Ask five clinicians what to do about pain at the front of your kneecap and you will hear two camps: strengthen the quad, or strengthen the hip. A trial of 200 people settled the argument in a way neither camp expected.
The study, briefly
The paper is Hansen R, Brushøj C, Rathleff MS, Magnusson SP, Henriksen M. “Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial,” British Journal of Sports Medicine 2023;57(20):1287 to 1294 (doi:10.1136/bjsports-2022-106197, PMID 37137673, trial registration NCT03069547).
This was a single-centre, assessor-blinded randomised equivalence trial. That design detail matters: instead of asking “is one better,” the researchers asked “are these two close enough to call the same,” and they defined that in advance as a difference of 8 points or less on the Anterior Knee Pain Scale. Setting the bar before you look at the data is what keeps a null result honest.
They screened 288 people and randomised 200, with 100 to a quadriceps-focused program and 100 to a hip-focused program. Everyone had clinically diagnosed patellofemoral pain (kneecap pain), average knee pain of at least 3 out of 10 during daily activity, and a gradual, non-injury onset lasting at least 4 weeks. The group skewed young and lean: mean age 27.2 years (SD 6.4), 69% women, mean BMI 22.6.
Both programs ran 12 weeks at home, 3 sessions per week, 3 sets of 8 to 12 repetitions, with a clinician visit roughly monthly. Patient-reported outcomes were collected again at 26 weeks.
What they found
The two programs landed on top of each other. The quadriceps group improved 7.6 points on the Anterior Knee Pain Scale, the hip group improved 7.0 points, and the difference between them was 0.6 points (95% CI -2.0 to 3.2). The equivalence test came back at p less than 0.0001, meaning the result sat comfortably inside that pre-set 8 point margin.
- Every secondary outcome agreed: KOOS pain differed by 2.9 points (95% CI -0.6 to 6.5), physical function by 1.0 point (95% CI -1.8 to 3.9), and knee-related quality of life by -1.2 points (95% CI -6.1 to 3.7). All met the equivalence criteria.
- Strength rose in both groups regardless of the target: hip abduction and knee extension strength each improved 10% to 11% after 12 weeks, in both arms. Train the hip and the quad got stronger too, and vice versa.
- Results held at 26 weeks. Nothing separated at the 6 month check either.
- Adverse events were mild and similar between groups, mostly muscle soreness. Eight participants had sets and reps reduced because of a knee pain flare, 5 in the quad group and 3 in the hip group.
Adherence was decent but not perfect: participants averaged 28 of 36 possible sessions, about 77%.
The catch
The authors were refreshingly blunt about the biggest one, and it is not the hip versus quad question. Neither group’s average improvement crossed the minimal clinically important change for the Anterior Knee Pain Scale, which is 8 to 10 points. Both groups improved about 7 points. So the truthful summary is not “both work equally well,” it is “both produced the same modest change, and modest may not be enough on its own.”
The programs were also almost entirely unsupervised. Home based, self-reported adherence, monthly check-ins only. That is realistic, and it is also the most likely reason the effect was small: nobody was watching the technique, correcting depth or tempo, or pushing the load up when the exercise got easy. Contamination between groups was possible too, since people trained unobserved and could have added whatever they liked.
Finally, this was one centre with a young, lean, mostly female group. A 55 year old with kneecap pain and a higher body weight was not represented here, and neither was a competitive athlete.
What this means for you
Stop agonising over which muscle group to blame. The choice that actually predicts your outcome is whether you will do the program three times a week for three months and keep making it harder.
- Pick the version you will do. If leg extensions and squats fit your gym and your knee tolerates them, go quad. If side-lying or banded hip work feels better on the knee right now, go hip. The trial says the ledger balances either way.
- Use the trial’s dose as your floor: 3 sessions a week, 3 sets of 8 to 12 reps, 12 weeks. Circle the end date on a calendar so you are not evaluating results at week 4.
- Progress the load, do not just repeat it. This is where I think the study’s modest result comes from. When 12 reps feels easy, the exercise has stopped being treatment. Add weight, range, or tempo.
- Modify the aggravating activity at the same time. Exercise alone produced about 7 points. Trimming your running volume, adjusting stair habits, or changing squat depth for a few weeks is the other half of the plan.
- Plan for a longer horizon than 12 weeks. Kneecap pain is often a months-long project. That is normal, not failure.
One practical note from the clinic: if your kneecap grinds or clicks while you do this work, that noise on its own is rarely the problem. I unpacked why in my joints are making noises, should I be worried. And if the underlying question is whether your everyday activity is loading your legs enough to change anything, is walking enough to build strength is the companion read.
The part worth paying for
If this trial tells us anything useful for practice, it is that the exercise selection is the easy part and the coaching is the hard part. Loading correctly, progressing on schedule, and adjusting when the knee complains is what separates 7 points from a real result. That is what a training session with a PT is built around: someone watching the reps, changing the load, and keeping the 12 weeks on track. Bring me your kneecap and we will pick a lane and load it properly.
References
- Hansen R, Brushøj C, Rathleff MS, Magnusson SP, Henriksen M. Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial. British Journal of Sports Medicine 2023;57(20):1287 to 1294. doi:10.1136/bjsports-2022-106197 (PMID 37137673). https://bjsm.bmj.com/content/57/20/1287
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