Posts

Do Males and Females with Patellofemoral Pain Need to be Treated Differently?

Today’s guest post is an interesting topic by Heidi Mills from the Sports Injury Clinic in the UK, asking if we should be treating male and female patients with patellofemoral syndrome differently.  The basis of the post comes from a recent journal publication showing different running mechanics between gender.  I am a firm believer that each person should have an individualized program based on their specific biomechanics and examination, meaning that we WOULD treat them differently – not because of gender itself, but because of the biomechanical differences between the genders.

Are Mechanics Different between Male and Female Runners with Patellofemoral Pain

patellofemoral pain syndromeA recent article published recently in Medicine and Science in Sports and Exercise found that males with patellofemoral pain syndrome (PFPS) demonstrated different mechanics whilst running and performing a single leg squat, to females with the same pain condition. So this leads to the question “should we be treating men and women with the same condition, differently?”

The authors analysed the gait cycle and single leg squat movement in 18 female and 18 male runners with PFPS as well as 18 male runners without knee pain.  Results showed that men with PFPS ran and squatted with an increased knee adduction and external rotation than men without knee pain. Men with knee pain also demonstrated less hip adduction but more peak knee adduction that female runners with PFPS.

To simplify, in those men with knee pain, the knee joint falls in and rotates outwards more than in those without knee pain. In comparison with women who suffer knee pain, men’s thighs fell in less but the knee joint itself underwent more knee adduction (between the Tibia and Femur bones).

The authors concluded that these differences in mechanics between men and women warrant that PFPS treatments be gender specific.

Clinical Applications

Based on this information, should we be treating men and women differently?  Or is it more accurate to assess each individual as a separate entity regardless of their sex?

My personal opinion is that gender should not be a leading influence on treatment protocols. Each person should be evaluated independently to determine their specific movement patterns, muscle imbalances, injury history and sporting / training techniques and how these factors all combine to cause the pain in question. If this is all evaluated thoroughly then their gender is largely irrelevant. Treatment should focus on the findings of the assessment, not what research suggests may be causing the injury due to the patient’s sex alone.

Based on this study, it appears that there may be gender based biomechanical differences, but a proper evaluation must be performed for each patient.  We can use information like this to help streamline our diagnostic process.

Treatment Considerations

What can be taken from the results of this research is that hip adduction, knee adduction and knee external rotation may be contributing factors for patellofemoral pain sufferers. Treatment should be as individual as the patient and address their specific problems.

Hip clam exerciseThose with excess hip adduction on squats and other functional movement patterns should focus on strengthening the hip abductors such as gluteus medius. This can be achieved with a number of exercises, including the hip clam exercise.

Those with excess knee adduction and external rotation should be examined for overpronation at the sub-talar joint, which can result in these movements. Overpronation can be corrected with orthotics in day-to-day footwear and specialist running shoes.

Hamstring length tests should also be administered, as a tight Biceps Femoris muscle could increase external knee rotation. If this is the case then hamstring stretches and massage may be effective.

Other common factors include tight lateral Quads, IT bands and hip adductors which can be corrected with quad and groin stretches, self-myofascial release (using a foam roller, or similar) and sports massage.

A weakness or delayed firing of the vastus medialis oblique muscle can also be to blame as it fails to counteract the stronger pull of the tight lateral structures. Re-training of this muscle can be performed initially in a seated position (with 10° knee flexion) and progressed to a standing position.

These are all potential things that we could look at when evaluating and designing a program for someone with patellofemoral pain syndrome.

Learn more about patellofemoral pain syndrome from SportsInjuryClinic.net.  Also, RehabWebinars.com has a couple of great webinars on the Biomechanics of Patellofemoral Rehabilitation and Rehabilitation of Patellofemoral Pain.

 

heidimills

About the Author

Heidi Mills BSc (Hons) GSR, is a Graduate Sports Rehabilitator, working in the UK for www.sportsinjuryclinic.net.

