Patellofemoral syndrome

July 16th, 2008  |  Published in Doh! and ouch  |  14 Comments

One of the most common problems for female trainers, particularly younger female trainers, is a loosely named constellation of symptoms known as patellofemoral pain syndrome or PF. PF should not to be confused with chondromalacia patella, which refers to a wearing of the cartilage under the kneecap. The “patella” part of PF is the kneecap, and “femoral” refers to the femur, or thighbone. Essentially, PF refers somewhat nonspecifically to pain experienced in the knee around the area where the patella contacts the end of the femur.

Symptoms of PF typically include pain at the front of the knee while performing certain activities such as descending stairs or hills, running, or after prolonged periods of sitting. Crackling or grinding in the knee may also be experienced, although this is more likely to indicate chondromalacia.

The kneecap, or patella, is a roughly oval piece of bone, held in place by connective tissue, that sits in a little groove on the femur, and slides up and down as the knee bends or straightens. One of the most likely culprits behind PF is improper patellar tracking, or movement in its groove, and this can be caused by a number of things. Bear in mind that not all explanations are equally accepted by all members of the medical establishment. Also, some things are a bit chicken-and-egg. Which came first, bad structure or bad movement patterns?

1. Women tend to have wider hips than men, and as a result, their femurs must swoop down to the kneecap at a greater angle. This is known as the Q-angle. This increased Q-angle can increase the likelihood that the patella will not be properly aligned.

2. Pronation (inward lean) or supination (outward lean) of the foot can also exacerbate PF syndrome. Pronated feet require the ankle and consequently the femur to compensate, and supinated feet provide decreased shock absorption when the foot hits the ground. Both of these conditions can be alleviated by purchasing good shoes, and using orthotic inserts. Check the bottoms of your shoes to see if you have this problem. Pronators will have the worn spot of the sole on the inside of the ball of the foot, while supinators will show wear along the outside of the sole.

3. Muscular weaknesses in the thigh muscle (quadriceps). Some suggest that a weakness in the vastus medalis (inner quad muscle above the knee) is the problem (see below for more of a discussion about this). Others add that weak hip muscles play a part, especially weak external rotators. We see this problem with trainees who let their knees cave together when squatting.

4. Inflexibility in some areas, particularly the iliotibial band (a piece of connective tissue running from the hip to the knee along the thigh), hamstrings (back of thigh), calves or lower back. Again, folks are divided on this. PTs argue that the IT band can’t be stretched. On the other hand, stretching of the aforementioned muscles can do little harm and is quite likely helpful. Hamstrings are involved in bending the knee, and inflexible hamstrings can cause pressure to increase between the patella and femur.

5. Poor running mechanics. If you run, you should probably be striking the ground with the forefoot (ie the ball of the foot) rather than the heel. For more on the biomechanics and proper technique of running, see Ozzie Gontang’s page on mindful runnng and Michael Yessis’ excellent book Explosive Running.

so, your knee is screwed. what to do?

immediate treatment

1. Rest. Quit doing whatever you’re doing that causes pain, if possible. That means jogging, skiing, high-impact aerobics, allowing your two-year-old to whack your knee with her Pokemon doll, whatever. Chronic overloading is one of the most significant causes of PF pain.

2. Ice. Wrap some crushed ice in a ziploc bag, or a bag of frozen peas in a dishtowel and sit with it on your knee for 10-15 minutes (no longer). Do not allow ice to touch skin directly, if possible. Do this 1-3 times daily, especially after activity if you’re able.

3. Pain relief. Now, I stay away from anti-inflammatories because they upset my tummy. That means ibuprofen, naproxen drugs like Anaprox, and so forth. You are welcome to try them over the short term, since they do help reduce some of the underlying cause of pain, which is the inflammation. Dietary supplementation with things like bromelain (pineapple enzyme) and fish oil are a better choice for long term anti-inflammatory, as they does not have many of the negative effects of OTC anti-inflams. If you just want some short-term pain relief, acetaminophen (Tylenol) is fine.

