If you have had Patellofemoral Pain Syndrome before, then you understand the challenges with managing this condition.
The challenge in managing Patellofemoral Pain Syndrome has led to the utilization of MANY different treatments.
However, of all the different treatments used, strength training for Patellofemoral Pain Syndrome is BY FAR the best option.
This is due to the fact that one, strength training for Patellofemoral Pain Syndrome decreases pain and improves function in patients [1]. And two, compared to all the other treatments, strength training for Patellofemoral Pain Syndrome has the strongest evidence to support its use.
The challenge with strength training for Patellofemoral Pain Syndrome is figuring out what exercises are the best.
So, if you have Patellofemoral Pain Syndrome and are unsure what strengthening exercises are best, you are in the right place!
In this article you will learn all about strength training for Patellofemoral Pain Syndrome, including:
Purpose of strength training for Patellofemoral Pain Syndrome
The most important purpose of utilizing strength training for Patellofemoral Pain Syndrome is for this reason:
It has shown to significantly decrease pain and improve function [1].
For those of you that are more analytical, there are other proposed purposes that aim to explain why strengthening does decrease pain and function that I will cover now.
Purpose of quadriceps strength training for Patellofemoral Pain Syndrome
Quadriceps weakness is not only a common finding in patients, but is also thought to be a risk factor for developing Patellofemoral Pain Syndrome in the future [1] [2].
Furthermore, it is commonly accepted that excessive stress to the knee is one of the mechanisms that causes Patellofemoral Pain Syndrome.
In an attempt to explain the cause of increased stress to the patellofemoral joint, several theories have been proposed.
For example, one theory states that increased patellofemoral joint stress may be due to a strength imbalance that occurs between the lateral and medial quadriceps [3].
For these reasons, quadriceps strength training for Patellofemoral Pain Syndrome is thought to be important for improving strength and possibly reducing stress on the joint. In turn, this may explain the improved pain and function.
Purpose of hip strength training for Patellofemoral Pain Syndrome
Hip weakness is another common finding in those with Patellofemoral Pain Syndrome. Specifically, weakness in the hip abductors, lateral rotators, and extensors have been reported [4] [5].
Furthermore, increased hip adduction and medial rotation is another finding in some patients while walking or running.
This movement pattern is thought to increase the stress on the patellofemoral joint, and may eventually lead to the development of Patellofemoral Pain Syndrome.
As such, hip strengthening is utilized based on the assumption that doing so will reduce stress on the patellofemoral joint [4] [5]. Which, similarly to quadricep strengthening, may explain the improved pain and function.
Don’t forget the big picture
I understand that it may be helpful to know the fine details behind the purpose of an exercise.
That being said, the mechanical approach to understanding the purpose of utilizing quadriceps and hip strengthening has conflicting evidence, or is based on assumptions.
It is more likely that the improved pain and function occur from multiple factors, such as mental health, rather than from increased strength and reduced joint stress alone.
I cannot emphasize this enough, the main reason that strength training for Patellofemoral Pain Syndrome is used is due to the fact that it decreases pain and improves function, period!
Now that you know the purpose behind strength training for Patellofemoral Pain Syndrome, it is time to see what strength training is best!
Knee strength training for Patellofemoral Pain Syndrome
Knee-targeted strength training Patellofemoral Pain Syndrome has been around for a long time.
And I mean, a LONG long time.
This has led to an abundance of research over the years in an attempt to identify the best knee strategies for Patellofemoral Pain Syndrome.
Some examples of different knee strengthening strategies that have been compared:
Open vs closed chain exercises for strength training for Patellofemoral Pain Syndrome
An open chain exercise is used to describe exercises that are performed with your limb(s) moving through space. Conversely, a closed chain exercise refers to exercises that are performed with your limb(s) moving, but maintaining contact with a fixed surface at all times.
So, what is the big deal with open vs closed chain exercises in terms of strengthening for Patellofemoral Pain Syndrome?
It all started in 1998, when it was found that the muscles around the knee behave differently during open and closed chain exercises. More specifically, the amount and pattern of muscle activation was different between the two [6].
Since then, additional research has emerged demonstrating additional differences between open and closed chain exercises.
It has been found that a lunge exercise (closed chain) activates the medial and lateral quadriceps evenly. While on the other hand, a knee extension machine (open chain) has been found to activate the lateral quads much more than the medial quads [7].
Furthermore, the position of the knee where the highest amounts of stress occur in the patellofemoral joint has shown to differ between open and closed chain exercises.
In open chain exercises, peak patellofemoral joint stress occurs when the knee is extended. Whereas, in closed chain exercises, it occurs when the knee is flexed [8].
Now do you know what knee exercise is best for strength training for Patellofemoral Pain Syndrome?
I will answer for you: no you do not!
Although all these findings sound intriguing, they all share a common problem.
The subjects in these studies DID NOT HAVE PATELLOFEMORAL PAIN SYNDROME. That is, only subjects without any history of knee pain were used.
By doing this, it is impossible to know how open or closed chain exercises influence pain or function in a person with Patellofemoral Pain Syndrome.
