Knee Pain: Outer Edge of Knee Cap

Hey everyone,

My knee started bothering me during a DE squat day(doing box squats), the weight wasnt an issue(the pain was there with no weight, just bar). When I reached the bottom of the lift, the pain was around the outside of my left knee’s, knee cap.

From some investigation. I’ve found a possible problem area…

Im wondering is this is the likely problem? What should I do to recover? Is it as simple as laying off the knee till it feels better. As it stands my job dictates that Im on my feet a lot, as a result it tends to be slightly sore.

thx for any help

this is like dela vu…i posted about a similar problem nearly 2 weeks ago. With me, the problem was a tight/spasmed vastus lateralis. I wasn’t doing box squats, but was doing speed squats. The tight VL was putting excessive tension on the lateral aspect of the kneecap, causing is top track laterally. This may or may not be your problem. You could check the tone of your quads. Check to see if any muscles are excessively tight. If so, deep tissue work or ART may help. Also, ice the hell out of your knee.

thx for the help

I started hearing a cracking noise about a few years back. This noise kept on getting worse and worse throughout the years, finally after losing a lot of weight and doing cardio twice a day, my knee was just to painful to do lunge. I went to many different physiotherapists and they all sucked until I met a woman who was the physiotherapist for the Canadian Olympic rugby team. She explained to me that the reason I was hearing that noise every time I would flex my knees past parallel was that my patella (knee) was grinding against my knee cap and wasn’t going in its proper alignment. She said that my legs were really tight on both sides and especially on my IT-Band (side of leg). She said that my inner muscle/s of my quad shut down to protect my legs from getting worse by the contracting of my outside quads. So when I contracted my knee my kneecap would veer off to the outside of my leg.

The recipe for recovery was to quit any lifting immediately and work on stretching for a couple of weeks. The stretches I did were the figure 4 stretch were your lying on your back and with one foot against the wall at a 90 degree angle and the other foot crossed below your knee towards your waist and the other stretch was the I-band stretch with you placing one foot in front of the other with both feet about shoulder width apart and most of the weight on the back leg with some on the front for balance and then you bend towards the back leg side. She would then have me come in throughout the week and do one legged squats with a biofeedback machine so that my brain could relearn how to use my muscle properly, afterwards she would have me sit on the doctors bed and partially contract my leg (each leg one at a time) to full extension while do electro stim. This is how my body learned how to restart the inside muscles of my quad.

Also do stretching for a couple of weeks, then continue stretching and start one-leg squatting to a comfortable degree, then couple of weeks later do full squats, then slowly add weight (i.e. if your max is 335lbs then start by doing the bar at 10-30 reps and then add 10 pounds every week till about 4 months, then you can do your regular lifting but start out on the safe side. Always do stretching throughout the rehab process. Stretch for 1 minute on and 1 minute of for a total of 3 times per day. Also use anti-flam cream on your knee after each weigthlifting session or whenever your knee gets irritated and if it does get irritated the stop doing the thing that irritated it.

These are just general guidelines, know the root cause of your injury first before rehabing it; otherwise you will be wasting your time!

I could not to do a lunge in January, now I’m squatting 405lbs, lunging 180lbs with dumbells, feel no pain while doing the exercises and rarely feel pain at any othertime.

Your knee may have sublaxed or slipped out of it’s natural groove for a split second which would cause massive inflammation for a week so any time off your feet along with icing would be optimal as well as stretching!


Should you prescribe the squat as a rehabilitation exercise? Here’s a review of the evidence
The squat is a well-known exercise for the knee and hip muscles and is commonly used in rehab programmes.

The advantage of the squat is that it is a closed-chain exercise where ankle, knee and hip joints must be co-ordinated, developing a functional movement pattern as well as training the muscles.
The squat can be performed in various ways, in terms of weight with or without a barbell, in terms of knee angle with the degree of knee flexion, and in terms of foot position with wide or narrow stance. This variation of loads and in exercise technique has an impact on the resultant knee joint forces and knee muscle activity. In turn this affects the suitability of the squat as a rehabilitation exercise. For example, very deep squats involve high compression forces making them unsuitable for patients suffering with knee injuries.
In a comprehensive review of the available research of the biomechanics of squat, (Rafael Escamilla (2001) Medicine & Science in Sports & Exercise, 33(1), 127-141), Escamilla provides a complete picture of the forces and muscle activity involved in the variations of the squat exercise. This is very helpful information for practitioners and trainers to make informed decisions about prescribing the squat exercise.