 

 

 

[hr]

 

Assessing and Treating Loss of Knee Extension Range of Motion

Assessing and treating loss of knee extension range of motion is an important component of rehabilitation following any knee surgery.  We recently discussed how loss of knee extension range of motion may be one of the biggest factors associated with the development of osteoarthritis following ACL reconstruction.

The purpose of this article is to review some of the many methods of assessing and treating loss of knee extension range of motion to help maximize outcomes following knee surgery or injury while minimizing long term complications.

 

Assessing Loss of Knee Extension Range of Motion

There are many ways to treat loss of range of motion in the knee, however, proper assessment of range of motion is even more important.  A certain degree of hyperextension is normal, with studies citing a mean of 5 degrees of hyperextension in males and 6 degrees in females.  Simply restoring knee range of motion to an arbitrary 0 degrees is not advantageous.

The most important factor in assessing loss of knee extension range of motion is looking at the noninvolved knee.  As simple as this sounds, this can not be overlooked as you need to establish a baseline for what is “normal” in each patient or client.

The first thing I look at is simply grasping the 1st toe with one hand to lift the foot off the table.  My proximal hand can stabilize the distal femur.  This is a quick and dirty assessment but I always recommend quantifying the available range of motion.

To accurately measure knee extension range of motion, you will need to use a towel roll of various height to assure the knee is fully hyperextended before taking a goniometric measurement.

Knee Hyperextension

Other aspects of assessment that should be performed when dealing with loss of knee extension range of motion should include patellar mobility, tibiofemoral arthrokinematics, and soft tissue restrictions.  Patellar mobility is especially important after ACL reconstruction using a patellar tendon autograft.  Any restrictions in patellar mobility can have an obvious correlation with restricted knee extension.  Scarring of the patellar tendon can restrict superior glide of the patella and full knee extension.

These assessments will help guide our manual therapy approach to restoring normal arthrokinematics and range of motion of the knee.

Documenting Knee Range of Motion

I took a poll of a large group of students coming through my clinic in the past and found that there was great confusion regarding how we document hyperextension of the knee.   Is + or – when defining a numerical value?

Let’s say that someone has a contracture and is sitting in 10 degrees of flexion and is unable to straighten their knee.  That would be +10 degrees of flexion, thus has to be -10 degrees of extension.  They are on two ends of the spectrum.

Still, using a + or – can be potentially confusing, so I have long taught my students that we should document range of motion using the A-B-C method.  Other authors, such as Dr. Shelbourne, recommend this method as well.

  • If a person has 10 degrees of knee hyperextension and 130 degrees of knee flexion, it would be documented as 10-0-130.
  • If a person has a 10 degree contracture and loss of full knee extension with 130 degrees of knee flexion, it would be documented as 0-10-130.
Using the A-B-C method eliminates the potential for confusion while documenting.

Treating Loss of Knee Extension Range of Motion

There are several ways to improve knee extension range of motion, however, if a person is struggling with this motion I have found that self-stretches, low load long duration (LLLD) stretching, and range of motion devices can be superior to us cranking of a already cranky knee!  Allowing gentle, frequent, and progressive load to the knee is usually more tolerable for the person, especially those that are sore or guarded in their movements.

The intent of this article is to discuss some specific independent strategies to enhance knee extension range of motion.  Other skilled treatments should focus on patellar mobility, soft tissue mobility, and other aspects of manual therapy for the knee as needed.   However, patients will need to perform stretches at home to assure good outcomes.

 

Self Stretches for Knee Extension Range of Motion

Two of the first stretches that I give patients following surgery are simple self stretches for knee extension.  The basic version simple has the patient applying a stretch into extension by pushing their distal thigh.  The second and slightly more advanced version, has the patient press down on their distal thigh while using a towel around the foot to pull up and simultaneously stretch the hamstrings.

Knee Extension Stretch

Towel Knee Extension Stretch

Similar to how we assess knee extension range of motion, you will want to use some sort of wedge under the heel to assure that you are restoring full motion.

