The Influence of the Hip and Foot on Patellofemoral Pain

image The influence of the kinetic chain on the patellofemoral can not be underestimated.  Because the knee is located mid-way through a weightbearing extremity, it is vulnerable to excessive force from biomechanical faults located both proximally and distally to the knee itself.

While forces from the foot and ankle have been associated with patellofemoral pain for some time now, the influence of the hip is becoming more of a hot topic as research has demonstrated significant increases in forces and injuries originating from biomechanical faults associated with the hip.  A particular pioneer in this research has been Dr. Christopher Powers from the University of Southern California.  A Pubmed search on Dr. Powers reveals several significant papers on the topic, specifically one of my favorites from JOSPT on the influence of the kinetic chain on patellofemoral biomechanics.

Examination of the joints proximal and distal to the knee is imperative in the treatment of patellofemoral pain.

I believe a significant reason why “patellofemoral pain” has been such a challenging diagnosis in the past is because we are treating the symptoms, not the cause of the pain, which is many times may be coming from elsewhere within the kinetic chain.

The following is part 7 of the series on solving the patellofemoral mystery:

The Influence of the Hip on Patellofemoral Pain

The influence of the hip on the patellofemoral joint has been well documented over the last decade.  The biomechanical works of Dr. Powers have shown that excessive hip adduction and internal rotation places the patellofemoral joint in a disadvantageous position.

Unfortunately, our population is dominated by sagittal plane strength and weakness in the coronal and transverse planes.  It seems like it is a normal part of daily living now as the majority of our functional tasks take place in the sagittal plane.  Even more unfortunate is the fact that exercises outside of the sagittal plane are often neglected in rehabilitation and strength training programs.  This creates a significant biomechanical disadvantage.

To fully understand the significance of this, imaging the weightbearing knee.  When the hip moves into adduction and internal rotation while the foot is planted, the femur will change position around a relatively stable patella (there is movement, just using this as an example).  It is the reverse concept that is commonly seen in patellofemoral rehabilitation.  The movement, or “tracking” of the patella on the femur is less relevant in this weightbearing position.  It is the movement of the femur on the patella that is significant.  Below is an example of how the femurs moves on the patella in the weightbearing position, note the patella is fairly stable while the femur rotates internally:

image  image

This is likely the mechanism of patellar subluxations and dislocations and the cause of wear and tear of the joint.  Patients often describe an injury that occurs when planting and pivoting or planting on an unstable surface.  The quadriceps contracts to stabilize the knee while the femur is adducted and internally rotated, resulted in a lateral displacement of the patella in relation to the femur.  This can cause an acute injury as well as degeneration over time.

A recent study by Dr. Powers in JOSPT showed that females with patellofemoral pain had greater hip rotation during running, jumping, and stepping down.  This also lead to subsequent decrease in hip strength.  In fact, another study by Dr. Powers’ group published in AJSM demonstrated that patellofemoral pain in women is the results of decreased hip strength not anatomical variations (wider hips, etc.).

imageTreatment of these patients requires training the hip to abduct and externally rotate.  Also, it is important to train the hip abductors and external rotators to isometrically stabilize the knee during sagittal plane movements and to eccentrically control hip adduction and internal rotation.  A simple test I perform is the step-down exercise.  I am specifically looking for the ability to eccentrically lower the body in the sagittal plane while preventing the hip from dipping into adduction and internal rotation.  This is harder than it looks and will often be an issue in your patients.  But trust me, overtime this will improve, and POOF!  Your patient’s patellofemoral pain while climbing stairs and running will have vanished!  You are a genius now, the last three times she went to rehabilitation elsewhere they perform ultrasound on her knee and had her squeeze a ball between her knees during mini-squats to “strengthen her VMO.”

