Anterior Knee Pain

Even though it’s commonly called ‘runner’s knee’, you don’t have to be a runner to suffer from anterior knee pain — (AKA patella-femoral pain syndrome). It’s very common in any sport that involves running, or quick stops, starts and changes of direction. So for instance if you play netball, football or enjoy skiing, or seven sometimes just walking, you could develop anterior knee pain. It’s also common in cycling because of the fixed leg position and repetitive movement, so if you’re a triathlete or cyclist it pays to be aware of this. It is also not uncommon as you get a bit older — in fact I often see ladies in their forties and fifties with this condition.


The pain is caused by poor alignment of the kneecap as it moves in the groove at the bottom of the femur (thigh bone). The kneecap (or patella) improves the mechanics of the quadriceps muscles — the ones that extend your knee and enable you to take weight without your knee collapsing. So you’d think that just strengthening the muscles and stretching them would help. But unfortunately it’s more complicated than that.

There are lots of things that will affect the alignment of your kneecap — some of these are structural, for example women have a wider pelvis, so the angle that their leg comes down is wider, affecting the alignment of the patella, this is called the Q angle.

Showing Q angle — the angle from the pelvis to the attachment of the patellar tendon via the patella = note the difference in posture of the feet on the right, and the kneecaps are turned in.

If your kneecaps sit very high or are very small, that can also cause problems with the patello-femoral joint

Flat feet can cause knee pain, because the foot turns in, which then turns the lower leg inwards and the upper leg, ending up with a posture similar to the figure on the right in the picture.

There are also muscle imbalances that can impact on runner’s knee as well:

• Weakness in gluteal and hip muscles (most common)

• Tight muscles such as the ilii-tibial band, the long structure going from above your hip to below your knee, or your quadriceps muscle, hip flexor muscles, hamstrings, and calf

  • Weak core musculature — lateral trunk and gluteal muscles
  • poor footwear — shoes that are not supportive (thank goodness no more flipflops) or trainers that are too old can also contribute.


As many things can affect patella tracking, and everyone presents differently, treatment can be challenging — but effective.

We need to look at the strength of the muscles in your buttock, particularly the ones that turn your leg outwards, and they control the position of the thigh and prevent inwards rotation that causes the patella to not track properly.

We will also look at gluteus Maximus, the big extensor in the hip as this often doesn’t switch on well. Improving the length of muscles around the knee is also important. Then we need to strengthen your quadriceps, but only when the alignment of the knee is correct.


This can be tricky as there so many factors are involved. However, the most important things you can do are to:

  • Strengthen your buttock muscles

• Stretch and roll tight structures in your legs — calves, hamstrings, quadriceps, etc.

Depending on the severity of your pain, tape, acupuncture and manual therapy will also help. So do book an appointment at Blue Koala where Cathy is expert at all three.