 

Low Load Long Duration Stretching for Knee Extension Range of Motion

For the person that is having a hard time achieving knee extension, my next line of defense is usually LLLD stretching.  Several research articles have been published showing the benefit of LLLD stretching in achieving range of motion gains.

I prefer performing LLLD stretching for knee extension in the supine position rather than prone knee hangs (follow the link to learn why).  This has always been a more comfortable and thus more beneficial position for me.  To perform this exercise, place a towel roll or similar item under the heel to allow full knee extension and then a comfortable weight over the distal thigh.

Low Load Long Duration Stretch Knee

The purpose of this exercise is to be gentle and to hold the stretch for several minutes.  I typically use anywhere from 6 to 12 pounds and hold the position for at least 10 minutes.  If the person is fighting against the weight, then it is too aggressive.  Lower the weight and you’ll see better results.

Don’t forget that you can apply moist heat to the knee simultaneously for even more benefit.

LLLD Knee Stretch with Heat

Devices for Knee Extension Range of Motion

I am also quick to prescribe a range of motion restoration device for people that may be struggling with range of motion or are not moving their knee enough throughout the day.  I have tried some of the dynamic splinting in the past but found that many people would rather control and hold a sustained stretch rather than have the brace apply a dynamic stretch.

The two devices I have used and enjoyed are from Joint Active System (JAS) and End Range of Motion Improvement (ERMI).

JAS Knee Brace        ERMI Knee Brace

Both devices allow the patient to apply their own tolerable LLLD stretch at home.  This is helpful as frequent movement throughout the day is always beneficial.

Personally my criteria to use these devices is usually when I perceive the person will self-limit themselves and avoid motion.  I will get a device in their hands early so that they can move their knee more at home and have a feeling that they are controlling the restoration of range of motion.  We probably resort to using these devices when it is too late and the patient is already too stiff.

 

Conclusion

These are just some of the many ways to assess and treat loss of knee extension range of motion.  Considering how important it is to restore full knee extension after knee surgery, properly assessing early signs of loss of motion and effectively treating the knee to avoid long term loss of motion is critical.

What has the Biggest Impact on Outcomes Following ACL Reconstruction Surgery?

Loss of knee extensionIt is no surprise that loss of motion is one of the biggest factors in patient satisfaction following ACL reconstruction surgery, specifically loss of knee extension.  In addition to the limitations in functional activities that occur with loss of knee extension, we have also discussed some of the risk factors of loss of motion following ACL reconstruction.

Loss of knee extension has a dramatic impact on gait, muscle activity, and normal tibiofemoral and patellofemoral arthrokinematics.

Imagine not being able to straighten your knee out.  You can’t lock out your knee for stability.  You naturally will shift your weight to the other extremity and overload your other knee, hip, and probably even your back.  Your quad and hamstring never get to shut off and relax.  Your patellar tendon will probably be on fire, and your patella will always be engaged and taking stress.

I can definitely see why patient satisfaction would be poor if you had long term loss of motion following ACL reconstruction!

Impact of Loss of Motion on the Development of Arthritis

In addition to poor patient satisfaction, recent research has shown that loss of motion following ACL reconstruction also results in the development of osteoarthritis.  In a recent study in AJSM, Shelbourne et al followed 780 patients for a mean of over 10 years.  They showed that of the group of patients that had normal motion on follow up examination, 29% exhibited signs of osteoarthritis on radiographs.  Conversely, 47% of the group that showed loss of motion had developed osteoarthritis.

This makes perfect sense as your arthrokinematics, center of rotation of the joint, and tibiofemoral and patellofemoral contact pressure will be altered.

How Much Loss of Extension is Significant?

More importantly, the authors also showed that even a loss of 3-5 degrees of motion had a significant impact on both patient satisfaction and the development of early arthritis.  Those subjectives that exhibited greater than a 5 degree loss of motion had an even more dramatic impact.

According to DeCarlo and Sell, the average amount of knee extension in healthy individuals is 5 degrees of hyperextension, with 95% of individuals demonstrating some amount of hyperextension in the knee.