4. Accurate diagnosis. See a doctor and make sure what you have is really PF. One quick test you can do at home (but I warn you, this is painful) is to sit with leg out straight in front of you. Relax your leg. Then have someone put their hand on your thigh, just above your kneecap, and exert a gentle but firm pressure downwards, towards the floor (not down your leg towards your foot). Flex your thigh. If you feel a sharp pain, it likely means you’re having kneecap tracking problems. When I read about this, I tried it on myself, and I can attest that it does hurt. I then tried it on my somewhat unwilling but PF-free husband, and he had no problems with it. However, this test has a few problems. First of all it hurts like hell, and second it is likely to return a lot of false positives (in other words, it can cause pain for people who don’t have PF).

long term treatment

1. Quadriceps strengthening. It used to be that PTs would try to strengthen the vastus medialis, believing that its weakness relative to the other quad muscles allowed the patella to be pulled out of the groove. More recent studies agree that since the quads are designed to work in concert, you can’t really isolate a single one. So, attention is now focused on having people do compound exercises that strengthen the entire thigh muscle group.

Despite all that stuff about squats supposedly being bad for your knees, full depth squats are actually great for knee rehab. They strengthen all the leg muscles with a compound, natural movement. If you can squat without pain, then by all means do so, even if you can’t use any weight. If you can’t squat the full range, squat in the range of motion that is pain-free for you, and gradually try to increase the range. Front squats are an ideal exercise, both because they put more emphasis on the quads, and because they seem to put pressure differently on the knee joint. When I was having real PF problems, I could do full depth front squats with no difficulty whatsoever.
Some folks recommend leg extensions, but I am very hesitant to recommend these. Putting frontal/lateral as opposed to downward force along the shin (tibia) can actually worsen knee problems with the shearing force that is created in the joint. If you choose to do leg extensions, do them with very light weight, and only the top 1/3 of the movement (like from nearly straight leg to straight leg) and don’t lock your knee.

Other exercises to do if you cannot do squats at all without pain, try these:
-Step up onto a step or block with one leg, then step back off (land gently, and don’t lock knees). Over time, increase the height of the step. Focus on driving through the heel of the foot on the step rather than pushing off with the back leg.
-Step down from a step with one leg, then back up
-Sitting on the floor with legs outstretched in front of you, slowly raise one leg, keeping it straight, as high as you can go; hold it in the air for 10 seconds, then lower slowly. This can be done with ankle weights.

2. Hamstring, hip, and calf stretching.

One good stretch given to me by my PT is this. Stand with right side facing a wall, feet together about 6 inches away from the wall. Take your right foot and cross it over your left leg, placing it on the floor. Stick your hip out to the left like Mae West workin’ it, and turn your upper body to face the wall, placing hands on wall. Push outward on hip to the left. You should feel a stretch along your left hip and down the outside of your left thigh. Hold for 30 seconds, then repeat for other side.

For lots of folks, though, this stretch doesn’t do much. So I came up with a better one. It’s like a standing hamstring stretch with a twist — literally. Stand facing a staircase. You can do this on any elevated surface, but a staircase works best, because you can wedge your foot into the corner so that it doesn’t turn. Lift the right leg and place the right foot on the second or third step. Keep your leg straight.  That’s step 1. Step 2: turn your entire body except for the elevated leg (especially your hips) slightly to the right. You want to turn towards your elevated leg, but leave the leg where it is. Now the elevated leg is slightly across your body at a diagonal rather than straight out in front. Step 3: Just like a regular hamstring stretch, bend forward from the hips (not the waist). You should feel this down the outside of your hip, thigh, or even the side of your calf. You won’t be able to go down very far. Repeat on other side.

To stretch hamstrings and calves: stand, cross one leg over the other, then bend at hips as far down as you can go. You should feel a pull along the back of the rear leg. Repeat for other leg.

Other stretches can be found here – click on the body part you want to stretch.

3. Hamstring strengthening. Again, full squatting is useful here, so do it if you can. Also, you can do stiff legged deadlifts and hamstring curls.

4. Shoe orthotics. If you do indeed pronate or supinate, orthotics will help. Also, folks in athletic shoe stores are often very knowledgeable about which brands of shoe are better for which problems.

5. Checking exercise form. Many people allow their knees to cave in while squatting or leg pressing. Bad!! When ascending from a squat, focus on pushing knees outwards. You won’t really push them out much, but it will feel like you are. When going up stairs, shift your weight back onto your heels as much as possible. Same goes for the stairmaster.

6. Supplementation. Supplementing with glucosamine and chondroitin sulfate may help. Other supplements such as bromelain, fish oil, and MSM will help reduce inflammation.

7. Soft tissue therapy such as Active Release Technique and self-massage of the soft tissue of the thigh with a rolling pin.