DON’T FORGET THE BIG PICTURE!
When open and closed chain exercises are compared for strength training for Patellofemoral Pain Syndrome, the outcomes are not DIFFERENT!
That is, open and closed chain exercises decrease pain and increase function equally in those with Patellofemoral Pain Syndrome.
Mind you, these studies were completed A LONG TIME AGO!
Yes, it would help to have more recent evidence, but there isn’t.
As such, this is the most evidence based statement regarding open vs closed chain strength training for Patellofemoral Pain Syndrome:
They are the same!
Blood Flow Restriction (BFR) for strength training for Patellofemoral Pain Syndrome
Blood Flow Restriction (BFR) has been another area of interest for knee strength training for Patellofemoral Pain Syndrome.
BFR is one of the hottest trends in the Physical Therapy world.
BFR is performed by using a tourniquet to restrict blood flow and oxygen to an area. The mechanism behind BFR is not well understood, and it is a topic for another day.
That being said, it is thought that BFR can produce strength gains with much less amount of weight than is typically required.
For example, if your max squat is 200 lbs, you are probably squatting 175 lbs and more to increase strength. Whereas with BFR, it is thought that similar gains can be achieved by only squatting 60 lbs.
A 2015 study looked at the effects of BFR for strength training for Patellofemoral Pain Syndrome [11].
In this study, compared to traditional strength training, it was found that pain reduced more in those that completed BFR. However, the reduction in pain was just slight, and the authors did not deem it significant.
For that reason, this is the most evidence based statement in regard to using BFR for knee strength training for Patellofemoral Pain Syndrome:
It is not known if BFR is better than traditional strength training for Patellofemoral Pain Syndrome.
Hip strength training for Patellofemoral Pain Syndrome
For the last decade or so hip strength training for Patellofemoral Pain Syndrome has been another hot topic.
And let me tell you, there is a reason why it is still a hot topic today!
It has been shown that significant reductions in pain and function occur when completing hip strengthening exercises only [12].
Given that hip weakness is a common finding in those with Patellofemoral Pain Syndrome, it makes sense too!
So what does this tell us?
Well, it does tell us that hip strength training for Patellofemoral Pain Syndrome is beneficial!
However, so is knee strength training!
With that said, the question running through your head should be, “Is knee or hip strength training for Patellofemoral Pain Syndrome better?”
Hip vs Knee strength training for Patellofemoral Pain Syndrome
Ali vs Frazier. Celtics vs Lakers. Red Sox vs Yankees. UM vs MSU (shoutout to the 406). And now, hip vs knee strength training for Patellofemoral Pain Syndrome.
Who are you betting on?
Let the game begin!
Hip strengthening comes out aggressive with the results from numerous studies [3] [13]. The findings from these studies show hip strength training for Patellofemoral Pain Syndrome to be superior to knee strengthening.
So it appears, hip strengthening has the edge. But, it’s still neck and neck.
Knee strength training fights back from the results in a separate study [14]. Here, there were no differences in pain or function when comparing the two for strength training for Patellofemoral Pain Syndrome.
In the closing minutes, hip strength training comes back to its aggressive mentality.
In two more additional studies, hip strength training for Patellofemoral Pain Syndrome was shown to be superior to knee strengthening [15] [16].
The buzzer sounds, and the game is over.
And the winner…. hip strengthening, maybe???
As there are more studies that show hip strengthening is superior than knee strengthening for Patellofemoral Pain Syndrome, I need to add some more details.
First, it is VERY hard to isolate exercises strictly into “knee” and “hip” exercises. This is in part due to the anatomy of the hip muscles. Also, many common exercises activate both hip and knee muscles.
For example, a squat is traditionally known as a way to strengthen muscles that surround your hip. However, the muscles around your knee are also activated while squatting.
Based on this, I need to inform you about how these studies organized “hip” and “knee” exercises.
Before I say anything else, have you ever done a single leg squat? Do you really think that type of movement would only activate the hip or the knee muscles in isolation?
If you aren’t sure, stop reading and go try a ten single leg squats.
Just kidding, I know you aren’t going to and I don’t want to be cursed at because you are sore tomorrow.
The point is, hip and knee muscles are BOTH activated while performing a single leg squat.
So, based on how these studies classified a single leg squat, it makes me wonder if the outcomes would have been different!
Nevertheless, there is greater abundance of evidence favoring hip over knee strength training for Patellofemoral Pain Syndrome. So technically, hip strengthening does appear to be the winner!
But, I am still leaving out a key detail.
In all of these studies, knee strength training for Patellofemoral Pain Syndrome ALSO significantly reduced pain and improved function.
I know you know what I am going to say next.
What would happen if hip and knee strength training for Patellofemoral Pain Syndrome were combined?
Hip and Knee strength training for Patellofemoral Pain Syndrome
At last, our final strategy to assess strength training for Patellofemoral Pain Syndrome.
If you are still reading at this point, I appreciate that! I will make this quick.
It has been found that combining hip and knee strength training for Patellofemoral Pain Syndrome is the best choice of them all!
Multiple studies have demonstrated significant improvements in pain and function when combining hip and knee strengthening [4] [5].
