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The Relationship between Knee Pain & Hip Strength

22 Feb 2016
Christian Barton
Knee cap pain, also known as patellofemoral pain affects people of all ages, from adolescents through to the elderly. Patellofemoral pain is a difficult condition to treat. This may be however the result of a health professional’s poor understanding of how best to manage the condition. There are many factors to consider including quadriceps strength and function, foot motion and mobility, muscle flexibility, pain sensitivity, and most importantly load management. However, we are beginning to learn that the key to success may be ‘all in the hips.’

Here are 5 reasons why:

1. The hip controls half of the patellofemoral joint

Patellofemoral pain is thought to be caused by too much lateral tracking of the knee cap on the thigh. Importantly, thigh motion is controlled by the hip joint, and research has shown us that greater rolling in motion at the hip leads to greater lateral tracking of the knee cap in people with patellofemoral pain.[1]

Picture Causes of lateral tracking of the knee cap in people with patellofemoral pain, including rolling in motion of the hip (2)

  1. Pelvis drops on opposite side, placing increased tension on the outside of the leg and pulling the knee cap outward
  2. Hip collapses inward and rolls under the knee cap due to poor function and weakness of the hip muscles
  3. Thigh muscles are weak or function poorly, meaning there is inadequate support for the knee and knee cap
  4. Foot rolls in too much, causing the shin and knee to collapse inward under the knee cap

2. People with patellofemoral pain have more hip motion

Reviews tell us people with patellofemoral pain have more motion at the hip. Specifically, people with patellofemoral pain have hips which collapse and roll in more than people without pain, during activities including running, squatting, and walking on stairs.[2, 3]

3. Teaching people with patellofemoral pain to reduce hip motion is very effective in reducing pain

Although there is not a lot of research on the effectiveness of teaching people with patellofemoral pain to reduce hip motion, participants in studies report large reductions in pain. From my perspective, this is often one of the key things which needs to be done for my patients with patellofemoral pain, during running, squatting, walking on stairs, and various other activities which may be painful.[4, 5]

4. People with patellofemoral pain have weak hips

Studies show people with patellofemoral pain have weak hips. Muscles which are responsible for controlling the collapsing and rolling in of the hip were weaker in people with patellofemoral pain compared to people without pain.[6]

5. Improving hip strength is very effective in reducing pain

Exercises targeting the hips seem to me more effective than those more traditional exercises targeting the quadriceps such as the VMO.[7] However, an important consideration here is that you should not choose between one or the other. An exercise program targeting both the hip and the quadriceps may in fact be more effective.


  1. Souza, R.B., et al., Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther, 2010. 40(5): p. 277-85.
  2. Barton, C.J., et al., Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Gait Posture, 2009. 30(4): p. 405-16.
  3. Neal, B., et al., Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: a systematic review and meta-analysis. Gait Posture, 2016. In Press.
  4. Noehren, B., J. Scholz, and I. Davis, The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British Journal of Sports Medicine, 2011. 45(9): p. 691-6.
  5. Willy, R.W., J.P. Scholz, and I.S. Davis, Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clin Biomech (Bristol, Avon), 2012. 27(10): p. 1045-51.
  6. Rathleff, M.S., et al., Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. Br J Sports Med, 2014. 48(14): p. 1088.
  7. Lack, S., et al., Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med, 2015. 49(21): p. 1365-76.

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