to help you live, play, and be pain free.

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