Which brings up a great topic, do you still want to squeeze that ball between your knees and emphasize hip adduction and internal rotation?  I would actually recommend just the opposite.  I frequently use a piece of Theraband (or even those new knee resistance straps that Theraband just started making) around the patient’s knees during exercise.  This will require the patient to isometrically control the hip from adducting and internally rotating while performing mini-squats, wall squats, leg press, and other sagittal plane exercises


The Influence of the Foot and Ankle of Patellofemoral Pain

Just as forces located proximal to the knee can have a significant impact on the patellofemoral joint, forces distal to the knee may also contribute.  Treatment for patellofemoral patients should include a thorough assessment of the foot and ankle to establish biomechanical factors that need to be addressed.  Orthotic fabrication is often necessary, though off-the-shelf orthotics have had some success in the literature.

  • imagePronation.  Excessive pronation of the foot causes a reciprocal internal rotation moment of the tibia.  This turn increases the resultant Q-angle at the knee.  As we previously discussed in our previous post on the biomechanics of the patellofemoral joint, an increased Q-angle will cause a greater amount of force on a more focal portion of the patella.  Furthermore, an internal rotation moment of the tibia also results in internal rotation of the femur and a more laterally displaced patella.  This may be a cause of ELPS as discussed previously when we discussed the differential diagnosis of patellofemoral pain.
  • Leg Length Discrepancy.  I chose to include leg length discrepancy with the group of distal forces as the impact of a longer leg length tends to impact the positioning of the foot and ankle.  The longer leg will tend to have a toe-out and pronated position to compensate for the longer length.
  • Supination.  Patients labeled as “pronators” seem to get all the attention, but excessive supination is likely just as bad.  Not only do you diminish the foot’s ability to dissipate force, supination will result in external rotation of the tibia and more force to the patella.

You can see that the position of the foot and ankle when the foot hits the ground is important to evaluate as it will alter the arthrokinematics and patellofemoral joint reaction forces.

It can not be stressed enough that it is imperative that the proximal and distal aspects of the kinetic chain need to be evaluated and treated in patients with patellofemoral pain.  I am sure that your outcomes will begin to improve by not neglecting this important aspect of treatment.

Have We Solved the Patellofemoral Mystery?

Probably not, but although the patellofemoral joint may still be a complicated area of sports medicine, I hope that this series has helped take the some of the mystery out of patellofemoral pain!  Be sure to go back and review if you missed some of the articles in this series on the patellofemoral joint.  In putting the pieces of this series together, remember to:

  1. Understand the source of patellofemoral pain and realize it might not be from “chondromalacia.”
  2. Perform a thorough examination and attempt to identify a specific diagnosis, lets stop using the term “patellofemoral pain” and describe the actual diagnosis!
  3. Consider the basic principles of patellofemoral pain rehabilitation, including understanding the biomechanics of the joint and the biomechanics during exercise.
  4. Look proximal and distal within the kinetic chain to identify a potential true “source” of patellofemoral pain and stop treating the “symptoms!”

Powers CM (2003). The Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint Dysfunction: A Theoretical Perspective J Orthop Sports Phys Ther DOI: 14669959

36 replies
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  5. Noumenon
    Noumenon says:

    Just thought I’d leave a comment from someone who is NOT a spammer for a change — this really helped me focus on which part of my knee was the problem, and I love the step down exercise. Thank you.

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    Ray Lorenzana says:

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  7. Nick
    Nick says:

    Hi Mike,

    I was wondering if you are looking for any people to conduct research on?
    I am having severe issues – I had my right knee reconstructed 7 years ago for a torn ACL/MCL – 2 years ago i broke my fibula in the right leg(no force, rolled ankle – but doctors didnt think it was broken at the time so it healedi ncorrectly(not horribly be there is a malunion, they don’t recommend surgery). Lastly over the last year and half i have had severe pain all around my hip – doctors now found a torn labrum in the right hip w/ FAI… which is being repaired in December… Any suggestions? Or would you have an interest in an examination?

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  9. Victor
    Victor says:

    I would like to stress that practicing the external rotation of the femur is very hard and simply not possible in some cases without the reduction of the swelling, trust me im such a patient.

    Been doing rehab for a 6 months without any sucess, did a scope and they found out that during my first and hopefully last knee injury had cartillage damage behind my knee cap. This causes so much irritation that my knee is constantly a little swollen. I worked SO HARD with does clamshells still don’t get any activation. But sometimes for some strange reason the entire chain just “starts working” again and I do gain activation without foam rolling or stretching.