The tibiofemoral joint
A range of studies have calculated the shear forces acting on the tibiofemoral joint. These are the forces which draw the tibia forwards or backwards relative to the femur. A posterior shear force draws the tibia back, placing strain upon the posterior cruciate ligament (PCL) and an anterior shear force draws the tibia forward, placing strain upon the anterior cruciate ligament (ACL).
The studies find that there is a moderate load placed on the PCL during the squat, which increases as the knee flexes. The PCL force occurs after 600 of knee flexion - when the quadriceps force exerts a posterior force on the joint - with a magnitude in the range of 1000-2000 N. The maximum load of the PCL has been estimated at 4000 N, and so the squat exercise is perfectly safe for athletes with a healthy PCL. Those recovering from PCL injury should restrict the range of movement to no greater than 600 of knee flexion, as this is when PCL loading begins.
Contrary to the PCL, ACL forces were generated between 0 - 600 of knee flexion - when the quadriceps force exerts an anterior force on the joint. However the ACL loads are found to be low, at a peak of 500 N. Considering that the maximum load of the ACL is around 2000 N, it would seem squats involve little strain on the ACL and should be safe for ACL patients to include in their programmes. By increasing the forward lean of the trunk during the squat, ACL stress can be reduced to zero due to the increased hamstring activity providing extra posterior force on the joint. However, by increasing the forward movement of the knees the shear forces can increase and so rehabilitation patients should avoid this position by keeping the knees behind the toes.
The exercise speed can also affect shear forces. One study showed that a fast cadence squat (one second ascent and one second descent) produced up to 30% greater shear forces than slower cadence squats (two seconds each phase). Therefore slow and controlled technique will safeguard the cruciate ligaments.
The studies also calculate the compression forces in the tibiofemeral joint. This is the load due to the articulating surfaces of the tibia and femur. These compressive forces calculations range from 500 - 8000 N, where compression increases with the amount of weight lifted during the squat. There is no data concerning the maximum compression force that is safe for the joint, but one can assume that if very high loads ( > 7000 N ) are produced on a regular basis then miniscus and cartilage injury risks will increase.
Interestingly, increases in weight lifted do not effect the ACL or PCL forces in the same way as compression forces. One study involved lifters squatting 250kg, and although the compression and quadriceps muscle forces were very high (8000 N) the shear forces for ACL and PCL were in the normal range described above. This data suggests that a greater compression force may be important for the stability of the joint, helping to control shear forces.
The width of stance during the squat was also shown to increase compression forces, with wider stance increasing compression force by 15%. Stance width had no effects on shear forces, but shear forces are greater during the ascent phase of the squat exercise.
One important finding on a practical level is that as fatigue increases so do the shear and compression forces in the tibiofemoral joint. Most biomechanical studies will analyse a few repetitions; however, in reality patients and athletes will complete a few sets of a number of repetitions, e.g., 4 x 8. A study involving 50 repetitions of the squat showed that shear and compression forces increased from 25-85% from the first to last repetitions. This suggests that if your clients complete a number of sets of the squat, the joint stress may be much greater towards the end. This is why a cautious and progressive approach to the exercise prescription is important.

Patellofemoral compression force
Patellafemoral compression force is caused by the contact between the underside of the patella and its articulation with the femur. Calculations of the patellofemoral compression forces during the barbell squat with a weight of around 70% of maximum show that the joint force is 4-7 times bodyweight (about 4000 - 5000 N). These are generally greater loads than many patients will lift in the initial stages of a rehab programme, and so patients are unlikely to load the joint as much in a rehab context until the injury is healed and strength is regained.
The peak compression force occurs at the greatest knee flexion angles, generally around 900 and beyond. Patellofemoral patients (eg chrondomalacia patella) need to perform squats in the 0-500 range as the loads are moderate in this range.
The compression force increases with stance width. A study showed that the wide-stance squat increased patellofemoral compression force by 15% during the descent. Additionally, if the squat is performed in the low bar position, with the barbell held below the acromium, then greater trunk and hip flexion occurs in the movement and the patellofemoral forces are reduced. Patellofemoral patients should use a narrow-stance low-bar technique to minimise patellofemoral compression.

