Quadriceps and knee pain: effective exercises

The quadriceps, located at the front of the thigh, help extend the knee and control the movements of the patella. The patella is the small bone at the front of the knee. Strengthening the quadriceps can reduce pain around or behind this bone, known as patellofemoral pain. A program that combines strengthening the quadriceps and the hip muscles is better supported by research than quadriceps strengthening alone for reducing pain. ^{1, 2, 3}

Why is the quadriceps essential for knee health?

Le quadriceps aide à tendre le genou et à contrôler la façon dont il se plie pendant la marche, les escaliers et les accroupissements. Sa contraction transmet aussi des forces entre la rotule et l’os de la cuisse, appelé fémur. Un muscle fort ne supprime donc pas les forces sur l’articulation⁴. Le modèle proposé par Dye en 2005 décrit plutôt une douleur liée à une sollicitation dépassant ce que les tissus peuvent supporter. Cet avis d’expert propose une explication de la douleur, sans établir une cause unique pour toutes les personnes.⁵

Increased strain on the knee can contribute to pain if it exceeds what the person can tolerate. This explanation does not cover all possible causes. ^{1, 5}

People with patellofemoral pain often have weakness in the quadriceps or hip muscles. This can guide the choice of exercises, though it does not prove that weakness alone explains their pain. The review on the quadriceps notes reduced strength in several types of contraction, without establishing a single percentage that applies to everyone. ^{1, 6}

The vicious cycle of weakness

Pain may cause you to avoid certain activities. A prolonged decrease in activity can then lead to a loss of muscle strength. In one study, 24 healthy young men had one leg immobilized in a cast. Quadriceps strength decreased by an average of 9% in the group that was immobilized for 5 days and by 23% in the group that was immobilized for 14 days. ⁷ These results pertain to complete immobilization, not simply a reduction in your activities. Gradually regaining strength and range of motion is part of the treatment.

After a knee injury or surgery, it may become difficult to fully contract the quadriceps. Signals from the joint then alter the muscle’s control. This phenomenon is called arthrogenic muscle inhibition. ⁸ This difficulty can slow down your return to normal activities. An evaluation helps tailor the exercises to your ability to contract the muscle.

Should we specifically target the vastus medialis obliquus?

Le renforcement devrait cibler l’ensemble du quadriceps et les muscles de la hanche, sans chercher à isoler le vaste médial oblique. Cette portion du quadriceps se trouve du côté intérieur de la cuisse, près de la rotule. Une revue ne montre pas qu’un changement de position de la jambe active systématiquement davantage cette portion que le vaste latéral, situé du côté extérieur de la cuisse. Les études ont toutefois des limites⁹. La rétroaction musculaire utilise des capteurs pour vous montrer l’activité du muscle pendant l’exercice. Certains résultats à court terme sont favorables : une revue de 2024 rapporte des bénéfices possibles sur la douleur, les activités, la force ou l’activation musculaire. Les programmes et les comparaisons varient, et plusieurs combinent différents soins. Un essai de 26 personnes observe une augmentation de l’activité du vaste médial par rapport au vaste latéral après huit semaines, sans démontrer un renforcement isolé du vaste médial oblique.^{10, 11}

Le vaste médial oblique contribue au contrôle de la rotule (notre article sur la biomécanique de la rotule), notamment en s’opposant à une traction vers l’extérieur. Dans certaines tâches, comme les escaliers, un léger retard d’activation du vaste médial par rapport au vaste latéral est associé à la douleur fémoro-patellaire.⁶ Cette association ne prouve pas que le retard déplace la rotule puis cause la douleur chez chaque personne.

The 2019 guidelines do not recommend knee braces, such as splints, sleeves, or straps, for treating patellofemoral pain. ^{1, 12}

The 2019 guidelines do not recommend adding a device that monitors the electrical activity of the vastus medialis to quadriceps exercises. This recommendation predates the 2024 review described above. The primary goal remains strengthening and returning to activities. ¹

What exercises effectively strengthen the quadriceps?

