Sports Medicine Research: In the Lab & In the Field: Hip to Rid Patellofemoral Pain Syndrome (Sports Med Res)
Wednesday, December 11, 2013

Hip to Rid Patellofemoral Pain Syndrome

Proximal Exercises are Effective in Treating Patellofemoral Pain Syndrome: A Systematic Review

Peters JSJ & Tyson NL. International Journal of Sports Physical Therapy. 2013; 8 (5): 689-700. PMCID: PMC3811739

Take Home Message:  Hip exercises consistently provide greater improvements for PFPS than knee exercises alone.  However, any exercise provides alleviation from PFPS.   

Patellofemoral pain syndrome (PFPS) is relatively common and a disabling condition.  We often opt for conservative management, yet it remains unclear which exercises may yield the best results  This systematic review evaluated the effectiveness of proximal strengthening exercises (lumbar, pelvic, & hip exercises) in comparison with knee-only strengthening exercises. The authors identified 8 relevant articles that met the inclusion criteria (studies on adults or adolescents with PFPS who underwent exercise programs focused on proximal OR knee musculature and reported functional outcomes). The authors then evaluated the methodological quality and extracted key data from each study.  All studies were of moderate to high quality – three were randomized clinical trials.  On average, the 4 studies that utilized proximal exercises demonstrated a 65.1% reduction in pain levels and a 37.5% improvement in function while only 3 of the 4 studies that focused on knee exercises demonstrated an improvement. Overall studies focused on knee exercises only found an average reduction of 36.8% in pain and a 20.5% improvement in function.  Among the studies that focused on proximal exercises, all four targeted hip muscles with single joint movements (e.g., hip abduction), 1 included lumbo-pelvic exercises, and 2 included stretching.

Nearly all exercises provided some relief of pain; however, proximal exercises consistently and drastically alleviated symptoms associated with PFPS.  This information confirms to clinicians that some form of activity is better than nothing.  Despite pain or an inability to perform certain exercises, modifications should be made, and exercises should focus on strengthening the areas that a patient is able to.  Furthermore, most of the proximal exercises can easily be done without the need for expensive equipment, which is commonly needed for knee exercises.  The results of this review should be interpreted with caution as they did not focus on studies that did  a direct comparison of proximal and knee exercises.  Another limitation recognized by the authors was that interventions are recommended to be daily with 2 to 4 sets of 10 repetitions for more for six or more weeks; however, more than half of the included studies did less than this.  The studies included a variety of length of programs, exercises, participants, and randomization among included studies, which can make interpreting the results challenging.  There is a need for more high quality research to compare standardized exercise protocols that meet minimum recommendations.  However, despite these limitations proximal exercises seem to be a good selection for addressing symptoms associated with PFPS.     

Questions for Discussion:  Given the multifactorial etiology of PFPS, are there any other variables that you have found to be potential culprits other than hip strength?  Has anyone seen or addressed distal (foot/ankle) interventions to alleviate PFPS?  
 
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Peters JS, & Tyson NL (2013). Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. International Journal of Sports Physical Therapy, 8 (5), 689-700 PMID: 24175148

4 comments:

Liz said...

I think when dealing with any joint injury or pain it is important to look both proximal and distal to the joint in question. The body is an intricate network that is in a delicate balance when working properly. Kinematic changes at a more proximal or distal joint would disrupt the network. Often when I have an athlete presenting with knee pain consistent with PFPS or other generalized non-traumatic knee pain the first thing I ask about are their shoes, followed by a history of their exercise routine. More often than not I find their shoes are old or worn out, they didn't prepare for pre-season like they should have. In some cases I watch them walk on a treadmill and look what their ankles and hips are doing during gait. In addition to strengthening exercises for knee and hip addressing footwear problems and providing addition support to the arches where necessary have provided me with good results in treating knee pain.

Nicole Cattano said...

You make great points Liz! Have you found that any particular brand of shoes helps better than others?

(Only reason I ask is that the basketball population that I work with SWEARS by certain brands over the brand that is mandated by the University.)

But you are absolutely right about the entire kinetic chain being involved. I think its great that you take the time to watch gait on a treadmill and look at footwear. More clinicians should follow your lead.

Are there any hip exercises that you like to do that may be beneficial to clinicians?

Erin said...

I agree with Liz. Looking at proximal and distal segments is key when determining the source of pain when dealing with joint injuries. When dealing with PFPS, I feel that clinicians may sometimes get caught up in looking at just quadriceps strength and hip strength. We know that that ratio of VL to VMO activation can effect the movement of the patella and become a factor in PFPS patients. Correcting quadriceps muscle imbalance is important as well as improving hip strength. However, I have read a few different studies that shows weakness in the gastroc and hamstrings of PFPS.

One question to ask is does this LE weakness come from the pain or does the pain come from muscular weakness?

I also agree with looking at gait. This can show other biomechanical deficits that may lead to PFPS. Because of the non-specific nature of this pathology, there are many different factors that can lead to its source.

Joshua Naterman said...

I would say that, while exercise lists are nice, it is more important to take careful note of what muscles the patient feels working.

For example, I had trouble with my right foot externally rotating during squats. I had extremely strong peroneals, anterior and posterior tibialis, digital plantar flexors, etc. All that strength did nothing for me until I started doing isometric internal rotation + dorsiflexion in a squat position. This was when I realized that the peroneals were extremely dominant in this particular position vs the anterior and posterior tibialis.

I found that retraining this dominance back to a tibialis dominance has completely gotten rid of my valgus tendencies in squats, and knee pain as a result.

In a similar situation, I also have periodic knee pain at the front of the joint line directly behind the right knee cap.I used to not have any good idea what was going on, butI have noticed that 100% of the time this happens, my right gastrocs have no sensation whatsoever. It feels like they are not even there. I just focus on turning them on a little and the pain is instantly gone, pretty much permanently until the next time this occurs. By focusing on this once or twice a day I have found that the knee pain has only hit me once in about four months, and I know exactly how to get rid of it, whereas it was multiple times per week prior to this observation. It was extremely frustrating, because I would basically be unable to walk properly until it calmed down.

I have used this concept of muscle activation, which was introduced to me by a good friend that specializes in Greg Roskopf's Muscle Activation Techniques.

He has a growing number of physical therapists and doctors referring their patients to him because he has gotten such remarkably good results with the medical professionals while treating them, and has done the same for his clients as well.

I've had firsthand experience with this, and so has my girlfriend (who is a physician trained at Balliol College at Oxford University). My girlfriend got hit by a car while biking, and even after months of physical therapy (which did help a lot) there was consistent pain in her hip and knee that could not be resolved. I was able to help her with the knee pain, but the hip pain was more difficult. Jason Colleran, my M.A.T. friend, took care of it in two sessions.

I think that M.A.T. gives a very useful model for approaching pain, and the concept is easily integrated with physical and manual therapy modalities by simply being able to quickly change recruitment patterns so that the desired exercise is giving the patient the desired treatment effect in the minimum amount of time, usually immediately. It is honestly a very useful toolkit for those of us interested in developing a maximally effective approach to injury recovery, movement correction/optimization, and pain management.

I wanted to share these experiences so that those who are interested can become aware of what I have found to be a very effective approach to treatment.

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