Understanding the Biomechanical Anomalies Associated with Anterior Knee Pain; What is the Solution?

As a podiatrist, Anterior Knee Pain is one of those common presentations I see in clinic, its prevalence can affect children, young adults, athletes and geriatrics. The symptoms associated with Anterior Knee pain may cause a dull, nagging ache around the kneecap — especially when walking upstairs, sitting for too long, or squatting. Despite how common it is, the root causes often go deeper than just “bad knees.”Let’s explore what’s really happening biomechanically (the science of human movement) when knee pain starts — and more importantly, what you can do about it and how we can assist at Hip to Sole Podiatry.

The Hidden Biomechanics Behind Knee Pain

Your knee doesn’t operate in isolation. It’s part of a biomechanical chain involving your hips, ankles, and feet — and how well (or poorly) those parts work together often determines whether or not pain arises.

Poor Patellar Tracking

One major contributor to anterior knee pain is patellar maltracking, where the kneecap moves abnormally, often laterally. This happens when the vastus medialis obliquus (VMO), the inner part of the quadriceps, is weak compared to the lateral muscles (Witvrouw et al., 2005). This imbalance pulls the patella off-center, increasing stress on the joint.

Weak Hips, Big Impact

Hip weakness — particularly in the gluteus medius and maximus — leads to poor control of femoral rotation during dynamic movement. This can result in increased knee valgus (inward collapse of the knee), a known contributor to PFPS (Powers, 2010). In fact, studies have shown that hip strengthening can significantly reduce symptoms in individuals with PFPS (Boling et al., 2009).

The Role of the Foot and Ankle

Overpronation (excessive inward rolling of the foot) and restricted ankle dorsiflexion can disrupt the entire lower limb alignment. These changes lead to compensatory mechanics at the knee and can increase the risk of anterior knee pain (Barton et al., 2010). Addressing foot posture and ankle mobility is essential, particularly for runners and active individuals.

Tight Lateral Structures

Tightness in the iliotibial band (ITB) and lateral retinaculum can also contribute to patellar malalignment by exerting an outward pull on the kneecap (Fredericson & Yoon, 2006). Coupled with quadriceps dominance and weak posterior chain muscles, this tension further compounds abnormal joint loading.

✅ The Solution: Fix the Chain, Not Just the Pain

The best approach to anterior knee pain is to address the entire kinetic chain — not just the knee itself. Here’s what the evidence suggests:

• Strengthen Weak Links

Targeting the hip abductors, external rotators, and the VMO is critical. Exercises like bridges, clamshells, and single-leg squats, hip thrusts help activate and strengthen these areas. Research shows that hip-focused strengthening produces better outcomes than quadriceps-focused alone (Ferber et al., 2011).

• Stretch the Tight Spots

Stretching the IT band, hip flexors, calves, and hamstrings can help reduce excessive lateral tension on the patella. Foam rolling and mobility work are commonly used to improve flexibility and reduce discomfort.

• Retrain Movement Patterns

Poor biomechanics during squatting, running, or jumping often need to be re-educated through neuromuscular retraining. Functional movement training with proper feedback has been shown to improve patellar tracking and reduce pain levels (Earl & Hoch, 2011).

• Don’t Forget the Feet

In individuals with overpronation or foot alignment issues, orthotics may be helpful. A systematic review by Collins et al. (2008) found that foot orthoses provided significant short-term pain relief in people with PFPS.

The Bottom Line

At Hip to Sole Podiatry, we recognise that the source of the issue may be different for each person, a Biomechanical Assessment can help unveil what the root cause to your biomechanical issues are. Anterior knee pain doesn’t have to be your new normal. With the right blend of strength training, mobility work, movement correction and guidance with a podiatrist, you can restore balance to your biomechanics and get back to moving pain-free. Remember: the knee is often just the messenger — the real problem might be coming from somewhere else in the chain.

References

• Barton, C. J., Levinger, P., Crossley, K. M., Webster, K. E., & Menz, H. B. (2010). The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome. Clinical Biomechanics, 25(4), 378–383. https://doi.org/10.1016/j.clinbiomech.2009.12.003

• Boling, M., Padua, D., Marshall, S., Guskiewicz, K., Pyne, S., & Beutler, A. (2009). A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: The Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort. American Journal of Sports Medicine, 37(11), 2108–2116. https://doi.org/10.1177/0363546509337934

• Collins, N., Crossley, K., Beller, E., Darnell, R., McPoil, T., & Vicenzino, B. (2008). Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: Randomised clinical trial. BMJ, 337, a1735. https://doi.org/10.1136/bmj.a1735

• Earl, J. E., & Hoch, A. Z. (2011). A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. American Journal of Sports Medicine, 39(1), 154–163. https://doi.org/10.1177/0363546510379967

• Ferber, R., Bolgla, L. A., Earl-Boehm, J. E., Emery, C. A., & Hamstra-Wright, K. L. (2011). Strengthening of the hip and core versus knee-focused strengthening for the treatment of patellofemoral pain: A multicenter randomized controlled trial. Journal of Athletic Training, 46(6), 573–580. https://doi.org/10.4085/1062-6050-46.6.573

• Fredericson, M., & Yoon, K. (2006). Physical examination and patellofemoral pain syndrome. American Journal of Physical Medicine & Rehabilitation, 85(3), 234–243. https://doi.org/10.1097/01.phm.0000200391.13261.1a

• Powers, C. M. (2010). The influence of abnormal hip mechanics on knee injury: A biomechanical perspective. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 42–51. https://doi.org/10.2519/jospt.2010.3337

• Witvrouw, E., Callaghan, M. J., Stefanik, J. J., Noehren, B., Bazett-Jones, D. M., Willson, J. D., ... & Crossley, K. M. (2014). Patellofemoral pain: Consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013. British Journal of Sports Medicine, 48(6), 411–414. https://doi.org/10.1136/bjsports-2014-093450