8. Surgery. This should be a final, final, final option, after all other non-invasive avenues of treatment have been tried.


  1. Orvette says:

    February 21st, 2009at 11:56 am(#)

    I recently joined a gym after losing 50 lbs using diet. I have 25 lbs more to lose but want to start getting truly fit and defined. I have had knee symptoms on & off since I was a kid that sound like patellofemoral syndrome. I outgrew the knee pain I had as a kid and then didn’t experience it again until I gained 75 lbs in my 30’s. I lost 25 lbs during that time and the knee pain once again totally resolved. I regained the weight plus some and am now in my 40’s. My weight loss this time has not resolved the knee issues. It’s not usually actually painful – just makes an AWFUL noise during the first 1/3 of a squat for example. And after bicycling or using an arc trainer regularly they do begin to feel sore. This has scared me away from the gym for a while, but I really want to get back. Should I endure the noise my knees make but continue to do low impact exercises and just rest when I have soreness? I’m afraid of wearing down cartilage or something due to the loud grinding sounds they make.

  2. bsmith says:

    March 15th, 2009at 11:30 pm(#)

    You may want to look into Dick Hartzell, the Rubber Band Man, on icing. His approach, NOT to ice, has brought athletes from a sprained ankle back to the field sometimes in the same game.

    Icing is a big no-no in Traditional Chinese Medicine, which is one of the best joint medicines in the world.

  3. Cynthia says:

    July 8th, 2009at 7:09 pm(#)

    I have had patellofemoral pain for a year and half and even going to physio for strengthening and soft-tissue work but nothing seems to work. I do my excercises at home and ice 3 times a day. It frustrates me because I can’t play soccer. What should I do now? I like can’t stand it. My physiotherapist said there was nothing wrong when I run or my body shape and he said my muscles were very strong and he didn’t know what the cause of my pain is. I can’t stand it. What should I do next.

  4. Cynthia says:

    July 8th, 2009at 7:12 pm(#)

    I have had patellofemoral pain for a year and half and even going to physio for strengthening and soft-tissue work but nothing seems to work. I do my excercises at home and ice 3 times a day. It frustrates me because I can’t play soccer. What should I do now? I like can’t stand it. My physiotherapist said there was nothing wrong when I run or my body shape and he said my muscles were very strong and he didn’t know what the cause of my pain is. I can’t stand it. What should I do next. There is never a sec that my knee doesn’t hurt.

  5. rosibel says:

    July 9th, 2009at 12:40 am(#)

    My friend is athletic and healthy, but about 5 months ago, as she began running regularly after a temporary break, she started having knee discomfort. After researching about knee problems, she found that her knee discomfort was probably what is known as “runner’s knee”.

    She says that 8 years ago she hurt her knee slightly while skiing, but it never bothered her again until now.

    She has tried different things like icing, taking breaks from running, wearing a brace, but the problem has persisted. Wearing a brace may have kind of aggravated it because she took to wearing it all the time, and so may have weakened the muscles around the knee somewhat.

    Now she’s talking about taking something called “Wobenzyme N” which is said to be an all-natural anti-inflammatory pain reliever, useful for sports-related injuries. I’m a bit skeptical about it, and have been trying to find the dirt online about this ‘Wobenzyme’ (which can be rather pricey) but am not finding much besides propaganda from the people who sell it.

    So I turn to my most trusted source of info. on all things athletic/body/pumping iron/kicking ass. (I love this website, I don’t know how you find time to write so much on tons of useful topics, impeccably *and* make one laugh out loud and do training on top of that. Canadians to the rescue yet again!

  6. dajohnson89 says:

    August 23rd, 2009at 12:33 pm(#)

    Anti-inflammatory drugs relieve the symptoms of patellofemoral syndrome. However, they do nothing for treatment. Most anti-inflammatory drugs have minor side effects, which prevents even the strongest constitutions ingesting them over long periods of time. Furthermore, PF pain is typically activated with stress, and latent otherwise. So a much better recourse to pain management is maximum rest.

    As a word of caution to anyone with this injury: you CANNOT run through it using ice and pain-killers. You need rest, flexibility, and strengthening. And rest. All of this is to allow the knee-cap to track around the aggravated cartilage. Otherwise, it will continue rubbing up against damaged and jagged cartilage, exacerbating the inflammation and delaying recovery.