Taking this into consideration, we should challenge the common belief that 0 degrees of knee extension is “normal.”  Individuals with 5 degrees of knee hyperextension that only restored their knee to 0 degrees of extension after ACL reconstruction surgery have a significantly greater chance of developing early osteoarthritis.

Clinical Implications

Based on these recent studies, there are bunch of clinical implications that we should all consider.  Here are just a few that I thought of right away:

  • Timing of ACL reconstruction surgery and pre-operative rehabilitation is important to settle down the knee, reduce swelling, and most importantly restore range of motion.
  • Knee extension should be restored as soon as possible after surgery, and should be one of the focuses of the initial postoperative phase
  • Even a small 3-5 degree loss of either extension of flexion range of motion has a significant impact
  • Most patients will have a certain degree of hyperextension, restoring a person to 0 degrees of knee extension is likely not enough
  • For those training post-ACL rehab clients, keep this in mind if the individual does not have full motion.  Advancing to exercises with high tibiofemoral and patellofemoral compressive and sheer forces before achieving full knee motion should be performed with caution.
  • Each patient should be assessed individually and range of motion should be restored to their unique assessment
This information also shows the importance of skilled therapy following ACL reconstruction, despite some of the studies that may show that home exercise is equally as effective.  If loss of the motion has the biggest impact on outcomes following ACL reconstruction, the development of osteoarthritis, and the subsequent health care costs, this strengthens the need for skilled manual therapy during the postopertaive rehabilitation process.

In regard to what to do with the tight person, I’ll work on a future post that discusses how I assess and treat loss of knee extension range of motion, but in the meantime I would love to hear what you think about this information and what you do with these patients.

The Importance of Hip Flexion Strength

Today’s post is a guest article written by Chris Johnson on the the importance of hip flexion strength when dealing with lower extremity pathology.

 

The Importance of Seated Hip Flexion Strength

Just over eight years ago, I accepted my first job as a physical therapist at the Nicholas Institute of Sports Medicine and Athletic Trauma (NISMAT) of Lenox Hill Hospital. This experience afforded me the opportunity to train under the late Dr. James A Nicholas, one of the “Founding Fathers” of sports medicine, and the winner of the 2004 President’s Cup award from the Sports Section of the American Physical Therapy Association (APTA). One of the greatest lessons I learned from Dr. Nicholas pertained to “linkage” and the importance of assessing seated hip flexion strength in patients presenting with lower extremity pathology, especially patellofemoral pain syndrome (PFPS).

In 1976, Dr. Nicholas and colleagues published an article in The American Journal of Sports Medicine entitled, “A study of thigh muscle weakness in different pathological states of the lower extremity.” This study documented that subjects with patellofemoral problems exhibited significant hip flexor weakness on the involved side when compared to a group of controls. Furthermore, Dr. Nicholas and his co-authors concluded that the hip flexor resistance test affords a quick and accurate way of detecting unilateral weakness of the trunk, thigh flexors, and quadriceps group making it a valuable clinical assessment tool.

More recently (2006), Tim Tyler and colleagues did a study investigating the role of hip muscle function in the treatment of PFPS. This study corroborated Dr. Nicholas’s original findings and demonstrated the importance of addressing hip flexor strength in the context of PFPS. The authors proposed that improving hip flexor strength helps to establish a stable pelvis during gait thus preventing it from going into excessive anterior tilt, which would result in excessive femoral internal rotation. The iliopsoas is also a secondary femoral external rotator and strengthening this muscle helps to align the trochlear groove and patella. It should also be mentioned that this study documented the importance of establishing adequate flexibility of the hip flexors and iliotibial band (ITB), which would induce posterior pelvic tilt and relative femoral external rotation. One of the major takeaways from this article is that in addition to resolving any hip flexor tightness, it is also important to ensure adequate strength of this muscle group.

