Preventing Injuries Before They Ruin Your Routine: Part 8
by Fred DiMenna, C.S.C.S.

While injuries like cartilage and ligament tears are common in the world of sports, the most frequent knee problem is an overuse condition known as patellofemoral syndrome. This malady is characterized by pain under the kneecap and, while initially not as serious as the aforementioned tears, can develop into an extremely debilitating problem if ignored.

There are a number of factors responsible for patellofemoral syndrome including imbalanced muscular development, insufficient range of motion and poor biomechanics. No matter what the cause, however, the end result is the same: The patella (kneecap) rubs on the femur (thigh bone), which causes its underside to become irritated.

Patellofemoral syndrome usually presents as diffuse pain under the kneecap. Activities involving movement at the knee typically exacerbate the pain, although sitting for extended periods with the knee flexed can also be problematic. A grinding sensation and crepitus (a cracking sound) might also be present. As with all other overuse conditions, rest, ice, compression and elevation should be used to break the inflammatory cycle. In addition, a realignment technique is sometimes employed by physical therapists. This involves literally taping the kneecap in an attempt to stabilize it. Ideally, this will enable pain-free movement and allow exercises to be performed that can potentially restore proper alignment.

One of the most common causes of lateral patellar tracking involves a relative muscle imbalance. The vastus lateralis and vastus medialis (two muscles of the quadriceps group of the front thigh) attach to the patellar tendon on opposite sides. When the medialis is overpowered by the lateralis, lateral deviation of the kneecap is likely to occur. In addition, a shortened iliotibial band, which runs from the tensor fascia lata (a muscle of the hip) to the outside portion of the knee, can also pull the kneecap to the side. In accordance with these precipitants, stretching the iliotibial band and strengthening the vastus medialis are the most frequent exercise interventions for addressing this condition.

Patellofemoral syndrome can also be caused by biomechanical abnormalities below the involved joint. During any closed-chain activity (one where the bottom of the foot is in contact with a supporting surface), alignment at the knee depends on how the foot is positioned against the surface. An abnormally pronated (flat) foot causes a deficiency known as genu valgum (or “knock knees” in layman’s terms).

This foot posture will be maintained into the propulsive phase of gait, preventing the appropriate transition (neutrality to supination) necessary to propel the body forward. This causes the lower leg to be internally rotated at a time when it should be externally rotated (the thigh above it has already turned outward to swing the opposite leg forward). This creates an unnatural twist at the knee, which takes its toll on the kneecap.

Abnormal pronation of the foot results in an increased Q angle (the angle formed between the femur and a reference line extended from the outside portion of the hip to the center of the knee). As this angle increases past 20 degrees, the kneecap is likely to rub. Women with wider hips also typically have increased Q angles. As a result, they are at greater risk for developing patellofemoral syndrome.

When biomechanical imbalances of the foot are at the root of this injury syndrome, orthotics can be used to address the problem. When muscular imbalance is the cause, the solution is not so simple. Unfortunately, some of the best exercises to strengthen the vastus medialis involve actions at the knee that can worsen the symptoms. That’s why training your lower body correctly at the first sign of trouble to prevent the problem from becoming serious is critical. Once knee movement is compromised, you’ll have to incorporate a less aggressive approach.

Quadriceps exercises that involve virtually no movement at the knee (straight leg raises and quadsets, where the relaxed thigh is tightened maximally with the isometric contraction held for a prescribed period) are the most conservative strengthening activities used. Knee extensions are also done over a limited movement range (terminal knee extensions), with the fully contracted position stressed. Conventional knee extensions (on a machine with a pad on the ankle), on the other hand, should be avoided because the full range of motion and perpendicular application of resistance (shear force) is not appropriate. When compound movements can be reintroduced, wall squats (squats performed with your back sliding up and down against a wall) provide a functional activity that stresses the quads.

Fred DiMenna, a Certified Strength and Conditioning Specialist and Lifestyle and Weight Management Consultant, is a two-time Natural Mr. United States and a WNBF drug-free professional bodybuilder. Visit him on the web at or email him at: