Sports Medicine Research: In the Lab & In the Field: Guest Post: Hip and Core Rehabilitation Improves Patellofemoral Pain Syndrome (Sports Med Res)
Friday, April 29, 2011

Guest Post: Hip and Core Rehabilitation Improves Patellofemoral Pain Syndrome

A Proximal Strengthening Program Improves Pain, Function, and Biomechanics in Women with Patellofemoral Pain Syndrome

Earl JE, Hoch AZ. Am J of Sports Med. 2011. Vol 39. No 1. Pages 154-163

Patellofemoral pain syndrome (PFPS) is a wide spread issue throughout sports medicine clinics. It is an overuse injury marked by complaints of pain surrounding the patella and is worsened by many athletic activities. It is commonly seen in adolescents and occurs in women more than men. This study examines the effectiveness of a hip and core strengthening program for improving pain, function, hip and core strength/endurance, and running biomechanics in women with PFPS. Nineteen women participated in a preliminary testing procedure as well as an 8-week “proximal stability program.” The preliminary testing consisted of functional outcome measures (Kujala Anterior Knee Pain Scale and visual analog pain scale), lower extremity running kinematics and kinetics, hip strength (external rotation and abduction using a hand held dynamometer), and core endurance (timed static positions for anterior, posterior, and lateral core). The paper fully describes the rehabilitation program, which I recommend everyone to check out. It consisted of three phases, a neuromuscular reeducation of the hip and core muscles, dynamic exercise phase, and a functional exercise phase. They found that pain, functional ability, lateral core endurance, hip abduction and hip external rotation strength improved following the 8 week rehabilitation program in women with PFPS.

It is currently theorized that the pathogenesis of PFPS starts with a decrease in hip and core neuromuscular control and strength; causing dynamic malalignment of the lower extremity. Ultimately this dynamic malalignment leads to increased stress at the patellofemoral joint and pain. Traditionally, therapeutic management has focused on vastus medialis quadriceps strengthening in both open and closed chain activities. This approach attempts to correct the line of pull of the patella from a superior lateral direction to a more superior medial direction solely with the control of the quadriceps. A proximal stability approach focuses on altering the course in which the patella tracks through proper alignment of the femur in relation to the tibia. Far too many women have functional deficiencies that can contribute to PFPS, such as poor core stability, weak hip extensors, abductors and external rotators; hip flexors, and IT band tightness. Many of these deficits can be caused by or a result of improper pelvic positioning. We, as clinicians, are aware that many of our patients exhibit anteriorly rotated hips. This position can be caused by a laundry list of factors that can be discussed in another post. An anteriorly rotated pelvis will cause femoral internal rotation and adduction, which will malalign the femoral groove (trochlear groove). A proximal stability program may allow patients to maintain pelvic neutral assisting in externally rotating and abducting the femur. The femoral groove is then rotated into a more lateral position and reestablishes normal patellar tracking; potentially decreasing joint stress and ultimately pain. Clearly the development of PFPS is multifactorial and therefore rehabilitation programs should aim to address each of these factors. The proximal stability program used in this study proved to be an effective and efficient treatment for women with PFPS but larger clinical trials with a control group are needed to verify this. Have others had success with this rehabilitation protocol for treating PFPS? Does anyone have any tips or clinical pearls for patients that don’t seem to get symptomatic relief with any treatment?

Written by: Tommy Nowakowski
Reviewed by: Stephen Thomas

2 comments:

Tom Martin said...

Great post Tommy
More and more we are reading about this topic in relation to PFPS, especially with the female population.
I have had nice results with utilization of Hip (and to a lesser extent core) stability/strengthening exercises in the treatment process for those with PFPS.

I especially focus on this with knee post op patients (those possibly predisposed to developing PFPS) that have issues with quad tone/strength. I like to work proximal in terms of strength, assess flexibility/ROM issues, and bomb the quad with E-Stim to help improve tone early on in the rehab process.

I must admit the anteriorly rotated pelvis is thought provoking. I usually have patients maintain a drawn in position (transverse abd.) for core stab. when performing hip strengthening exercises, but now I think I may add some trunk stab exercises to the program based on the results.

Thanks again

Tommy Nowakowski said...

I really try to focus on core with most of my rehabilitations, sort of my personal 6 philosophy. To me, my 6 philosophy says the hips affect the LE and the LE affect the hips in a cyclical fashion, similar to the base of the six. The hips also affect the spine and UE to complete the 6. I currently have a freshman female athlete that has a history of PFPS and shockingly complaints of shoulder instability. I don't believe they are a coincidence!

I incorporate core work in EVERY exercise by emphasizing position, like the sled example I drew on in another post. By getting these athletes into posteriorly tilting with scapular stabilization work lets say, they are not only stabilizing the scapula but also working on stabilizing the core.

Two cues I use is their reflexive response to me surprisingly punching them "in the gut" or, in the supine position, bracing for me dropping a med ball on their stomach. These have worked well.

These ideas have helped me immensely in my rehabilitations with athletes that have "bought in" to my programs. Needless to say, not everyone is going to be 100% compliant. Things just need to be tweaked to accomodate that.

Now if I only could get people to stop stretching the hamstrings and start stretching hip flexors and strengthening the gluts...we can get even further!

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