Solving Patellofemoral Pain – It’s All In The Hips

Hip Strengthening for Knee Pain

That dull, achy pain in the front of your knee – it feels like it’s right behind your kneecap. Running, going up and down stairs, squatting, and standing up from chairs all seem to make it worse. You’re an active person, so I know you’re a believer in the benefits of exercise – but when all these activities hurt, how can exercise make it better? Surprisingly, Patellofemoral pain, as this type of knee pain is known, can get better by strengthening the muscles in your hip…that’s right – your hip.

Let’s take a look at how this works…

The Force Is Strong

Patellofemoral pain is common, making up about 25% of injuries to the knee1.

What causes this pain is an increase in pressure in the Patellofemoral joint – between your kneecap (Patella) and thigh bone (Femur).

Where does this increase in pressure come from?

Normally, your kneecap should glide up and down smoothly as your knee bends back and forth. In people with Patellofemoral pain, however, the kneecap has been shown to rotate laterally – toward the outside of your leg2,3.

What causes this rotation?


It’s All In the Hips

When we look up at the hip in people with Patellofemoral pain, we see that it often tends to rotate inward. This inward rotation of the hip, along with an inward angle at the knee (valgus) leads the kneecap to rotate outward 4,5,6.

If this all sounds confusing, the “light bulb” moment for many of my patients comes when I have them watch themselves perform a single leg squat in front of a full-length mirror.

Go ahead and try it yourself.

Watch what happens at your hip and your knee. Likely, your hip will rotate inward, leading to your knee angling inward7. Now try comparing this to your other leg – is there a difference?

Okay, now that this is making more sense, the logical next question would be: what causes your hip to rotate inward?

The answer: weak muscles in your hip! 8,9,10,11,12

Strengthening Your Hip To Help Your Knee

Studies show that hip strengthening for 4–8 weeks can significantly decrease Patellofemoral pain even 6 months later13,14.

This makes sense, right? If you strengthen the muscles that rotate and angle your hip outward, it will gradually rotate and angle less inward…leading to less of an outward pull on your kneecap…ultimately leading to less pain!

Here’s some great exercises you can do to strengthen your hips:

1. Clamshells


2. Hydrants


Once your hips are strong enough, single leg squats are a great way to further strengthen them. The key is to focus on your form, though. Your knee may naturally want to angle inward – don’t let it! Use your hip strength to rotate it outward. Also, try not to lean too much with your upper body. Force those hip muscles to work hard!

3. Single Leg Squats


Question: What other hip strengthening exercises are part of your program? You can leave a comment by clicking here.

  1. J.E. Taunton, M.B. Ryan, D.B. Clement, et al.A retrospective case-control analysis of 2002 running injuries. Br J Sports Med, 36 (2002), p. 95  ↩
  2. Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G (2000) Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. Am J Sports Med 28:480–489  ↩
  3. Wilson NA, Press JM, Koh JL, Hendrix RW, Zhang LQ (2009) In vivo noninvasive evaluation of abnormal patellar tracking during squatting in patients with patellofemoral pain. J Bone Joint Surg Am. 91(3):558–566  ↩
  4. Myer GD, Ford KR, Barber Foss KD, Goodman A, Ceasar A, Rauh MJ, Divine JG, Hewett TE (2010) The incidence and potential pathomechanics of patellofemoral pain in female athletes. Clin Biomech (Bristol, Avon) 25(7):700–707  ↩
  5. MacIntyre NJ, Hill NA, Fellows RA, Ellis RE, Wilson DR (2006) Patellofemoral joint kinematics in individuals with and without patellofemoral pain syndrome. J Bone Joint Surg Am 88(12):2596–2605  ↩
  6. Souza RB, Draper CE, Fredericson M, Powers CM (2010) Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther 40(5):2772–2785  ↩
  7. Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM (2011) Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med 39:866–873  ↩
  8. Baldon R, Nakagawa TH, Muniz TB, Amorim CF, Maciel CD, Serra ˜oFV(2009)Eccentrichipmusclefunctioninfemaleswithand without patellofemoral pain syndrome. J Athl Train 44(5):490–496  ↩
  9. Bolgla LA, Malone TR, Umberger BR, Uhl TL (2008) Hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 38(1):12–16  ↩
  10. Brent JL, Myer GD, Ford KR, Hewett TE (2008) A longitudinal examination of hip abduction strength in adolescent males and females. Med Sci Sports Exerc 39:34–45  ↩
  11. Padua DA, Marshall SW, Beutler AI, Demaio M, Boden BP, Yu B, Garrett WE (2005) Predictors of knee valgus angle during a jump-landing task. Med Sci Sports Exerc 37:398–404  ↩
  12. Prins MR, van der Wurff P (2009) Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Physiother 55(1):9–15  ↩
  13. Thiago YK, et al. short term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. JOSPT. 2010;40(11):736–742.  ↩
  14. Khayambashi K, et al. 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. JOSPT. 2012;42(1):22–29.  ↩
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