    BTW great articles. I’ve started icing my knee every single time I have now. Been in a “acute” phase for a long time..

  10. impotence
    impotence says:

    I think personally myself I have gotten better results utilizing some of the principles you and Mike shared from a biomechanical standpoint, but where I struggle is that I have not been very good at tracking my outcomes. Are you seeing the patient get increase functional outcome (Lysholm or OPTIMAL score) in less visits and if so what are you seeing them average visit length for? I wish I was better at having these numbers, so wondered if you tracked them and how to help me out.

  11. physical therapy
    physical therapy says:

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    toenail fungus treatment says:

    I have found in the past that performing any movement of the knee, either through ROM or even isometrics can be extremely painful for a patient that is extremely irritated; while addressing the SIJ & hip, the pt can perform much needed therapeutic exercise and gain more initially than going straight to the knee.

  13. Anonymous
    Anonymous says:

    Mike, great series on the patellofemoral joint. A thought I'd like to add is another joint to look at even more proximally is the pelvis. A forwardly rotated pelvis can cause the femur to be oriented in internal rotation (TFL and Vastus lateralis dominance) and position the femoral-acetabular joint in ER (thus losing the Add/IR ROM alluded to earlier). In this situation, proximal hamstring, abdominal, glute med and adduction function need to be addressed.

  14. Mike Reinold
    Mike Reinold says:

    Kory, thanks for the comments. I like your exercise selection, i do a variation of this too with step downs. I am going to discuss this a bit in my webinar next week. Thanks.

  15. Kory Zimney, PT
    Kory Zimney, PT says:

    Great work Mike, excellent series. Just wanted to throw in 2 cents worth to the conversation.

    I think the comments by Brian and Jamie are great and have been a follower of Gary Gray and Dave for a few years through their course and the functional video digest series and fast function series. Jamie being a fellow I am sure you have much more to offer on the conversation, I applaud you on your work through the GIFT program. But I think we might be splitting hairs just a little…Mike your point with the theraband around the knees is a great exercise. I don't think you are implying to the patient “the old stay still don't move stability”, but utilize this as a cue to facilitate the gluts. I also will use some Functional Manual Reaction to assist with the pronation of the lower extremity and even utilize sometimes a quick stretch and manual resistance with the down and in like you suggested Brian. Another trick I have tried sometimes is using theraband as they go into an anterior lunge or other plane and provide a valgus force (same as with the band around both knees with the leg press) I can even tweak it a little with pulling more with one hand to create a little transverse plane movement with internal rotation as needed. All of these exercises have the same principle in mind of activating the hip to stabilize the femur, thus getting the knee joint to function with less pain. This is the primary goal of our treatment. When the quad can strength up without pain to inhibit because the gluts are doing their job and the low back (good point Dr. Stu) then it will function more optimally.

    One thought and question I have to throw out is: Brian, when you say you are getting excellent results with these what does that objectively mean? I think personally myself I have gotten better results utilizing some of the principles you and Mike shared from a biomechanical standpoint, but where I struggle is that I have not been very good at tracking my outcomes. Are you seeing the patient get increase functional outcome (Lysholm or OPTIMAL score) in less visits and if so what are you seeing them average visit length for? I wish I was better at having these numbers, so wondered if you tracked them and how to help me out.

  16. Dr. Stu
    Dr. Stu says:

    Don't forget about the spine!! Many times the lower segments of the lumbar spine are involved here. Weakness of the abductors or external rotators or the hip are a common finding with patients that have L4-5 and L5-S1 segmental dysfunctions. Knee and hip pain can facilitate this dysfunction and the segmental facilitation and neurogenic guarding can create weakness in the associated (myotomal or sclerotomal) areas. This is a chicken or the egg conversation however. Aberrant movement patterns in the lower extremity are a normal adaption of the body to pain, whatever the source. Working with the spine to inhibit muscle guarding and facilitate the desired movement patterns can be a very powerful way to start.

