Is Knee Cap Pain
Limiting Your Activity?

Knee cap pain, also called patella femoral syndrome, is a common knee joint pain condition. When the knee cap hurts, everyday activities can become painful. Symptoms in the anterior knee can be influenced by a variety of different components. What are they and what can you do to relieve your anterior knee pain?

What is Knee Cap Pain?

Knee cap pain is a knee condition that can affect both young and old. The knee cap, or patella, forms a joint with the femur termed the patella femoral joint. Pain in the front or anterior aspect of the knee can be related to dysfunction around the patella femoral joint called patella femoral syndrome (PFS). Most commonly PFS occurs when the underside of the patella becomes irritated secondary to abnormal movement of the patella in the femoral groove.

knee patella femoral syndrome

From an anatomical standpoint, the patella sits in the femoral groove. The quadriceps muscle attaches to the patella from above and continues on to form the infra patella tendon below. Additional soft tissue structures attach to the patella including the medial retinaculum on the inside and the lateral retinaculum on the outside.

Signs and Symptoms of Knee Cap Pain

The most common symptom with PFS is pain in the anterior or front of the knee. Activities such as moving from sitting to standing, walking stairs, walking down hills, and jumping will reproduce pain. The patella can also create a crunching sound called crepitus. This crepitus is not a concern unless it is painful.

Causes of Anterior Knee Pain

Many variables can contribute to the development of PFS. Leg biomechanics, muscle strength, and soft tissue flexibility can all help to cause anterior knee pain.

For some, excessive patella movement can contribute to patella pain. This hypermobility of the patella can allow excessive motion of the patella to occur, increasing the likelihood of patella irritation.

In the past, the patella and the immediate surrounding tissues were the only focus of patella related pain. Today the patella femoral joint is no longer looked at in isolation. Rather, the entire lower extremity must be assessed as a whole.

A great visual is to consider the leg as a train track. The patella functions like a train sitting on the track. When the patella becomes derailed, it is generally because the track underneath the train moved as opposed to the train itself moving. Because the track (leg) moves during functional activity, derailment of the patella can occur. This movement of the patella outside of the femoral groove is what causes the underside of the patella and surrounding tissues to become irritated.

The two main areas that can create excessive movement of the leg, or track, are the foot and the hip. A foot that pronates or rotates inward creates inward movement of the tibia and knee. This excessive movement can derail the patella from the femoral groove.

knee valgus

A second source of excessive movement comes from the hip. Weakness of muscles around the hip can allow excessive internal rotation to occur, again allowing the track to move under the train and keeping the patella from staying in the groove of the femur. The patella femoral joint in essence becomes the “pickle in the middle” between extra movement occurring from the foot below and the hip above.

Conservative Treatment Protocol

As with all joint pain issues, reducing inflammation is the first step for effective treatment of patella joint pain. The use of ice therapy is an easy means of reducing inflammation. Medication to reduce inflammation can also be a part of the treatment plan (consult your doctor regarding medication). When medication is not successful, cortisone injections may be used to minimize joint inflammation.

Addressing the mechanics of the foot is a key component to pain relief. For patella pain that is related to the foot, controlling foot pronation is required. For pronated feet, running shoes are generally the best at controlling excessive foot motion and minimizing tissue stress. Running shoes that are labeled as ‘motion control’ or ‘stability’ are generally best for pronated feet. In certain cases, the use of custom shoe inserts is warranted. As custom shoe inserts can be expensive, a good over-the-counter shoe insert is the Superfeet brand and can generally be found in sporting good stores.

foot pronation

For those that also have excessive or hypermobility of the patella, the use of a knee brace can be helpful. The brace functions to help keep the patella in place, limiting the possibility of excessive motion.

knee patella brace

Physical Therapy Exercises

Physical therapy treatment of PFS can be complicated as symptoms can be affected by a number of different variables. Years ago treatment focused simply on strengthening the quadriceps muscle on the front of the thigh. The specific muscle, called the VMO (vasus medialias oblique) was thought to be the main culprit. The belief was that the patella would move laterally, or towards the outside, and out of the groove of the femur because of a lack of VMO strength. This movement out of the groove would cause the underside of the patella become rough and inflamed. Thus, the main focus of treatment was to increase VMO strength.

We now know that for effective treatment of PFS, the entire leg must be addressed. Flexibility of the muscles around the hip and knee is an important component of an overall pain reduction plan. The IT band, hip flexor, hamstring and even calf muscles all can have a negative impact on patella alignment.

As mentioned earlier, addressing the strength of the knee and hip muscles must also be part of an effective treatment plan for knee cap pain. Strengthening of the quadriceps, hip abductors, and glute muscles must all be part of the program.

It is important that all strengthening exercises be performed pain free, especially quad strengthening. Pain experienced while performing strengthening exercises will only add to joint inflammation.

The following is a link to a typical stretching and strengthening program for PFS: knee cap pain exercises.


• Patella femoral syndrome is caused by irritation of the underside of the knee cap.

• Symptoms of PFS generally involve anterior knee pain with running, stairs, inclines, and jumping.

• A number of variables can impact anterior knee pain including patella hypermobility, foot biomechanics, soft tissue tightness, and weakness of muscles around the hip and knees.

• The use of shoe inserts, braces, and following the knee cap pain exercise program will help you reduce anterior knee pain.

Knee cap pain is not always a simple injury to treat. Effective treatment must include looking at the big picture of the entire leg. Implementing the recommendations can help to get you on the road to eliminating your knee cap pain.

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