Muscle activity
All the knee muscles - quadriceps, hamstrings and gastrocnemius - are involved in the squat to a greater or lesser extent. The quadriceps are the prime movers, particularly the vasti muscles, which show significantly greater activity than the rectus femoris. The peak quadriceps activity occurs at 80-900, with no further increases with greater knee flexion. This supports the idea that the half squat (to 900 of knee flexion) is the preferred technique as no further quadriceps activity will result from performing a full squat movement.
Hamstring activity is greatest during the ascent phase of the movement and is strongly related to weight lifted. During the bodyweight squat, hamstring activity is minimal and not until loads of around 12 RM are lifted do the hamstrings show significant activity, presumably to enhance
knee stability. Gastrocnemius activity is moderate during the squat.

Summary table
ACL stress
Low stress. Heavy weights are safe. Slow and non-fatigued is best. Forward lean, low bar technique is best.

PCL stress
Moderate stress. Limit to 600 flexion. Slow and non-fatigued is best.

Tibiofemoral compression stress
Stress high with high weights and deep flexion. Very heavy & deep lifting should be limited. Narrow stance is best.

Patellofemoral compression stress
Stress high with increased knee flexion. Limit to 500 flexion and avoid heavy weights. Forward lean, low bar technique is best. Narrow stance is best.

Muscle activity
Quads activity increases with knee flexion, peaking at 900 flexion.

Increased weight increases quads activity Hamstrings require heavy weights for significant activity. Half (900) squats are best.

Hi - I’ve been a structural integration bodyworker and stretching coach - to relengthen fascia systemically and reorganize the body and its muscle groups for 22 years. I agree with the person who said the Illiotibial tendon fascial band on the outside of the thigh is tight and then pulls at its connection on the outside of the knee area. Let me add some info.

This tendon is the extention of the gluteus maximus on the buttocks and the tensor fascia lata muscle on the front of the pelvis. So THEY need to be significantly lengthened and loosened so the tendon band will more easily lengthen and will actually go farther in length when things are not holding it tight from the top end.

Further, the gluteus medius and minimus muscles going from the top of the thigh bone (femur) to the crest of the pelvic bone (illium) also need lengthening. Then in the back of the thigh are the hamstrings, and the inner thigh the adductors, both of which hold each other tight and the hamstrings affect the tendon band on the outside of the thigh, and vice versa. Further, the lower leg affects the thigh all around, and even the feet are involved. Up above, the abdominals and psoas, and on the inside of the pelvis the illiacus, all pull tightly on the legs.

So it pays to do a lot of systemic and interconnected structural stretching.

You can read a bunch of free articles on my website

Right side home page menu links:

Just below the testimonials list (testimonials - especially from the athletes -are helpful in themselves for info and encouragement to get worked on and to stretch a lot) are three articles on sports medicine, performance and a very good one on the fascial-muscle anatomy and tightness called fixing accumulated shortness. On the Free Articles page (link is just above the testimonials) is an article called stretching tips and one about improving yoga, and at the bottom of the Free Articles menu page list are articles about how the fascial lengthening of the whole body including the legs helps both massage (and is very different from massage) and chiropractic (a lot). There’s also a link to a Fascial Structural Stretching approach near the top of the home page menu.

The important thing, whether doing stretching alone, or mixing it with deep massage (which often helps by loosening the muscle hardness to make the fascial pulling stretching work easier) or getting the structural integration bodywork from a practitioner (see links page for scchools who have geographic lists) is to do it in whole muscle groups areas.

Even the head and arms affect the lower back, for instance.

Just wanted to thank you guys for extremely detailed posts,

thank you

I had a similar problem about a year ago. I’m not 100% sure where you are experiencing the problem though. Mine wasn’t actually on the knee cap, but just outside (on my left knee also). The problem was I had a very tight IT band. The problem is it’s very difficult to loosen as it isn’t contractile tissue, meaning it can’t really be stretched. However massage seemed to help me. I was told sprinters are prone to tight IT bands, so every now and then I try to get a massage done on them to keep them looser. Not sure if this is of any help or even related to you, thought I’d try though!!! :smiley:

How do you massage it then?

How to lengthen the IT Band?

Start by loosening and lengthening the pelvic muscles and hamstrings and calves, also the adductors, and those leg releases will help the pelvic muscles to loosen all around. Do twist stretching of thighs and pelvis. Then you can do a pull from over your head pulling one arm with another and bending in a bow, pushing out first the shoulder, then rest, then push out the ribs, then rest, then push out the waist and pelvis, then do the outer thigh. But you have to loosen around the pelvic muscles because they control that tendon.