 

Assessing Hip Flexion Strength

While clinicians and fitness professionals routinely assess for and correct hip flexor tightness, it has been my experience that screening for hip flexor weakness in a seated position is not routinely performed. Considering the research, medical and allied health professionals should include this as part of their screening or examination process, especially in the context of lower extremity pathology such as PFPS. To perform this test, the patient should be seated at the edge of a table or plinth with their back straight and legs dangling over the edge of the table while holding on to the front of the table. The patient is then instructed to flex one hip by bringing the knee up towards the chest and to hold it in place while the examiner pushes down on the thigh with the palm of his or her hand. Comparison is then made to the contralateral side. It is the author’s opinions that break testing is the best approach to strength test the hip flexors given the limited range available in a seated position. Standard manual muscle testing grades can be applied or clinicians can use a handheld dynamometer/manual muscle tester to establish a more specific strength index.

When assessing seated hip flexion strength, there are several key to ensure the test is properly performed. First off, patients should have 120 degrees of clean hip flexion so that they can get the involved extremity in to the proper test position without any compensatory motion. Secondly, patients should hold on the front of the plinth to prevent leaning back, which is a common substitution or trick movement when testing hip flexor strength. This will allow the examiner to isolate the hip flexor muscle group as well, thereby ensuring accurate results. Lastly, pay close attention to the low back during testing as patients presenting with hip flexor weakness often fall into excessive anterior pelvic tilt secondary to poor spinal stability, which can result in shearing of the lumbar segments. This may also indicate the need to incorporate spinal stabilization exercises in to the overall treatment program.  Here is a quick video demonstration:

YouTube Preview Image

 

Next time you find yourself evaluating or treating a patient suffering from a lower extremity injury, make sure to test their seated hip flexion strength, especially in the context of PFPS.  And remember that it is not only important for the hip flexors to be extensible but also for them to be STRONG, and without assign hip flexion strength you’ll never know!

 

References:

  1. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different pathological states of the lower extremity. Am J Sports Med. 1976 Nov-Dec:4: 241-8.
  2. Tyler TF, Nicholas SJ, Mullaney MJ, McHugh MP. The role of hip muscle function in the treatment of patellofemoral pain syndrome. Am J Sports Med. 2006 Apr; 34(4): 630-6.

 

About the Author

Chris Johnson, MPT, MCMT, ITCA is a physical therapist and competititive triathlete.  He has a private physical therapy practice in Manhattan.  Youcan learn more from Chris at his website ChrisJohnsonPT.com and Twitter.

Chris has a great website that has a lot of information, especially in regard to running and triathlons.  Thanks for such a great article on the importance of hip flexion strength!

 

 

 

Patellar Tendon Straps Decrease Patellar Tendonitis and Patellar Tendon Strain

patellar tendon strapPatellar tendon straps, or infrapatellar straps, have been long used to decrease pain and patellar tendon strain in individuals with patellar tendonitis.  However, the exact mechanism behind why patellar tendon straps work has been unclear, despite much anecdotal reports of their effectiveness.  We have talked in the past about the effectiveness of lateral epicondyle straps, or tennis elbow straps, in reducing symptoms of tennis elbow and it is commonly reported that they reduce the strain on the extensor carpi radial brevis tendon by applying counter-force pressure.  But for some reason, there have been few studies looking patellar tendon straps.

One proposed mechanism of reducing strain on the patellar tendon using patellar tendon straps was recently assessed in a study published in Sports Health.  The authors report that past modeling of the knee suggest that patellar tendon strain at the site of patellar tendonitis increased as the angle of insertion of the patellar tendon to the inferior pole of the patella decreased.  Here is an example of the patella-patellar tendon angle (PPTA):

patella tendonitis strap

Basically, what this means is that a patellar tendon strap may reduce strain on the patellar tendon by changing the angle that the patellar tendon inserts into the patella and the length of the patellar tendon (if you really want to read the whole computational modeling study from AJSM, here it is).

