Knee Pain? Ignore it; Fix the Hip!

I have posted on this topic many, many times. Unfortunately, many still revert to antiquated rehabiltiation protocols. Thus, I feel compelled to keep talking about it.  If you or a client has knee pain focus on the hip, not the knee. There is so much data out there on linking decreased glute strength to knee pain. A weak or inhibited glute medius is unable to control femoral internal rotation and obligatory knee frontal plane motion.  These motions are a primary cause in knee pain – traumatic and acute. Today I discovered two, recently-published, systematic reviews to prove my point.

The first review examined 47 studies which looked at factors causing Patellofemoral Pain Syndromeknee_patella_intro01  (PFPS) (1). This review identified decreased muscle strength for hip abduction and hip external rotation as an important factor associated with the cause of PFPS. The pooled data also found increased Q-angle and sulcus angle to be factors – both of which have been linked to muscle imbalance.

The second systematic review was more specific by evaluating gluteal muscle activity – via EMG – and PFPS (2). The authors identified ten studies to be included in their review, with six of these studies considered to be high-quality and eight studies having a score of 8 or higher on the Downs and Black scale. The authors conclude there is moderate to strong evidence linking delayed or short Glute medius muscle activity to PFPS. The authors also state, “If gluteal muscle activation is delayed, frontal and transverse plane hip motion control may be impaired, leading to increased stress on the PFJ and subsequent symptoms associated with PFPS.”

Rehabilitation practitioners should note this when developing rehabilitation programs. Specifically targeting glute weakness and inhibition will limit hip internal rotation and obligatory knee frontal plane motion. Correcting faulty movement patterns will allow for optimal neuromuscular recruitment and joint kinematics, ultimately relieving or preventing pain.

If you are wondering which exercises will target the glute medius look at the study published in the recent JOSPT (3) and my recent blog titled “The Glute vs TFL Muscle Battle: Proper Exercise Selection to Correct Muscle Imbalance. The data represented in the JOSPT article demonstrate the bilateral bridge, unilateral bridge, side step, clam, squat and two quadruped exercises are best for activating the glute medius.

Are you ready to change your rehabilitation program?


  1. Lankhorst NE, Bierma-Zeinstra, SMA, and van Middelkoop, M. Factors associated with patellofemoral pain syndrome: a systematic review.  Br J Sports Med.  2013;47:193–206.
  2. Barton CJ, Lack, S, Malliaras, P, and Morrissey, D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013; 47:207–214.
  3. Selkowitz, DM, Beneck, GJ, and Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther. 2013; 43(2):54-64.

6 thoughts on “Knee Pain? Ignore it; Fix the Hip!

  1. Dan

    Hi Josh,

    Well put :-). Your post strikes a cord with me. If your able to offer any further advice to my predicament/problem it would be appreciated.

    Started with medial knee pain in November 2012. Diagnosed as an overuse road cycling injury. On examination it was recognised that my knee was quite severely internally rotated. I had never noticed but had felt mild hip pain in the past. My pedals and cleats wer adjusted to allow my foot to kick out and my knee to track straighter. The pain didn’t dissipate and my Dr sent me for various mri’s of the knee and hip. They didn’t see any major problems but decided to do a knee arthroscopic focusing on the medial plica. Surgeon said knee looked healthy. Knee as you have probably guessed is no better post op, in fact it’s probably worse due to tightness (10 weeks post op). I am now thinks pain is purely due to internal hip rotation. Could internal hip rotation cause my internally rotated knee and medial knee pain? Is it possible to correct this internal rotation at the hip and knee?

    I really hope you can offer some advice.

    Best Regards from a very frustrated
    Dan (UK)

      1. Dan

        Hi Josh,

        Thank you for your reply. I obviously hope it’s something that can be corrected :-/.

        I have had x-rays of the hip and I’m told nothing looked abnormal. Can you confirm if x-rays would clearly show congenital femoral retroversion?


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