I do the IT band lengthening regularly for clients by lengthening the fascia with hands on and we can often do it with a stretching relengthening of the fascial element of the muscles that govern the movement of this long tendon, and with the fascia that covers that tendon, and into the muscles interconnecting it with the rest of the leg in the whole bodysuit of the fascia. You CAN spread the fascial element covering the tendon if you also spread the fascia of the pelvic muscles involved and also lengthen the fascia of the hamstrings and adductors, and some of the lower leg muscle fascia, too.

How to massage it? You can massage, then stretch, or try the connective tissue manipulation spreading techbnique.

Have the person, or you, yourself, push deep into the muscles in the buttocks and front groin of the pelvis on top of the quads on the front of the thigh. Dig into the muscles so you can push your fingers thru the tissue instead of sliding over it. Get the muscle putty, which is the fascia interspersed on a microscopic level with the muscle fibers. The whole thing can widen, soften and lengthen. Then do the smooshing down the outside of the the thigh and under the legs in the hamstrings. That part, the hamstrings is often more difficult to achieve. Have a hot bath or hot shower on it, or a hot pack to soften up the muscle-nerve-blood tightness so you can just work on the putty spreading lement. You may also do massaging on the areas first and then try the spreading motion. Below, I give more principles and some more muscles to work.

It can lengthen, and people feel taller on the one side of the body that is done first.

Further if you lengthen the outer lower leg, including the peroneals, you’ll get better results in the thigh and pelvis. It’s a long interconnected fascial network of one big piece. You want it ALL to give way in a spreading way when you pull area by area with stretching and then smoosh it with your fingers or knuckles or get someone else’s arm and hands to do it. Be careful on the IT band itself though - do NOT push harshly into it, just spread small layer at a time lengthwise down the tendon or across it. We aren’t trying to force anything to “let go.” Instread, we are simply trying to spread shortened putty back longer agin. The skills involved are to be able to do the special kind of manipulation and to know where to work and in what order.

Here we have a two-joint muscle tendon mechanism. The gluteals and tensor muscles tighten and pull the tendon across the hip and knee joints to stabilize the leg, whenever we stand on one leg, including when we are walking and running.

Please see my long explanation just above in another forum entry As I said, we thus have to lengthen the gluteals, including the medius and minimus on the outside of the pelvis from the greater trochanter to the illiac bone crest. They, and the two other muscles are on the top end of the trochanter and this tendon you want to loosen is on the bottom end.

You’ll also get better results if you also lengthen the abdominals, the long muscles of the back, and the psoas and adductors. If you find someone who can spread the fascia of the illiacus inside your pelvic illium bone crests, that’ll help the IT band and all the leg muscles even more. See entry above for more info.

Consult an anatomy book so you can see what is connected to what, and simply relengthen or get massaged out, what you have bunched up with your running or weight workouts. Just spread in the opposite direction. Ida P. Rolf’s big “Rolfing” book has a good sketch, and it explains about fascia. So do the articles on my website . See Fixing Accumulated Shortness article sections 2 and 3 to have a detailed explanation of fascia-muscle anatomy. The above entry also indicates other helpful, informative articles to read. Rolf was a PhD physiologist-biochemist and a pioneer who took the fascial release method and extended it into a structural architectural bigger understanding. There is a good book by a couple of senior level Rolfers, called The Endless Web, describing the body’'s fascial network, with a lot of good illustrations of muscle bone networks as well.

You can look up the Rolf Institute on the web and get the books from their bookstore, and also maybe Amazon.

If your massage therapist likes to help by doing PNF stretching, which has the nerve signals turn off and the muscle fiber reflexes release, to get a onger stretch. Then relengthening the fascial envelopes will make the PNF stretch help the nerve-muscle release to give you a better stretch that way, too. I’ve even experienced foot reflexology to cause a big release of the whole body tightness when the fascia of the whole body had already been lengthening and some activity, reflexes or digestive imbalances had been holding the muscle fiber elements short.

Thanks for sharing that great story. I think the current prejudice against static stretching is probably going too far. THe more I stretch the better I feel.

and all around the world they tell you “don’t stretch, don’t stretch!”
i’ve seen your statement “the more i stretch the better i feel” in a discussion you had with Flash as well and i absolutely AGREE!
just to confirm it; don’t understand this anti-stretching obsession…

Thanks! Ian King has talked about how important stretching is, and how those who don’t are unning injury risk, long term.