 

Patellar Tendon Straps Reduce Strain on the Patellar Tendon

The current study’s authors sought to calculate the change in PPTA, patellar tendon length, and patellar tendon strain using two common patellar tendon straps in 20 subjects.  The two straps that were used were the Cho-Pat Knee Strap and the DonJoy Cross Strap.  Here is the Cho-Pat on the left and the Donjoy on the right:

 

Cho-Pat Patellar Strap DonJoy Cross Strap Patellar Strap

 

The methodology of the study was pretty sound and fairly complicated, enough so that I won’t go into the details here but feel free to read the entire study here.  One thing of note was that all subjects were asymptomatic males, however past studies have shown no anatomical differences in PPTA or inferior patellar pole anatomy between symptomatic and asymptomatic subjects.

Results of the study demonstrated the following findings:

  • Patella straps do alter the PPTA as well as the patellar tendon length, the authors believe that these two factors contributed to the reduction in patellar tendon strain.
  • The DonJoy strap reduced patellar tendon strain in 15/20 subjects, the Cho-Pat strap reduced strain in 16/20 subjects.  3 subjects did reduce patellar tendon strain with either strap.
  • The DonJoy strap reduced strain by an average of 34% while the Cho-Pat strap reduced strain by an average of 20%.
  • The patellar tendon straps did not significantly alter patellar tilt or congruence, so this is likely not the cause of effectiveness of Patella straps.

 

My Recommendations on Patellar Tendon Straps

We know that there are studies that show anywhere between 70-80% of people wearing patella straps reported improvement in both acute and chronic cases of patellar tendonitis.  It also now appears that patellar tendon straps are effective in reducing patellar tendon strain in the majority of subjects, which may be the mechanism behind the pain reduction.

One thing I did note about the study was that all participants were instructed on how to apply the straps but there was no standardized application.  For those that have used these straps, you know that you can really vary the amount of tightness of the straps significantly.  Past research on lateral epicondylitis straps have shown that both the location and tension of the strap has a significant impact in the reduction of strain.

Patella StrapThis may explain why the DonJoy strap had a much larger decrease in strain on the patellar tendon than the Cho-Pat strap.  With the DonJoy strap, you can tighten the strap as much as you would like.  You can see this well in the photo, the two straps intercross and the tightness can be adjusted.  (I should also note that “Procare” is a DonJoy company, it is the same strap).  This is the main reason why I recommend the DonJoy strap, as you can pull it really tight if you would like, but more importantly, you can adjust the tension very easily while you are wearing it.  This is helpful for everyone but especially in athletics as the strap can loosen a little with activities.  For the fitness enthusiasts, this is a cheap and simple option to at least try if you are experiencing some patellar tendon discomfort.  Check them out on Amazon for under $20.

To summarize my recommendations on patellar tendon straps:

  1. Patellar tendon straps are worth trying and may reduce pain and patellar tendon strain
  2. The location of application is likely important, try to aim for right in the middle of the patellar tendon
  3. The tightness of the strap is likely important, try to use an adjustable strap like the DonJoy Cross Strap used in this study to make sure that you can tighten it well.
  4. The DonJoy/Procare Cross Strap is pretty affordable too, here is a link to it on Amazon, try it and let me know what you think.

 

What has been your experience with patellar tendon straps?

The Difference Between the Location of Symptoms and the Source of Dysfunction

kinetic chain ripple effectLast week we talked about the kinetic chain ripple effect theory and how the kinetic chain has an impact throughout the body, but more of an impact closer to the source of dysfunction.  For this week, I wanted to discuss 3 common injuries that we all see that may actual just be a symptom, and not the actual injury or source of dysfunction.

As a general rule of thumb, we should probably consider that many of our traditional “injuries” that seem to be relentless and not responsive to treatments may actually be coming from elsewhere in the body.  Think back to how patellofemoral pain has been referred to as “the black hole” of orthopedics and how surgery and rehabilitation to correct patella alignment is often unsuccessful.  Perhaps patellofemoral pain is actually just a symptom and not the source of dysfunction.

