Patellofemoral Pain Syndrome Explained - Part III [Rehab] - Atletikka
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Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome Explained – Part III [Rehab]


In our two previous posts we discussed the possible causes of Patellofemoral Pain. You saw that this condition could be the result of multiple problems, from core weakness to foot misalignment and everything in between

Research shows that the best approach to combat this condition is to work the whole kinetic chain: core and trunk, Hips , Knee and foot.

I like to separate the treatment of PFPS in 3 components

  • Proximal Approach= Core and hip strengthening
  • Distal Approach = Knee strength and soft tissues techniques
  • Passive Approach = Taping and Orthotics


Proximal Approach – “Glutes, Glutes, Glutes…”



  • Restore muscle strength of the Core and the Hip
  • Hip dominant exercises to increase strength of Hip extensor and Hip External rotators muscles


All these exercises have a dual intention: strengthen  the Lower extremity with an already active core. I like to combine a core activation ( tight your belly like if somebody is going to punch you in the stomach ) before moving the legs. In this way the athlete  starts incorporating all the components of the kinetic chain into the movement control.

My first two exercises I prescribe to people with PFPS are clamshells and bridges. Both with the intention of correcting the Pelvis and Hip excessive internal deviation that is causing the anterior knee misalignment and pain


1. Clamshells


To strengthening of hip external rotation and abduction


Begin by lying on your side with your knees bent 90 degrees, hips and shoulders stacked, and a resistance loop secured around your legs.


Raise your top knee away from the bottom one, then slowly return to the starting position.

Make sure not to roll your hips forward or backward during the exercise. When done properly you should feel a burning sensation in the side of your hip

Recommended 3 sets of 8-10 reps and build up to 3 sets of 20 reps for more endurance to match up more demanding activities like running – jumping – sprinting



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2. Bridges


To strengthening of hip extension – Glutes


Begin lying on your back with your arms resting at your sides, your legs bent at the knees and your feet flat on the ground.


Tighten your abdominals and slowly lift your hips off the floor into a bridge position, keeping your back straight.

Make sure to keep your trunk stiff throughout the exercise and your arms flat on the floor.

Recommended 3 sets of 8-10 reps and build up to 3 sets of 20 reps for more endurance to match up more demanding activities like running – jumping – sprinting



Local Approach – “Work in the painful area “



  • Release any tension in ITB and lateral side of the thigh and knee.
  • Restore Muscle Strength and size of quadriceps with emphasis on Vastus Medialis Oblique (VMO)


1. Instrument Assisted Soft Tissue Mobilization (IASTM)

Using a silicone suction cup and a blade to release tension and modulate the pain in quadriceps and Iliotibial band. The last 30 degrees of extension are very symptomatic and this technique helps with this pain.



2. Quadriceps Strengthening

But Manual therapy alone will not do it. A decrease in the size of the Quadriceps is always found in runners with long standing Anterior Knee Pain. Furthermore, when the VMO muscle is too weak, the vastus lateralis will create a lateral (outwards) patellar tilt.

To address these deficits I Like of combination of both Open Kinetic (non-weight bearing) and Closed Kinetic ( weight bearing) Chain Exercises

Work on non weight bearing exercises  like Straight leg raises with a VMO bias as well as on Functional movements like Squat, Deadlift, Lunges. All Weight bearing exercises should be no painful so do them  with modifications to accommodate strengthening without irritation of Pain. For example, Limiting the squat to the angles that are not painful is a great exercises to start with . Box squats in combination with external hip rotation is my favorite exercise. Once pain free, we can remove the box and start lowering the squat

A- Straight leg Raise – VMO bias

Set up

Begin laying on your back with one leg bent and your other leg straight with a weight secured around that ankle.


Rotate your hip outwards and then Lift your leg off the floor keeping, your knee straight, then lower it back down and repeat.Make sure to not to arch your low back as you lift your leg.

Go heavy if tolerated, Use 5 to 10 lb cuff weights, 3 sets of 12 recommended




B- Box or Chair Squat with band

Begin in a standing upright position in front of a chair with a resistance loop around your knees. Lower yourself into a squatting position as you press your knees slightly outward against the resistance band until you lightly touch the chair. Then return to standing and repeat. Make sure to keep tension in the resistance band and do not let your knees bend forward past your toes during the exercise. 3 sets of 8 recommended.




Restore Function in patients with Patellofemoral Pain – “Putting all together”


At a later stage we need to start working on Power exercises for the runner  to be able to Jump, Accelerate, Stop and change of Directions.

Due to the chronicity of this condition many of these activities had been associated with pain and therefore there is a lot of muscle inhibition associated.

Practicing jumping and changing of directions are very important exercises for runners to be able to absorb the load and to generate power with affected leg.

Work both sides to achieve this dual requirement of shock absorption and power generation.

A- Side walking with bands around the feet

Very common exercises used in rehabilitation and training with the goal of activating the Gluteal Muscles . A brand new study ( J Athl Train. 2018 Nov – Hip-Muscle Activity in Men and Women During Resisted Side Stepping With Different Band Positions) looked at the effect on glute medius, glute maximus and TFL activity from placing a mini around the knees, around the ankles and around the feet.

This research study confirmed what we suspected, Mini band around the feet creates de maximal glute activation without triggering high TFL activity which is exactly what runners with Patellofemoral Pain need. High activity of the glutes and less dependence on ITB for support.

This is very important in rehabilitation when trying to activate the Gluteal Muscles to promote hip external rotation and prevent hip internal rotation and adduction (knee valgus) like in Patello-Femoral Pain Syndrome.

Set up

Begin in a standing upright position with a resistance band looped around your the middle of your feet.

Sit back in a semi-squat position

Activate your core before moving your legs


Slowly step sideways, maintaining tension in the band. Repeat in the opposite direction.

Make sure to keep your feet pointing straight forward and do not lean your torso to either side as you step. Also be sure don’t allow your feet to touch , keep them separated as much as possible otherwise you lose the glute activation.



B- Cone – Dynamic Lunges for hip Strengthening

Adding movement in all 3 planes is also very important to restore function and this drill is for this purpose



C- Skaters

Finally , we need to simulate the running mechanics and shock absorption / power generation mechanism . Use slow to  fast skater for introducing power exercises.

Slow and controlled with emphasis on shock absorption.



Fast with emphasis on power generation



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  • Patellofemoral Pain Syndrome ( PFPS) affects a large population of runners
  • Conventional physical or chiropractic  treatment usually fails to address all the possible causes of this condition
  • Our comprehensive approach is backed-up by the most recent research. Once you resolve the root of the problem the knee cap becomes pain free

Education and load management are key factors for people with PFPS


Do you have any questions? Drop a note, we’d love to hear from you.

Sign Up and ask the Therapist.



Lionel Pannunzio is a Physical Therapist and Board-Certified Sports Specialist, owner of White Bay Physical Therapy.

He has been helping runners for more than 20 years

“Keeping Athletes in the game”

With offices located at 17180 Royal Palm Blvd – Weston – Florida – 33326

You can reach him at 754-244-2561

Visit his website:

[email protected]



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