    I like the specific referrence to patellofemoral articulation. It could be this disturbance in PF arthrokinematics that is the source of pain and degeneration. Again, specifically applied manual therapy to the patellofemoral, tibiofemoral, talocrural, and hip joints can work magic here. I have personally found that a medial/superior mobilization of the patella (in the fiber direction of the VMO) yield execellent results.

    Just some thought. . . . . but, great blog!!

  17. dj
    dj says:

    Can't agree enough with the valgus collapse (fem IR and add) mechanism as conributor to PFS. I think this posture is problematic not just with PFS but also in ACL injury as Tim Hewett's research has demonstrated repeatedly- seems only to be a difference in force magnitude at time of injury versus chronic microtrauma or repetitive irritation. Went to Dr. Power's APTA ACP course and he had a PT with knee pain wear the SERF strap- she hated it because her glutes were so sore after one night…but I think that is at least limited anecdotal evidence that perhaps it was activating glutes/hip muscles that were not inadequately firing prior to using hte strap.

    Dan Bien PT, OCS, CSCS

  18. Harrison Vaughan, PT, DPT
    Harrison Vaughan, PT, DPT says:

    Thanks for the entire series on PFPS! It has really been helpful. As I have previously worked the proximal mm groups with knee pain; this has really my shaped skills and approach. It seems everyone who reads this can come out on top.

    I really do like the VMO aspect that you bring up. It just seems the "easy" way out when a physical therapist tells a pt that the reason they have anterior knee pain is that their VMO is weak. I think its a bunch of bull and even if it is so, research does exhibit that you can't isolate it anyway.

    I have found in the past that performing any movement of the knee, either through ROM or even isometrics can be extremely painful for a patient that is extremely irritated; while addressing the SIJ & hip, the pt can perform much needed therapeutic exercise and gain more initially than going straight to the knee.

    Overall, I do feel going proximal to the joint is the best approach, rather than distally initially. It seems a therapist can get into the binge of educating every patient that they need orthotics/support without actually addressing other regions first and further purchase unneeded equipment.

    If proximal isn't doing the job, then of course look lower.


  19. Mike Reinold
    Mike Reinold says:

    Thanks for the feedback Scott. I too like the "monster walk" exercise you perform and agree with your use of tape/brace. I need to get my hands on the SERF brace, havent played with one yet but have heard good things. Anyone else try these?

  20. Anonymous
    Anonymous says:

    Great series Mike, I am actually utilizing your blog as a source for my colleagues in a pediatric sports/orthopedic hospital outpatient facility. The patellofemoral joint is certainly a complex area of focus and you summarized it brilliantly. In adolescent sports we see a high volume of patients that are plagued with this annoying dysfunction that is multifaceted and your multimodal approach to summarizing evaluation and treatment is a great source for all therapists.

    I have attended a conference with Christopher Powers presenting and seeing the dynamic MRI, open chain vs. closed chain really changed by perception of the efficacy of prior treatment approaches and taping techniques.

    A few exercise we often utilize in our practice that elaborates on your example with the theraband squat are "monster walks" and "lateral strides" resistive band with a little padding placed at the knee or ankles and cuing to walk emphasizing hip ER/abduction "walk like a saddle sore cowboy" or "monster" Its a more dynamic movement that might please the previous poster regarding avoiding isometrics.

    Another mechanical consideration that is not often discussed but makes practical sense is considering my population of adolescence, the biomechanical impairments that are often observed in videos and still pictures of the hip adduction/IR "kissing knees" appears to be a fault seen in females and prepubescent boys. Once a male reaches puberty, and as development occurs of the male genitalia, motor learning is achieved with a painful reminder to not adduct/IR the thighs. Typically PFPS classification in males tend not to fall in a biomechanical dysfunction in males, but more in the trauma, overuse, hypermobility category.

    Powers research also has some funding provided by DonJoy promoting the product SERF strap (Stabilization through External Rotation of the Femur) i tend to use strapping and bracing as a method of enhancing motor control and stability and learning along with a good strengthening and flexibility program, as you outlined above, then ultimately not having to utilize the strap/brace due to the adaptation of the exercises that were emphasized. Keep up the great website/blog.

