Knee pain is one of the most common sporting complaints and has many different sources. Patello Femoral Pain Syndrome (PFPS), also known as “runners’ knee”, and is pain on the underside of the patella. It is often something that comes on gradually and there is no history of trauma.
The pain is thought to be caused by increased pressure between the underside of the patella and the femoral groove it moves in. The traditional thought process usually describes the cause as being mal-tracking. I often hear people who have a history of this diagnosis having been told that the lateral muscles are too strong or tight, and the VMO is too weak. If they are lucky they will simply have been given strengthening exercises for the VMO and soft tissue, and stretching work for the lateral structures. Sometimes this will be escalated to a surgical release of the lateral structures. Those are all strategies that attempt to correct the patella. Gary Gray talked about the patella femoral joint as a train (patella) on its tracks (femur). He said something along the lines of: “You can’t blame the train if the tracks lead you in the wrong direction.” This implies that we should be focusing more on the femur rather than the patella.
This makes far more functional sense: is it the femur that is misaligned rather than the patella? Patella mis-alignment doesn’t make much sense to me, but yet I would agree that the joint is misaligned. So maybe we need to assess and treat the femur in order to re-align the joint?

Let’s use the example of right knee pain, with the patella rubbing on the medial condyle of the femur. This would suggest to me that the femur is rotated to the left excessively, causing the medial irritation.

Which are the likely suspects here? I’m thinking initially the most likely is the same side foot or hip. If the foot is over pronating (which could be for many possible reasons)it can cause excessive left rotation at the tibia, dragging the patella medially into the medial condyle of the femur.

Alternatively, it could be a lack of internal rotation at the hip, which means a normally pronating foot would still torque the knee because the femur’s rotation to the left will be inhibited by the lack of internal rotation at the hip. This means that treating the patella may ease the symptoms but fundamentally will not solve the problem. As always we need to look beyond the symptoms and get to the root causes. I have no problem with addressing the symptoms in the short term, while you find and solve the root causes, but if all you are doing is fighting the symptoms you will be fighting for a long time.

Neil Poulton