Understanding Patellofemoral Pain Syndrome – Plus Prevention Exercises

When interventional chiropractor and Kuchipudi dancer Pranamya Suri was doing her residency, she spent less time dancing than usual. When she got a chance to practice, she noticed persistent pain around and behind her kneecap. Suri sees this pain as a warning sign of Patellofemoral Pain Syndrome (PFPS) and is able to recover with a combination of rest and targeted strengthening exercises.

Suri explained that it’s common for dancers to develop PFPS, but the condition is also easily treated. By understanding PFPS and its impact on dancers, recognizing warning signs early, and implementing mitigation strategies before they become a problem, dancers can protect their joints and prepare themselves for a long, healthy career.

What is PFPS?

PFPS is characterized by generalized pain around and behind the patella, or kneecap. This condition is often exacerbated when the knees are bent (as in giant push-ups), going up or down stairs, or even sitting for long periods of time. PFPS is an overuse injury – the more the quadriceps contract and the more the knee flexes, the greater the force pushing the patella back under the femur. The result is pain, explains Karen Clippinger, author of Dance Anatomy and Kinesiology Professor Emeritus at California State University, Long Beach.

“If you look at the big ropes, hinges and spirals on the floor, you’ll see that many of the movements in dance are associated with high compression forces, which puts dancers at risk for developing this disease,” Klipinger said.

Jennifer Coviello, a physical therapist who specializes in treating dancers, adds that the postures preferred in certain dance styles may increase a dancer’s risk for PFPS, especially if they have difficulty moving their knees over their toes in a bent-leg position. If a dancer relies too much on certain muscles, hyperextension can also increase the risk of making the knee less stable, Klipinger explains.

Treating PFPS

If you think you may be experiencing PFPS, be sure to seek personal attention from a medical professional. Most likely, you will work with a physical therapist to develop a series of exercises tailored to your specific needs. Physical therapists often recommend strengthening the quadriceps and hip abductors. Covello explains that in some cases, dancers may also need to further strengthen the kinetic chain and strengthen the abdominals and obliques. Tightness in the hamstrings and inner thighs can also contribute to PFPS, so stretches that target that area can be incorporated as well, she says.

Suri added that she sometimes uses tools like kinesiology tape and knee sleeves, but these tools should not replace the advice of a physical therapist or other medical professional. “They’re more of a proprioceptive reminder to help guide your kneecap this way rather than that,” she says.

Prevent future pain

Since many dance forms involve repetitive knee bends, it’s important for dancers to consider PFPS before it becomes a problem. Consider adjusting your cross-training routine to incorporate some preventative measures. Clippinger recommends three simple exercises that target different PFPS culprits (see sidebar). You can also start doing these exercises without props.

Klippinger recommends that dancers touch the front of the thigh just above the kneecap as the quadriceps contract to become familiar with their anatomy. Make sure that both the inner and outer components of the quadriceps are contracting, as this will help the kneecap track properly when flexing. “It really takes concentration to start figuring out how to activate the inner parts and make them contract,” she said.

Terminal knee extension and ankle weight

1. Place a support, such as a foam roller or pillow, under your hamstrings. Make sure your knees are bent less than 30 degrees to keep compression low, says Clippinger.
2. Straighten your knees and palpate with your hands to measure even contraction of the inner and outer thigh muscles.
3. Hold for five seconds. Repeat 3 sets of 10 times.

Side leg raises with elastic bands

1. Place the TheraBand on your upper thigh and lie on your side.
2. Rotate your legs outward and lift your top leg against the force of the band.
3. Hold in the final position for four counts, then repeat 8-12 times, starting with one set and gradually increasing to three sets.
4. Consider doing this exercise with your back against a wall and focus on using deep outward rotation by pressing your little toes into the wall. This exercise helps build muscles that allow the knee to track properly in external rotation and strengthens the hip abductors, Klipinger says.

Hip rotation at elbow

1. Wrap the TheraBand around your thighs just above your knees, leaning back with your weight supported on your forearms.
2. Rotate your legs outward, focusing from your hips, not your knees.
3. When you straighten your knees, avoid hyperextension. Instead, focus on using the same muscles you palpated during the first exercise.
4. Hold in the final position for four counts, then repeat 8-12 times, starting with one set and gradually increasing to three sets.