Patella Femoral Syndrome and Squatting

Question:

I have a client who is very bull-legged and has pain when doing squats or leg presses. His patella does not track straight over his knee. The patella tracks towards the outside of his foot. He has very limited external rotation and abduction at the hip. Are there any suggestions you can give for stretches and exercises that may help?

Answer:

The first thing I want to address is the term bull-legged. I am assuming the term bull-legged is the same as bow-legged. This term is used when it looks as though the person has been riding a horse too long. With that said, we now need to qualify if the condition is functional or structural. If the problem is structural, it is pretty much out of a personal trainer’s hands. We can only deal with functional issues. Structural issues are ones that have been there since birth or have been for so long, the bones have actually changed shape. With any structural deficiency you should seek outside medical assistance and/or clearance. I will answer this question as though we have determined the issue to be functional. The easiest way to make a reasonable assumption is to ask the client if they ever remember not being like that and ask them to bring in a photo album of themselves through the years. If the condition doesn’t seem apparent through childhood and there was no traumatic incident that happened which brought about the change, it is a good bet the issues are functional and the personal trainer can truly help.

The patella that is tracking over the outside of the foot is called lateral tracking, or even patella femoral syndrome. It can lead to a condition called chondromalacia, which is a change in the surface under the patella. I would like you to reference a previous article written on chondromalacia, which will give you many of the exercises I would recommend for your client as well. It is in the Research Corner section and you can reference it by looking up key word chondromalacia. The reason he has limited external rotation at the hip is because he is always in excessive external rotation. In fact, I would guess he also has limited internal rotation. The priformis muscle, a primary external rotator of the hip, is probably very tight. Many times this occurs because it is trying to do the job for a weak gluteus medius and maximus. When the glutes are not functioning as they should, the excessive load will be transferred to the much smaller piriformis. The piriformis will try to take the load on but will start to fatigue quickly. Quite often it will contract fully to have the most amount of cross-bridges available to deal with the excessive load. This is one of the ways a muscle will protect itself from being damaged. These afore mentioned muscles work synergistically to externally rotate the hip and more functionally to stop excessive internal rotation of the femur when decelerating or slowing down knee flexion and hip flexion. When you have your client do a squat or a leg press, you are eccentrically loading the leg on the way down. Loading the leg in this manner is very challenging to the dysfunctional structure. Because the hip is being loaded improperly, it will pass on the excessive load to the knee. The system will overload the vastus medialis obliques or VMO, which can eventually lead to a stretched VMO and the inability to track the patella correctly. Far too often with this individual you will notice a fallen arch during functioning activities such as squatting. The fallen arch will also put a rotation on the knee and hip. It is often challenging to determine if the foot caused the hip and knee pain, or the hip caused the foot and knee pain. The best way to determine this is to ask the client where they started to experience pain first.

You also mentioned he had limited ROM in his hip abduction. This is due to the muscular imbalance between the adductors and abductors. We described this posture as someone who has been on a horse too long. When you are on a horse, you must squeeze with the adductors to stay upright, but the hips are still widened because of the width of the horse. If you are constantly in this position it can create an imbalance between the adductors and abductors. When the foot hits during the gait cycle there must be a good balance between the adductors and abductors or the femur will rotate towards the dominant muscle group. The best advice I can give you is to try to stretch the tight muscles and strengthen the weak ones. This is easier said than done. Try to roll (use foam roller) on the adductors, vastus lateralis and piriformis as often as you can. Remember these muscles might be quite tender so take it easy at first. After you have rolled on those muscles, try to re-create the perfect squat. Keep the knees tracking over the second and third toes, keep an arch in the foot, tighten the inner unit and don’t allow excessive lumbar curvature, etc. Don’t be surprised if your client is only able to go down a few inches with good form. That is normal. After rolling the tight muscles you will create what is known as a naive range of motion. That means that the muscles that have lengthened are not strong in that new range of motion. Avoid heavy movements and high- speed movements until the muscles get accustomed to the new range and path of motion you are attempting. It is a slow and tedious process, but I’m sure you will see results if you stick to it.