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