Can Balance & Perturbation Training Fix Runner’s Knee?A Critical Review for Podiatrists, Clinicians & Athletes | Find Your Stride | Edinburgh Podiatrist

Overview

This 2026 randomised controlled trial by Zare Bidoki & Haj Lotfalian investigated whether combined balance and perturbation training improves the following in women with patellofemoral pain syndrome (PFPS):

• Gluteal muscle activation (EMG)

• Hip kinematics

• Pain (VAS)

• Function (AKPS)

Participants completed a 6-week neuromuscular training program (18 sessions) or no intervention.

Patellofemoral pain syndrome (PFPS) also known as Runner's Knee is a common complaint

🏃 Key Findings (What Matters Clinically)

The intervention group demonstrated:

• ↑ Gluteus medius activation

• ↓ Gluteus maximus overactivity

• Faster muscle activation timing

• ↓ Hip adduction (less “knee valgus”)

• ↑ Hip flexion during step-up

• ↓ Pain and ↑ function scores

  
  

👉 In simple terms: Better hip control = better knee mechanics = less pain

🦶 Why This Matters in Podiatry & Running

While the study focuses on proximal control (hip and glutes), it has direct implications for foot and ankle clinicians:

1. The Hip–Foot Connection

Excessive hip adduction contributes to:

• Dynamic knee valgus

• Increased patellofemoral joint stress

• Compensatory foot pronation

  
  

👉 This reinforces the kinetic chain model:

You can’t fully treat runner’s knee from the foot alone.

2. Implications for Orthotic Therapy

This paper indirectly challenges a common clinical trap:

❌ Orthotics alone for PFPS

✅ Integrated approach:

• Foot control (orthoses, footwear)

• Hip strength & neuromuscular control

3. Running Performance Angle

Improved neuromuscular timing (earlier glute activation) suggests:

• More efficient force transfer

• Reduced energy leaks

• Potential improvements in running economy

• 
  

However, this was not directly measured — a key limitation.

⚖️ Strengths of the Study

✔️ Randomized Controlled Design

A solid methodology strengthens internal validity.

✔️ Objective Biomechanical Measures

• EMG for muscle activity

• 3D motion capture for hip kinematics

This goes beyond typical “pain-only” studies.

✔️ Functional Task (Step-Up)

Relevant to:

• Running

• Stair climbing

• Daily loading patterns

⚠️ Key Limitations (Important for Clinicians)

1. Small Sample Size (n = 29)

Limits generalisability and statistical power.

2. Female-Only Participants

PFPS is more common in females, but:

• Results may not apply to male runners

3. No Active Control Group

The control group did nothing.

👉 This exaggerates perceived effectiveness:

• Any structured exercise may have produced similar results

4. Short-Term Outcomes Only

No follow-up beyond 6 weeks.

👉 Unknown:

• Do improvements persist?

• Does it reduce injury recurrence?

5. Not Runner-Specific

Participants were physically inactive 

👉 Major issue for sports clinicians:

• Running biomechanics ≠ sedentary movement patterns

6. Missing Foot & Ankle Data

No assessment of:

• Foot posture

• Ground reaction forces

• Running gait

👉 This is a critical gap for podiatry relevance.

🧩 Clinical Takeaways for Podiatrists

🔹 1. Treat PFPS as a Whole-System Problem

• Hip control is essential

• Foot mechanics still matter

👉 Best outcomes = proximal + distal integration

🔹 2. Add Perturbation Training to Rehab

This study supports adding:

• Balance boards

• Unstable surfaces

• Reactive drills

👉 Especially for:

• Runners with poor control

• Recurrent knee pain

🔹 3. Don’t Over-Rely on Strength Alone

The key improvement wasn’t just strength — it was:

👉 Timing + coordination (neuromuscular control)

🔹 4. Bridge the Gap to Running

Before return to sport, progress toward:

• Single-leg loading

• Plyometrics

• Running-specific drills

🏁 Final Verdict

This study adds valuable evidence that:

👉 Neuromuscular training targeting the glutes can improve pain and biomechanics in PFPS

However, for podiatry and running populations the study:

❗ Lacks foot/ankle integration

❗ Was not tested in athletes

Clinical Bottom Line

If you’re treating runner’s knee, don’t choose between orthotics or hip rehab. You need both — and ideally, you need coordination training on top.

📚 Citation

Zare Bidoki, F., & Haj Lotfalian, M. (2026). The effects of combined balance and perturbation training on gluteal muscle activity and hip kinematics in women with patellofemoral pain syndrome: a randomized controlled trial. BMC Musculoskeletal Disorders, 27:219.

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