Static contractions, squats, knee extensions, and stepping down from a step all work the quadriceps. The choice depends on what your knee can handle. A static contraction can serve as a starting point; it is not a required step before any other exercise. The examples below can be combined and adapted based on your symptoms and activities.

Exercise is the primary treatment for patellofemoral pain: it is the central component of management and should be prioritized over other approaches. ^{1, 12}

Strengthening the hip muscles complements quadriceps training. It may even be advisable to focus on hip training at the beginning of the treatment plan. ^{1, 2}

Contractions without movement

Static contractions, also known as isometric contractions, work the quadriceps while keeping the knee in a fixed position. They can be part of a strength-training program. Your response will guide which ones to choose; immediate relief is not guaranteed. The guidelines below are examples to be adapted in consultation with your physical therapist.

Contraction de la cuisse, jambe allongée : assis ou couché, le dos soutenu, poussez doucement l’arrière du genou vers le lit pour contracter la cuisse. Maintenez de 5 à 10 secondes, puis relâchez. Un premier repère est de 5 à 10 répétitions, en faisant moins au besoin¹³.

Position assise contre le mur : appuyez le dos au mur, les pieds avancés. Descendez à une hauteur confortable et gardez la position, puis remontez. Commencez moins bas si le genou est sensible. Un protocole étudié propose 30 secondes, puis de 45 à 60 secondes à un stade plus avancé, selon la capacité de la personne¹⁴.

Exercises Involving Movement

Light squats: Stand up straight, bend your knees slightly, then slowly stand back up. Keep your knees pointing in the same direction as your feet. Increase the depth based on your comfort level. A workout routine might include three sets of 10 to 15 repetitions, but you can start with fewer. Sets are groups of repetitions separated by a rest period.

Knee extension with a resistance band: Securely attach a resistance band in front of you and loop it behind your knee. From a slightly bent position, straighten your knee against the resistance, then slowly return to the starting position. Your physical therapist can adjust the resistance and range of motion.

Exercises for Daily Activities

Stepping Down from a Step: Stand on a low, stable step; bend the supporting knee to slowly lower the other heel toward the floor. Keep the supporting knee pointing toward your toes. Hold onto the handrail if needed. Start with, for example, 5 to 10 repetitions. Then increase the height or slow down the descent depending on your comfort level. This exercise helps you develop control over your movements on stairs.

Thigh press: On the machine, push the platform with your feet to straighten your knees, then return slowly. Start with a light weight and a comfortable range of motion. A deeply bent knee increases the forces between the kneecap and the thigh. The physical therapist may reduce the range of motion or the weight if the exercise causes discomfort in the knee. Gradually increase the resistance as the movement becomes easier.

How to Adjust Exercises Based on Pain

Une douleur légère et tolérable pendant l’exercice peut être acceptable si elle diminue rapidement après la séance. Votre genou ne devrait pas être plus douloureux le lendemain matin. Réduisez les répétitions, la résistance ou la profondeur si la douleur augmente nettement ou dure davantage. Arrêtez l’exercice et demandez conseil s’il provoque une douleur nouvelle ou une aggravation persistante¹⁵.

Fréquence : trois séances de renforcement par semaine, avec un jour de repos entre les séances, constituent un exemple de départ. La fréquence et le nombre d’exercices varient selon leur difficulté et votre réaction. Les contractions légères peuvent être réparties en petites périodes; tous les exercices n’ont pas à être faits chaque jour¹⁶.

Progress takes several weeks, sometimes several months. Royal Berkshire advises allowing three to six months, with further improvement possible beyond that. This timeframe does not predict your individual outcome. If your pain still does not improve, consult a physical therapist for a personalized evaluation.

When should you seek medical advice for a knee problem?

