August 18, 2022
Patellofemoral Pain Syndrome (PFPS): It May Not Be About Your Knee

Author: Dr. Leor Giladi, CSCS, CF-L2

If you’re here to read about your knee, you’ve come to the wrong place. We’re not here to talk about your hips and ankles either. Ok, that’s not ENTIRELY true, but we’re here mostly to talk about your diagnosis; patellofemoral pain syndrome, or PFPS for short, which typically describes pain in the front of your knee. Unfortunately, PFPS is more of a description than an actual diagnosis.

Before we dive any deeper, let’s talk quickly about the relevant anatomy. A joint exists anywhere that bones meet, and your knee is no different. The knee joint is where your femur (thigh bone) and tibia (shin bone) meet. From the outside it might look like your knee bends and straightens like a door hinge, but it doesn’t. Your knee, just like every other joint in your body, works via rotation. As you straighten your knee the femur rotates inwards while the tibia rotates out; bending your knee goes the other direction.

The top of your tibia is a relatively flat plateau, and the bottom of your femur looks like two big knuckles resting on top. How does your knee stay together? You can thank your ligaments and muscles for that. There are a lot of muscles that control the position and orientation of your knee, but the group most commonly discussed in PFPS is the quadriceps. That’s because the patella, or kneecap, literally floats within the tendon.

Now that we know what we’re looking at, let’s discuss how none of that really matters. What really matters is force management. As your foot hits the ground the shock must travel up the leg and through the body, you then drive a return force back through the body and into the ground so you can push off. This is called walking, and when you do it really fast, running. The same rules apply when lifting weights, even if your feet never leave the ground. How efficiently you absorb and redistribute forces determines how much strain the joint, muscles, and ligaments take on.

Don’t go worrying about “wear and tear”. Tissue strain is a completely normal part of being a human and is critically important for building a strong body. One of the hallmarks of being a living organism is the ability to self-heal. In a typical scenario you would use your body to move around in the world, tissues get stressed out, and then you heal and recover with food and rest. The problem is when the stress you take on begins to exceed your ability to recover from it. You can think of it like a budget where you’re slowly going into debt. This debt, over time, is what leads to the pain you’re feeling.

When you started reading this article I said that PFPS is a description and not a diagnosis. What I meant was that PFPS tells you what hurts, it doesn’t tell you why it hurts. The diagnosis itself therefore has little to do with how you treat it.

Typical advice for PFPS is to strengthen your quadriceps, hamstrings, calves, and glutes. The idea is that stronger muscles will both help you to resist force better and allow you to take on more strain before going into debt. For many reasons that go beyond the scope of this article, that approach is short-sighted. Strength training is an essential part of the rehab process, but it needs to be applied at the right time and for the right reasons. The strongest muscles on earth don’t mean a thing if they don’t turn on at the right time, in the right sequence, and coordinate with muscles throughout the rest of your body.

There are a lot of people who get complete relief through strength training alone, but if you’ve gone the strengthening route and are still having pain you missed something. Even if you have an old injury – a torn meniscus, arthritis, an injured or missing ligament – it might not matter when it comes to your pain. Address and improve the way you manage forces through the knee, and you will be surprised at how much you can improve.

If you’re reading this and have anterior knee pain that just won’t quit, I hope you now see that you don’t have to be stuck with it forever. All mechanical pain has a source, and with the right approach you can absolutely solve it.