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  • Writer's picturePursuit of Motion Physiotherapists

It's All Connected - Exercise and PFPS

"Patellofemoral pain syndrome (PFPS for short) is a common overuse injury of the knee that roughly translates to pain behind the kneecap."

“It’s all connected...” one of the many ubiquitous semi-truths that we hear all the time in rehab (like “no pain no gain”). Our response is usually to tell the client that if their parts are NOT “all connected”, they should put the disconnected part on ice and head to an Emergency Department and not a physiotherapy clinic.

So literally speaking, yes, your body parts should all be connected. Practically speaking, there are limitations to “it’s all connected”. Humans tend to be very good at seeing correlations between distant events.

Your current episode of back pain COULD be connected to that kid pushing you on the playground in 1983, but there’s a good chance that these events are not connected at all.


Patellofemoral pain syndrome (PFPS for short) is a common overuse injury of the knee that roughly translates to “pain behind the kneecap”. It’s characterized by - you guessed it - pain behind the kneecap!

This will typically be reproduced with activities that involve heavy quads contractions, such as stair climbing, squatting, or running. PFPS is a great example of when things actually are “all connected”, both literally (the hip to the knee) and in terms of effective rehabilitation (strengthening the hip and knee).

Exercise Versus Other Interventions

Different exercise programs have been used as an effective intervention for PFPS for a long time.

A 2014 review by Clijsen et al. found an average pain decrease of 40mm on a 100mm VAS scale after the completion of an exercise program. A 2019 systematic review by Willy et al. found that exercise is basically the ONLY thing that works for PFPS.

They suggested that therapists NOT use passive modalities, braces, sleeves or straps. They did suggest that taping or orthotics “may be useful” in the short term (first 4-6 weeks) and that gait retraining may be useful for runners.

So we should certainly be prescribing exercise, and recent evidence gives us the ability to narrow down the types of exercise that are most likely to benefit patients with PFPS.

Open versus Closed Kinetic Chain Exercises

Open kinetic chain exercises are those that are performed while the foot is free to move (think of straightening the knee against the resistance of an ankle weight).

Closed kinetic chain exercises are those that are performed with the foot in a fixed position (think of a squat). A systematic review by Van Der Heijden et al. (2016) found some evidence that open kinetic chain knee exercises were the most effective for treating PFPS. The review by Willy et al. in 2019 found no difference between open and closed kinetic chain exercises.

The decision to use open or closed-chain knee exercises should be based on patient preference, and the equipment practically available for their home program.

Knee Strengthening Versus Hip Strengthening

Here’s where “it’s all connected”. The Van Der Heijden et al. review found that strength exercises for the hip were superior to strength exercises for the knee, and that the best approach was to strengthen both joints.

Another review by Nascimento et al. in 2018 found that changes in pain and activity level were superior in the combined hip and knee group as compared to the knee-only group.

Hip exercises should focus specifically on the postero-lateral muscles group responsible for hip abduction and external rotation. The Van Der Heijden review found that high-intensity programs performed better than low-intensity programs.

The best advice may be to start with hip strengthening exercises if the knee is too painful to exercise, and to progress to a combined program as soon as possible, progressing intensity as quickly as can be tolerated.


So there you have it. Knee pain and hip strength are undeniably connected. This happens to be true for other knee conditions as well (for example, tendinopathy), but more on that another time! As always, if you any questions or comments please feel free to contact us or book an assessment and get your knee checked out today!



Clijsen, R., Fuchs, J. & Taeymans, J. (2014). Effectiveness of exercise therapy in treatment of patients with patellofemoral pain syndrome: systematic review and meta-analysis. Physical Therapy, 94(12)

Nascimento, L., Teixeria-Salmela, L., Souza, R. & Resende, R. (2018). Hip and Knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in individuals with patellofemoral pain: a systematic review with meta-analysis. Journal of Orthopaedic and Sports Physical Therapy, 48(1)

Van Der Heijden, R., Lankhorst, N., Van Linschoten, R., Bierma-Zeinstra, S. & Marienke Van Middelkoop, M. (2016). Exercise for treatment patellofemoral pain syndrome: an abridged version of Cochrane systematic review. European Journal of Physical Rehabilitation Medicine, 52(1)

Willy et al. (2019). Patellofemoral Pain: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American Physical Therapy Association. Journal of Orthopaedic Sports Physical Therapy, 49(9)


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