Knee pain while exercising?


With the temperature heating up and daylight savings in full swing most people are shedding the extra layers of clothing and some are hoping to also shed a few extra kilograms.

Gym and bootcamp numbers are increasing and it looks as though everyone is now coming out of hibernation. Unfortunately, as a consequence of this we see more people present to the clinic with common complaints related to their new exercise regimes.

What is patellofemoral pain?

One of the most common presentations we see is patellofemoral pain, that is pain arising from the kneecap and its articulation with the femur or thigh bone.

It often presents with the gradual onset of pain and will commonly be aggravated by squatting and lunging motions along with stair-climbing and running, it often settles with rest however, can often cause a dull ache when sitting for extended periods which is known as movie goer’s sign.

What causes it?

We often see people present with an increased load, they have often commenced or increased squatting, lunging and running which can cause aggravation of the patellofemoral joint.

There are a multitude of factors that play varying roles including behavioural, biomechanical/anatomical, technique, muscle imbalances, weakness or restriction.

Here we will cover a general but thorough approach to what is worth looking at in the treatment of patellofemoral pain.


Alignment and control

This is about looking upstream and downstream, the patellofemoral joint does not like a rotary component which can be caused by poor lumbopelvic control (what the core/hip is doing) upstream or poor foot biomechanics (what the foot is up to) downstream.


How do the movements look unweighted, weighted and when fatigued?

Load management

There is usually a load related component so it is always worth looking at how much you are doing currently vs what you were doing previously and furthermore how to plan the load to ensure it improves. Gradual loading is the best loading (3).


How strong are the glutes and quad muscles as these 2 groups of muscles are shown to be very important when it comes to patellofemoral pain (1-3). Additionally, how strong are the calves, groin, core and hamstrings? If everything is stronger than even better! There is a significant reduction in injury risk with increased strength (4-5).

Range of motion

Are there restrictions elsewhere in the biomechanical chain causing the knees to compensate?

Is there a previous ROM limitation at the ankle due to a previous injury causing the knee to compensate? Is there limitations/tightness in the hamstring or calf? Is there significantly limited thoracic extension causing you to fall forward placing excess strain on the knees during squatting or overhead movements? Is the foot rolling outwards to make up for restricted ankle ROM (1-3)?

How best to approach it?

Unfortunately, patellofemoral pain is often a very niggly condition and a large number of people experience ongoing issues even with some form of treatment (6). As patellofemoral pain is such a multi-faceted condition it requires a very thorough approach to specifically address all the potential contributing components. It will take time but it is important to be consistent, thorough and methodical in the approach to get best results.

General areas to address:

  • Alignment and control

  • Lumbopelvic control

  • Foot mechanics

  • Technique

  • Load management

  • Strength

  • Range of motion


  1. Barton CJ, Lack S, Hemmings S, et al. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med 2015;49:923-934.

  2. Crossley KM, Callaghan MJ, Linschoten RV. Patellofemoral pain. Br J Sports Med 2016;50:247-250.


  4. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British journal of sports medicine. 2014 Jun;48(11):871-7. PubMed PMID: 24100287. Epub 2013/10/09. Eng.


  6. Thomas MJ, Wood L, Selfe J, Peat G. Anterior knee pain in younger adults as a precursor to subsequent patellofemoral osteoarthritis: a systematic review. BMC musculoskeletal disorders. 2010;11:201. PubMed PMID: 20828401. Pubmed Central PMCID: PMC2944218. Epub 2010/09/11. Eng.

How to manage hip and knee osteoarthritis - What's the latest?


Did you know that Australians living with Osteoarthritis is expected to rise from 2.2 million in 2015 to almost 3.1 million by 2030?

So what can you do about it?

The Royal Australian College of General Practitioners recently updated their guidelines for management of hip and knee osteoarthritis.

Little to our surprise, the interventions that come with strong recommendations based on available evidence for managing these conditions include EXERCISE and WEIGHT MANAGEMENT.