    Scott McInturff, PT, DPT, ATC

  21. Brian O'Neil, PT
    Brian O'Neil, PT says:

    Thanks Mike, I hope the tone of my previous comments did not come across as harsh, obviously this is a something I am pretty passionate about. Again, I agree with 99% of what you have described, and I think the fact that we are discussing the hip as well as frontal and transverse plan motions is a great thing. And I absolutely agree that the majority of our knee patients will have a harder time controlling IR/ADD than those not being able to perform it. What I meant by a functional isometric was that patients become afraid of a certain motion, so they avoid it. They begin to function in the sagital plane, as you said. To train for excessive IR I promote IR. I really try to promote transverse plane mobility and power. Controlling into and out of it. I really don't want to shorten their range. So essentially we are both working the externals eccentrically, I am really focusing on that dysfunctional range. I guess the question is is the excessive range pathological because it is excessive or because they can't simply can''t control all of it?

    ps. I really enjoyed the post on the biomechanics of the PFJ with the contact areas. Keep up the great work.

  22. Mike Reinold
    Mike Reinold says:

    Jamie – great thoughts, I do use tubing in the manner that you describe. See below for more info regarding your comments.

    Brian – I would agree with you regarding your thoughts on isometrics and functional stability.


    My thought is that sometimes we need to take a step back and simplify our training to enhance mechanics. You seem to be taking Dr. Tiberio's reserach to the extreme. Yes, the the femur internally rotates during normal function. Yes, you suggestions above do sound reasonable and would fit nicely with the treatment guidelines I suggest. However, excessive IR has been shown to be disadvantageous to the knee. Our population presents in this manner the majority of time. I would say patients having a difficult time controlling IR during a step-up far outweigh patients that do not achieve enough IR during a step-up.

    How do you train people to prevent excessive IR? I would say by training the ER to control the eccentric motion, such as in the examples I provided. Simply cuing the patient to not rotate their femur/tibia seems less effective, and just working on moving out of the IR position does not address dynamic stability during functional and weightbearing activities.

    Patients need to train to utilize their hips to stabilize their knees. Using the theraband around their knees in the exercise example above is one method. I think you are oversimplifying the isometric concept. The exercise trains the hip abductors and ER to contract and control the harmful adduction and IR moment of the knee. It requires contract against the resistance band to stabilize and promotes carry over into functional activities by promoting the use of the frontal plane during sagital plane activities. The exercise does not promote an isometric contraction, that seems shortsighted. This is simply an exercise that is performed for 2-3 sets of 10 reps, it is by no means intended to permanently stop the femur from IR, but rather enhance the contribution of the hip ABD and ER during a sagital exercise. It is pretty effective, you should give it a try in addition to the training techniques you suggest.

    Thanks for the great discussion, what does everyone else think? What have you found to be successful?

    Brian – would love to have you express your thoughts more on this topic as a guest post one day, maybe include some photos or videos of some of the techniques you use, sounds like it would be a great demo for us all to see!

  23. Christie Downing, PT, DPT, cert MDT
    Christie Downing, PT, DPT, cert MDT says:

    Here are some questions I had about the study:
    1. Were the controls females as well?
    2. Were there structrual differences between the control group and the experimental group/what role do you think structural anomalies may play?

    My personal thought is that those with structural anomalies learn to adapt by developing the most appropriate neuromuscular patterns…but I'll leave someone else to debate this.

  24. Brian O'Neil, PT
    Brian O'Neil, PT says:

    I just think too often as therapists we confuse the idea of stability with the ability to isometrically hold something still, when we know in normal function isometrics rarely, if ever occur. We have all seen good PTs do it: trying to hold a pelvic tilt while walking on the treadmill, keeping the scapula locked back during a shoulder exercise, or preventing normal hip motion during knee exercises(I see this all the time with personal trainers keeping the knee over the toes). All we are doing with these is preventing the muscle from lengthening and essentially making it weaker. I just think we should focus more on enhancing normal movement patterns instead of preventing them. In the example above of the girl doing the step down, I would consider it just as dysfunctional if I did not see her opposite hip drop at all. She may have some strength, enough to hold her pelvis level, but she lacks the true strength necessary to eccentrically control adduction at the hip.