Severe pain, a locked knee, or an inability to bear weight require urgent medical attention. These symptoms should not be attributed simply to weak quadriceps. Also seek urgent medical attention in any of the following situations:

• You can't move your knee.
• The knee is very swollen or has changed shape.
• The knee gives way or makes a painful popping sound.
• A high fever, chills, or a sensation of feeling hot or cold may accompany a red or warm knee.

Un claquement sans douleur est généralement normal. Si la douleur ne s’améliore pas après quelques semaines, consultez aussi, même sans signe urgent¹⁷.

To learn more about therapeutic approaches for anterior knee pain, consult our complete guide on anterior knee pain.

References

1. Willy RW, Hoglund LT, Barton CJ, Bolgla LA, Scalzitti DA, Logerstedt DS, et al. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95.↩ Back to text: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th mentions
2. Lack S, Barton C, Sohan O, Crossley K, Morrissey D. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med. 2015;49(21):1365-76.↩ Back to text: 1st, 2nd mentions
3. Rogan S, Haehni M, Luijckx E, Dealer J, Reuteler S, Taeymans J. Effects of Hip Abductor Muscles Exercises on Pain and Function in Patients With Patellofemoral Pain: A Systematic Review and Meta-Analysis. J Strength Cond Res. 2019;33(11):3174-3187.↩ Back to text
4. Hart HF, Patterson BE, Crossley KM, Culvenor AG, Khan MCM, King MG, et al. May the force be with you: understanding how patellofemoral joint reaction force compares across different activities and physical interventions-a systematic review and meta-analysis. Br J Sports Med. 2022;56(9):521-530.↩ Back to text
5. Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clin Orthop Relat Res. 2005(436):100-10.↩ Back to text: 1st, 2nd mentions
6. Alsaleh SA, Murphy NA, Miller SC, Morrissey D, Lack SD. Local neuromuscular characteristics associated with patellofemoral pain: A systematic review and meta-analysis. Clin Biomech (Bristol). 2021;90:105509.↩ Back to text: 1st, 2nd mentions
7. Wall BT, Dirks ML, Snijders T, Senden JM, Dolmans J, van Loon LJ. Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiol (Oxf). 2014;210(3):600-11.↩ Back to text
8. Rice DA, McNair PJ. Quadriceps arthrogenic muscle inhibition: neural mechanisms and treatment perspectives. Semin Arthritis Rheum. 2010;40(3):250-66.↩ Back to text
9. Smith TO, Bowyer D, Dixon J, Stephenson R, Chester R, Donell ST. Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. Physiother Theory Pract. 2009;25(2):69-98.↩ Back to text
10. Ferlito R, De Salvo S, Managò G, Ilardo M, Sapienza M, Caldaci A, et al. The Role of Biofeedback in Patellofemoral Pain Conservative Treatment: A Systematic Review. J Funct Morphol Kinesiol. 2024;9(1).↩ Back to text
11. Ng GY, Zhang AQ, Li CK. Biofeedback exercise improved the EMG activity ratio of the medial and lateral vasti muscles in subjects with patellofemoral pain syndrome. J Electromyogr Kinesiol. 2008;18(1):128-33.↩ Back to text
12. Wallis JA, Roddy L, Bottrell J, Parslow S, Taylor NF. A Systematic Review of Clinical Practice Guidelines for Physical Therapist Management of Patellofemoral Pain. Phys Ther. 2021;101(3).↩ Back to text: 1st, 2nd mentions
13. Royal Berkshire NHS Foundation Trust. Anterior knee pain (patellofemoral dysfunction), feuillet pour les patients, mars 2026.↩ Back to text
14. Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. J Athl Train. 2015;50(4):366-77.↩ Back to text
15. NHS inform. Exercises for patellofemoral knee pain. NHS Scotland.↩ Back to text
16. Leeds Community Healthcare NHS Trust. Anterior knee pain or patello-femoral pain (PFP).↩ Back to text
17. NHS. Knee pain. National Health Service (Royaume-Uni).↩ Back to text

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