What is Osteoarthritis?

Osteoarthritis the most common form of chronic arthritis that is characterised by joint pain, stiffness and swelling, and mainly affects the hands, knees and hips.

Osteoarthritis frequently occurs in people aged over 55 years, however younger people can also be affected.

What are the risk factors?

Risk factors for OA include:

  • Joint injury

  • Being overweight or obese, and

  • Older age


How can you manage Osteoarthritis best? What does the evidence say?

Lifestyle, lifestyle, lifestyle. We are seeing a recurring pattern here. In short, regular exercise and weight management are the interventions that are strongly recommended for people living with osteoarthritis.

Regular exercise is strongly recommended as a key factor for relieving pain and improving function in people with knee and/or hip osteoarthritis. This includes muscle strengthening exercises as well as walking and Tai Chi.

Weight management is strongly recommended for people with knee and/or hip OA who are overweight or obese.


How can you get help to develop an exercise program for osteoarthritis?

An exercise program that is tailored specifically to you and your level of function is a key aspect of helping to manage osteoarthritis. It is not a once size fits all approach, particularly when it comes to proper programming for strength and cardiovascular endurance. This is where the help of a physiotherapist or exercise physiologist will help. 

The RACGP suggests the following;

Clinicians should prescribe an individualised exercise program, taking into account the person’s preference, capability, and the availability of resources and local facilities.

Realistic goals should be set. Dosage should be progressed with full consideration given to the frequency, duration and intensity of exercise sessions, number of sessions, and the period over which sessions should occur.

Attention should be paid to strategies to optimise adherence.

Referral to an exercise professional to assist with exercise prescription and provide supervision either in person or remotely may be appropriate for some people.

Exercise has many other health benefits that can assist in managing lifestyle diseases and optimising health. See post here.

What does it all mean?

In conclusion, what this means is that there is plenty that you can do in order to optimise your function and quality of life. Exercise, particularly strength training and weight management are strongly recommended in the management of osteoarthritis.

Getting advice from a physiotherapist or exercise physiologist will help in getting started on the path back to better health.



FLOW KNOWS - Syndesmosis injury - High ankle sprains

This week, Flow Knows dives into high ankle sprains or syndesmosis injuries.

There has been media coverage this week around Dylan Napa and his race against the clock to prove his fitness for Origin 2 on Sunday night.

The tibiofibular syndesmosis consists of the ligaments and interosseous membrane that maintain the joint at the bottom of the shin bone, above the ankle joint (high ankle).


The syndesmosis plays an important role in dynamic ankle function and is often injured in a planted, rotating foot/ankle. We tend to see this in contact sports like rugby league where the foot is planted as the player gets tackled.

As the knee goes over the foot, the tibia and fibula separate to accomodate the ankle joint. With intact ligaments and membrane this is controlled and limited. In the case of an injury to these ligaments, this separation can cause pain and dysfunction with ankle movements and weight-bearing.

When a suspected high ankle sprain presents we send you off for x-rays to determine if there is any widening of the distal tibiofibular joint and if referral to an orthopaedic surgeon is required.

If there is no widening, treatment consists of a strength, mobility and proprioception program to restore full function.

Severe injuries usually present with concomitant injuries like fractures and if there is a widening of the joint on weight-bearing x-rays, a surgical review is required. 



84% decrease in ACL re-injury risk using simple decision rules


A recent study outlines simple decision rules that may decrease re-injury risk by up to 84% after ACL reconstruction.

The main take-aways from the study were:

  1. Patients who returned to pivoting and cutting sports had a 4.32 times higher re-injury rate than those who did not

  2. Re-injury rate was significantly reduced by 51% for each month return to sport was delayed until 9-months after surgery

  3. Almost 40% of those who failed return to sport criteria suffered re-injuries versus 5% of those who passed

  4.  More symmetrical quads strength prior to return significantly reduced knee injury rate