  25. jamieatlas
    jamieatlas says:

    Hi Mike – just read your comments on Brians post (didn't show up until just then for me for some reason). Have you tried putting the knee into slight internal rotation from a standing position to have it return to neutral against resistance (a la the blue band example you use in the leg press) that might seem a happy medium – after all, we are not trying to teach the knee to stabilize external rotation forces from neutral, but to prevent collapsing once it has started to internally rotate.

    Again, appreciate you putting this post together and value your thoughts.

    Jamie Atlas

  26. Anonymous
    Anonymous says:

    Hi Mike – I have to agree with Brians comment for the most part.

    To me, it would seem to make sense that if the foot and the hip both play a role in the internal (or external) rotation of the hip.

    If we are to embrace the design of the body and use these mechanisms to improve the bodies movement to control the leg and body when landing, stepping, jumping etc.. Then it would seem that we could get better results by moving INTO this internally rotated position in order to facilitate and improve reaction that would take the knee back OUT OF that internally rotated position.

    However, although I have done much work with accomplished physical therapists (such as Gary Gray), this is by far the best explanation I have seen of how the leg works as a unit. I am truly grateful for this information coming out as in my eyes (and the eyes of many others that I work with) an analysis of this kind is long overdue.

    Thanks again

    Jamie Atlas (GIFT Fellow)

  27. Mike Reinold
    Mike Reinold says:

    Brian, thanks for the comments and sharing your experiences. You have great suggestions. I agree with your comments on the mechanics of the knee. There are numerous studies that show weakness of the hip is directly related to PF pain, a couple of which I linked to above. My thoughts are that patients have a hard time stabilizing their knee and preventing excessive IR and ADD. Notice I say excessive. While a certain amount is necessary, too much is detrimental. The exercise suggestions are designed to help train the knee to prevent excessive motion. This will hopefully carry over into functional activities. I dont think strengthening exercises in this fashion will stop the hip from IR and ADD, but hopefully will allow the hip muscles to control this moment and prevent excessive motion and a disadvantageous position for the joint. Thanks again for sharing, I am going to try some of the cues you suggest!

  28. Brian O'Neil, PT
    Brian O'Neil, PT says:

    Hi Mike, I have really enjoyed the series of posts on PF dysfunction. Although I agree with you that treatment should include a strong focus on the hip, and ankle, I disagree somewhat on the techniques you describe. My philosophy, based largely on the excellent biomechanical analysis done by Dave Tiberio at Uconn, focuses on the fact that the knee is supposed to abduct(w/adduction at hip) and internally rotate, and often patients will develop PF pain if the hip does not ADD/IR enough. You state that training should focus on training the hip to externally rotate and abduct. I would say instead treatment should focus on controlling hip ADD/IR. When our patients get weak they first lose the ability to lengthen the sarcomere, effectively "shorting" the motion and creating a functional isometric. This turns the knee joint into strictly a sagittal plane joint and results in the femur smacking into the back of the patella. I like your exercise with the theraband around the knees, however it keeps the knee too sagittal and doesn't allow for this normal ADD/IR to occur. I would instead cue the patient to "turn your knee down and in". I have been getting excellent results since I began incorporating these strategies. As far as the foot/ankle goes, I look at it not so much to see what it may be causing at the knee but more to see what the hip/knee has done to it. Often with these patients we see a blown mid-tarsal joint because of poor shock absorbing capabilities of the hip musculature, resulting in excessive pronation. An orthotic will just make these patients worse because we have just taken away their compensatory shock-absorbing ability.

Trackbacks & Pingbacks

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  6. Biomechanics of Patellofemoral Rehabilitation | Marcio Cunha says:

    […] Continue on to Part 7: Understanding the clinical implications of the kinetic chain: The influence of the hip and foot on the patellofemoral joint […]

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