Mind you, hip and knee strengthening have only been compared to knee strengthening only. This combined approach has not been compared to hip strengthening only.
But, you should already know that hip strengthening in isolation appears to be SLIGHTLY better than knee strengthening.
Also, knee strengthening for Patellofemoral Pain Syndrome has always been the gold standard. So the point of all this research has been aimed at trying to find an even better gold standard.
The results from hip strengthening in isolation were not significant enough to acknowledge it as the new gold standard. However, the results from the combined approach were significant enough to do so.
With that being said, THE most evidence based statement for the best strength training for Patellofemoral Pain Syndrome is:
The best strengthening strategy for Patellofemoral Pain Syndrome is a combined approach of hip and knee strength training.
Closing Thoughts
If you have ever been to Physical Therapy for Patellofemoral Pain Syndrome rehab, I hope the majority of your time was spent strength training.
If it wasn’t, your Physical Therapist was doing you a disservice.
Strength training for Patellofemoral Pain Syndrome has shown to significantly decrease pain and improve function and should be THE main component of a rehabilitation.
The purpose of this article was to show that a combined approach of hip and knee strengthening is the best option. However, don’t forget that every strengthening strategy mentioned in this blog post will also reduce pain and improve function!
To leave you with one last message:
If you have Patellofemoral Pain Syndrome, then you need to start strengthening!
Resources
- [1] Willy RW, Hoglund LT, Barton CJ, et al. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302
- [2] Neal BS, Lack SD, Lankhorst NE, Raye A, Morrissey D, van Middelkoop M. Risk factors for patellofemoral pain: a systematic review and meta-analysis. Br J Sports Med. 2019;53(5):270-281. doi:10.1136/bjsports-2017-098890
- [3] Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. J Athl Train. 2015;50(4):366-377. doi:10.4085/1062-6050-49.3.70
- [4] Fukuda TY, Melo WP, Zaffalon BM, et al. Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys Ther. 2012;42(10):823-830. doi:10.2519/jospt.2012.4184
- [5] Nascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. Hip and Knee Strengthening Is More Effective Than Knee Strengthening Alone for Reducing Pain and Improving Activity in Individuals With Patellofemoral Pain: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2018;48(1):19-31. doi:10.2519/jospt.2018.7365
- [6] Escamilla RF, Fleisig GS, Zheng N, Barrentine SW, Wilk KE, Andrews JR. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Med Sci Sports Exerc. 1998;30(4):556-569. doi:10.1097/00005768-199804000-00014
- [7] Irish SE, Millward AJ, Wride J, Haas BM, Shum GL. The effect of closed-kinetic chain exercises and open-kinetic chain exercise on the muscle activity of vastus medialis oblique and vastus lateralis. J Strength Cond Res. 2010;24(5):1256-1262. doi:10.1519/JSC.0b013e3181cf749f
- [8] Powers CM, Ho KY, Chen YJ, Souza RB, Farrokhi S. Patellofemoral joint stress during weight-bearing and non-weight-bearing quadriceps exercises. J Orthop Sports Phys Ther. 2014;44(5):320-327. doi:10.2519/jospt.2014.4936
- [9] Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weight-bearing exercises for patellofemoral pain. J Orthop Sports Phys Ther. 2007;37(4):155-160. doi:10.2519/jospt.2007.2433
- [10] Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D. Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med. 2004;32(5):1122-1130. doi:10.1177/0363546503262187
- [11] Giles L, Webster KE, McClelland J, Cook JL. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med. 2017;51(23):1688-1694. doi:10.1136/bjsports-2016-096329
- [12] Khayambashi K, Mohammadkhani Z, Ghaznavi K, Lyle MA, Powers CM. The effects of isolated hip abductor and external rotator muscle strengthening on pain, health status, and hip strength in females with patellofemoral pain: a randomized controlled trial. J Orthop Sports Phys Ther. 2012;42(1):22-29. doi:10.2519/jospt.2012.3704
- [13] Baldon Rde M, Serrão FV, Scattone Silva R, Piva SR. Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2014;44(4):240-A8. doi:10.2519/jospt.2014.4940
- [14] Bolgla LA, Earl-Boehm J, Emery C, Hamstra-Wright K, Ferber R. PAIN, FUNCTION, AND STRENGTH OUTCOMES FOR MALES AND FEMALES WITH PATELLOFEMORAL PAIN WHO PARTICIPATE IN EITHER A HIP/CORE- OR KNEE-BASED REHABILITATION PROGRAM. Int J Sports Phys Ther. 2016;11(6):926-935.
- [15] Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial [published correction appears in J Orthop Sports Phys Ther. 2011 Sep;41(9):700]. J Orthop Sports Phys Ther. 2011;41(8):560-570. doi:10.2519/jospt.2011.3499
- [16] Khayambashi K, Fallah A, Movahedi A, Bagwell J, Powers C. Posterolateral hip muscle strengthening versus quadriceps strengthening for patellofemoral pain: a comparative control trial. Arch Phys Med Rehabil. 2014;95(5):900-907. doi:10.1016/j.apmr.2013.12.022
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