    The good news is: once the cartilage is smoothed out and repaired, the excessive stretching and strengthening isn’t necessary (unless you have a chronic condition; but most cases seem to be acute).

    This injury floored me, and it will only go away with time.

  7. karen says:

    October 8th, 2009at 6:10 pm(#)

    I have had knee pain from torn cartilage for 4-5 years, which just gets worse as the years go ( I’m 31). Suffering from several wrong diagnosis and in addition plica surgery/ arthroscopy ( which made my knees stiff and more painfull).

    I am a fan of this site and would LOVE to see more training tips for ladies like me, where almost everything hurts big time: squats, lunges, leg extensions/- flexions, step up/down. And for those of us with this injury who have a difficult time doing any cardio because of this.

    Ups, need I say my elbows have startet acting up too !? sore all the time, lock when I do tricep exercises and pop out of place.

    Would love tips and shared stories.

  8. bbandef2 says:

    October 19th, 2009at 8:43 am(#)

    I had micro fracture surgery on my left knee 9 months ago. It has been a long recovery and I’m still not 100%. My knee is easily aggravated so I do low impact cardio and easy, light weight squats. I’m still working to get my quad muscles back after 6 weeks of crutches. I’m 52 so it takes me longer but I too would like more information on training tips for those of us with weak knees.

  9. Cheryl says:

    March 3rd, 2010at 9:56 am(#)

    First of all, a big thank you to Mistress Krista for relieving some of the tremendous stress I’ve been going through lately. Your humor is much appreciated. Your advice too.
    Second, I have had knee pain since at least going back to my teens. (An incident that sticks in my memory is going to mount my bicycle and having the earth-bound leg feel as if it bent backward and down I went, right in front of the cute neighbor kid.) Recently I came across a book called The Trigger Point Therapy Workbook. I borrowed it from my library, then purchased my own copy. It has helped me immensely! Not only for my knee pain either. Stiff necks, low back pain, pain down the side of my upper arm. According to the book much surgery could be avoided if people looked into getting rid of their “trigger points” (which is really just tensed, tightened muscle). Very, very helpful book, and I find it easy to understand and use too.

  10. Isabel says:

    March 22nd, 2010at 2:01 pm(#)

    I’d been having this same problem basically since I started doing weights, and it stopped a couple months ago. Obviously, I was highly suspicious since I didn’t know what I’d done to fix it and my feet tend to cause problems at bad times (I have high arches, with long, narrow feet—this is bad, bad, bad if my shoes get at all worn out or I run too much or…{insert endless series of problems caused by my darn feet}—so I assumed it had something to do with that).

    Now, thanks to your article, I know it’s better because I’ve been taking Omega3 oils every day for the past months. So, thanks for relieving my paranoia. And I’d highly advise trying Omega 3s for anyone who hasn’t, yet. Just make sure to eat something, or you’ll be burping fishy for a while (which is gross).

  11. Katie says:

    May 17th, 2010at 5:07 pm(#)

    I thought I tore my meniscus about a year back by trying to stretch out some jeans that had shrunk in the wash, and embarassingly, I told my doctor this when I went to have my knees looked at almost 6 months later. He diagnosed PFS, and now I’m trying to strenghen, stretch and take an anti-inflamitory suppliment. Sometimes I feel okay but I have a searing pain whenever I squat or kneel. I haven’t heard anyone mention this type of pain related to PFS. Does anyone have this symptom? Do you think I’ve been wrongly diagnosed?

    PS…I did some heavy duty hiking around the same time it started. I remember not stopping to rest at all.

  12. Dr. Michael Weber says:

    June 10th, 2010at 11:15 am(#)

    In 2002 I discovered Active Release Techniques, ART, a medically patented technique developed by Dr. Michael Leahy. I was amazed at the ART treatment I personally received which immediately resolved my chronic shoulder, knee, and ankle problems that had responded minimally to other types of care. ART gave me my life back. I got my life back, I began running, cycling, swimming, etc.. I give all the credit to ART.

  13. Mistress Krista says:

    June 10th, 2010at 12:34 pm(#)

    Agreed — ART is awesome!!

  14. Mistress Krista says:

    July 24th, 2010at 5:27 am(#)

    Katie: Get some physical therapy. PFS is kind of a catchall diagnosis simply meaning that the area is inflamed/irritated. I suggest you get a good, clear diagnosis from someone with specific expertise in the area of knee rehab.

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