Daily Mobility Exercises by Dr. Kelly Starrett Forums General Chronic IT band/quad TIGHTNESS and knee pain (chondromalacia patella?) for 6 years! Re: Chronic IT band/quad TIGHTNESS and knee pain (chondromalacia patella?) for 6 years!

I went to see a very good physiotherapist in my area he noticed a few things:

1) Weak Hamstrings – even weaker than my glute maximus, which he said they should be, however the glute maximus is weak as well (posterior chain is weak–>leading to anterior pelvic tilt–>putting the hips in constant flexion–>leading to weaker glutes, stronger and tighter hip flexors and quads–>leading to IT band tightness–>leading to a lateral and upward pull on the patella during flexion–>leading patellofemoral pain. 
Fix–>Strengthen hamstrings – he suggests strengthening the hamstrings with supine bridge curl, stiff leg deadlift, narrow stance squat (kicking the but back without having the knees track over the toes, kind of like a good morning)

2) Right glute medius doesn’t fire at all – He looked at my clamshell very closely and noticed that I cant isolate my glute medius and they werent firing at all during the exercise. He said I am doing a number of things to compensate for it such as activating other muscles (my low back, hip flexors) and rotating my pelvis. This is contributing to a dysfunctional right side kinetic chain. My previous glute medius isolation efforts have not been effective because I was compensating with other muscles and a faulty motor pattern. 
Fix –>Isolate and activate the glute medius – he suggests isolating the glute medius doing clamshells but with a very conscious effort on form and minimizing compensations (not shifting pelvis at all). He said I should only be feeling it in the glutes. He said this exercise is going to be the most annoying and hardest for me because I am focusing and re-learning a motor pattern which can get frustrating as I might not be able to isolate the glute medius easily at first. He said after I am able to isolate the glute medius and strengthen it, we will integrate the new motor pattern and strength to functional exercises. During my functional exercises he things they aren’t being activated. To help with glute medius activation during the clamshell he suggests to put a pillow between my legs focusing on a neutral pelvis with no rotation at all and to have my lower glutes (left glutes) against the wall, while the higher glutes (the right glutes) are slightly forward away from the wall. He said to have my hands behind my higher glutes (hand should not be touching the glute) to ensure that they dont move closer to my hand (indicating that my pelvis isn’t rotating to compensate)

3) Limited Range of Motion for Hip External Rotation 
The right side (side with knee pain) is worse than the left. It seems to be caused my tight/restricted joint capsule, deep internal hip muscles, and TFL pulling/rotating my hip/femur internal and making it hard to externally rotate the femur/hip. May also be contributing to reciprocal inhibition of glute medius: The tight internal rotators are preventing full range of motion for external rotation, thus preventing activation of glute medius on the right side. 
Fix –> Smash and stretch hip flexors/internal rotators: This is were some mobilitywod work will help. Will have to look into videos to decide what are the best mobs for tight hip internal rotators (to improve hip external rotation). Banded distraction/capsule stretching, and smashing the hip region (TFL, psoas), hip opener stretches.

One possible explanation of the cycle that is happening with me is this:

Hamstring weakness
1) Weak hamstrings* + sitting to much+ tight hip flexors + tight quads + quad dominant + weak glutes and core–> leading to anterior pelvic tilt
2) Anterior pelvic tilt –> glutes are inactivated because I am always in slight hip flexion due to the anterior pelvic tilt
3) Glute inactivation –> leads to a compensatory increase in hip flexor activation and tightness and also IT band tightness** 
4) IT band tightness –> leading to a lateral pull on the knee (especially during knee flexion), also hip flexor tightness may be leading to internal rotation of femur relative to the patella during knee flexion (all tho not in an obvious knee collapse)

Glute medius weakness:
1) Glute medius is not firing –> leading to compensatory increase in hip flexor and IT band tightness
2) IT band tightness –> leading to patella tilt

I will do what my physiotherapist suggests along with what I have already been doing and update my progress.