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Could Tight Hip Flexors Be The Cause Of Your Low Back, Hip or Knee Pain?

EnFuse Staff

Category: Strength & Rehabilitation

Could Tight Hip Flexors Be The Cause Of Your Low Back, Hip or Knee Pain?

The hip flexors are a group of muscles that are involved in flexion of the hip such as what occurs while running, ascending stairs, and squatting. The hip flexors consist of the Sartorius, Tensor fascia lata (TFL), Rectus femoris, Iliopsoas and Pectineus muscles. These muscles, especially the Rectus femoris and the Iliopsoas can become tight in those who sit for prolonged periods of time.2 The muscles become shortened which can cause increased pain with certain activities especially in the low back, hips, and knees. In this article we will focus on the effects of a tight Rectus femoris muscle on knee pain. 

The Rectus femoris is one of the four quadriceps muscles and is responsible for flexing the hip as well as extending the knee. It is located on the anterior thigh, originating at the hip bone and inserts on the shin bone as the patella tendon.1 If this muscle is tight, one is likely to experience knee pain when the knee is flexed during running or squatting. A few common overuse injuries caused by a tight Rectus femoris are Patella femoral syndrome and Patella tendonitis. Patella tendonitis occurs at the patella tendon which is located below the knee cap and is what attaches the Quadriceps to the shin bone. Pain is felt below the knee cap and is especially common in long distance runners and sports involving jumping.2 There are several methods involved in the treatment of Patella tendonitis, but one of the main goals is to decrease the increased tension in the patella tendon caused by a tight Rectus femoris.


Treatment of Patella Tendonitis

Stretching of the Rectus femoris muscle2

  1. Begin by standing in front of a chair
  2. One leg remains on the floor while the other leg is placed on the chair located behind you
  3. The leg on the chair in extended at the hip an flexed at the knee
  4. Tuck bottom under to perform a posterior pelvic tilt
  5. Hold this stretch for 30 seconds and repeat 3 times on each leg

***Avoid the “quad stretch” where you are standing and grabbing your ankle. This places increased stress on the patellofemoral and tibiofemoral joint and can actually cause increased knee pain. Most of the time when performing this stretch- if the IT band is tight -one is actually stretching that versus the quad when performing this stretch.***

Cross Friction Massage of the Patella Tendon2

  1. The patella tendon runs perpendicular to the patella and attaches at the shin bone. It is located below the patella and is the soft area that is felt between the knee cap and the shin bone.
  2. To perform cross friction massage, first sit with knee extended.
  3. Apply a tolerable amount of pressure perpendicular to the fibers of the patella tendon.
  4. Move fingers back and forth over the tendon.
  5. Perform for 3-4 minutes if tolerated. 2 

Eccentric Quad Strengthening 

In order to increase the strength of the quad tendon and increase its tolerance to stress it is important to perform quad strengthening exercises.2

Step ups

  1. Step up with affected leg on the step
  2. Step down leaving the affected leg on the step
  3. Make sure the knee is not coming over the toes when stepping up or down
  4. Repeat for 3 sets of 15  

Medial Step-Downs

  1. Standing sideways with the affected limb on the step
  2. Slowly lower the opposite limb to the ground just touching the heel on the ground
  3. Make sure to sit back with your bottom, knee is not collapsing medially and that knee does not come over toes
  4. The limb that is being lowered to the ground is not used to push off of. The limb on the step is elevating the opposite limb.
  5. Repeat for 3 sets of 15

 Eccentric Quads

  1. Sitting in chair with knee bent
  2. Take opposite limb and loop foot behind affected limb
  3. Use the unaffected limb to elevate the affected limb so that the knee is extended
  4. Remove unaffected limb at full extension and “squeeze” quad for 5 seconds at top
  5. Slowly let the affected limb lower back down into flexion
  6. Repeat for 3 sets of 15

Patella femoral syndrome is knee pain that can be caused by several factors. One common impairment of those experiencing knee pain is a tight Rectus femoris. As a result of the muscle being shortened, there is increased stress on the patella femoral joint as the Rectus femoris attaches as the patella tendon at the shin bone.2 This can cause increased compression on the joint leading to pain after sitting for long periods of time, pain while ascending or descending stairs, and squatting. Patella femoral syndrome is more common in females than males due to body type as well as muscle imbalances. Those with patella femoral syndrome often experience hypermobile patellar, malaligned patellar, hip weakness, poor quad control and medial, lateral or inferior knee pain as a result.2 The main goal of those with patella femoral syndrome is to decrease the symptom of knee pain by strengthening the quadriceps muscles, stretching the Rectus femoris, and strengthening the hip external rotators, extensors and abductors. Patellar malalignment can be corrected with taping over the course of time.

Treatment of Patella Femoral Syndrome

Stretching of Rectus Femoris

  • See above

Hip Strengthening


Double leg glute bridges.

  1. Patient is lying on back, drives through heels to lift glutes off of table.
  2. Holds for 3 seconds at end of range, squeezing glutes
  3. Lower body back to table.
  4. Performed for 3x15.


An exercise that can be performed to improve gluteus medius and external rotator strength is sidelying clamshells.

  1. Start by lying on your side with your knees bent and hips flexed to about 45 degrees.
  2. Feet remain together while the upper leg is raised.
  3. To increase difficulty a resistance band can be added above the knees.
  4. Perform for 3x15 each side 

Medial Step-Downs

  • See above

Exercises should be performed within a certain range for those experiencing patellofemoral joint pain due to the compression on the patella at varying angles.2 For closed chain exercises such as squats, one should squat within 0 degrees to 50 degrees of range. For open chain exercises such as quad extensions, the range should be within 90 degrees to 45 degrees of extension. It is important to ‘not’ exercise / work through pain with patellofemoral syndrome. Symptoms may increase if the quadriceps muscle is inhibited (meaning there is lack of control over the patella).

Note:  There is a lot of conflicting information as to whether a person’s knees should pass their toes while ascending / descending during bilateral (both legs) or unilateral (single leg) movements.    

First, never perform an exercise that causes pain. Muscle soreness and joint pain are very different.  It is important to distinguish between the two.

Second, we tend to align with the ideology of training for function.  Our knees pass our toes when we ascend / descend stairs or when we pivot and turn.  That being said, for most clients, we tend to train / strengthen this range of motion.  Again, we never work through pain and each clients’ own unique needs / background are considered . 

Third, there is a lot of evidence to suggest that training a full range of motion actually increases the health and stability of your knees. 

If you would like to have one of our coaches assess your movement and help tailor a strength training program specific to your individual needs, please contact our team- support@EnFuseFitness.com

We hope that you find this article helpful!

In Health,
Team EnFuse

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