Below are what I have found to be 3 common “injuries” that may actually just be symptoms from dysfunction somewhere else within the kinetic chain.  There are many more than 3, but these are likely to be some of the most common that you may encounter.  Feel free to leave a comment of more examples that you have encountered.  Furthermore, all three fit into the kinetic chain ripple effect theory as the source of dysfunction is pretty close to the location of symptoms

 

Groin Pain – Source: Hip Joint

I have to admit that in my career I have been stumped by groin strains that seem to be difficult to treat or frequently reinjured.  I am sure we have all seen this in our practices, groin pain that doesn’t really look like a groin strain, but what is it?  As our understanding of the hip has improved, we find that many people with intra-articular hip joint pathology present with groin pain, which is a common pain referral pattern from the hip joint.

Next time you have a patient with groin pain, clear the hip, you’ll be surprised how many times we find that the symptoms are coming from the hip and that will drastically change our treatment program.

 

Lateral Epicondylitis – Source: Cervical Spine

lateral epicondylitisAnother commonly misdiagnosis that I have seen involves lateral epicondylitis.  The C6 nerve root is one of the most commonly involved nerve roots involved in cervical radiculopathy as it exits between the 5th and 6th vertebrae.  Any radiculopathy from this nerve root can cause weakness in wrist extension.  I have seen even a subtle loss of strength of wrist extension cause a raging lateral epicondylitis.  Sometimes this weakness is so subtle that the person doesn’t even realize they have weakness until it is too late.  We continue to function and use our hands with this weakness and overload the area.  So, we can treat the heck out of the lateral epicondylitis, but if we don’t solve the nerve root issue at the cervical spine we will never regain the wrist extension strength that is needed to decrease the symptoms of lateral epicondylitis.

Patellofemoral Pain – Source: The Hip

patellofemoral painWe’ve spent a lot of time discussing the contribution of the hip has on symptoms of patellofemoral pain.  [If you haven’t yet, this would be a great time to sign up for my newsletter and receive a bunch of goodies, including my eBook on Solving the Patellofemoral Mystery.]  Over the last several years, we have made a giant leap in our understanding of why some forms of patellofemoral pain occurs.  More often than not, weakness and dysfunction of the hip muscles, specifically the abductors and external rotators, is a leading cause of biomechanical faults at the knee and subsequent patellofemoral pain.  Similar to lateral epicondylitis above, you can treat the symptoms all day but you aren’t going to solve the problem if you don’t address the source, weakness and dysfunction of the hip.

 

Take Home Message

I’m sure that many of my readers have observed all of the above findings.  Please do comment and add more examples.  So what is the take home message?  For the younger clinicians in the audience, I guess it would have to be that we should probably take a step back a rethink all of the injuries that we see that we consider “difficult to treat” or “unrelenting” such as lateral epicondylitis and patellofemoral pain.  Maybe we need to think of the bigger kinetic chain principle.  Perhaps we are only treating the symptoms and not the true source of the dysfunction.  So next time you seem to have a patient that is not responding to your treatments, take a step back, re-evaluate and assess elsewhere in the kinetic chain and make sure that you haven’t missed the true source of the person’s symptoms.

Simple Exercises Can Reduce the Incidence of Patellofemoral Pain by 75%

A recent study was conducted and published in the American Journal of Sports Medicine looking at the incidence of patellofemoral pain in over 1500 military recruits undergoing a standard 14-week initial training program.  This basic military training program consisted of 3-4 hours of training daily.  Past reports have identified that up to 15% of new military recruits will develop patellofemoral pain during the initiation of basic training.  This totally makes sense as their workload likely shoots up dramatically and can be used as a great model for the observation of overuse injuries.  Just another reason to be thankful for all our troops!

The recruits were divided into two groups, the exercise group and a control group.  The exercise group began a very simple exercise program of 4 stretches and 4 strengthening exercises designed to minimize the development patellofemoral pain.  These included:

Strengthening Exercise

  • Standing isometric hip abduction against a wall
  • Forward lunges
  • Single-leg step downs from a 20cm box
  • Single-leg squats to 45 degrees of knee flexion with isometric glute contraction

patellofemoral exercises

Stretching Exercises

  • Quadriceps
  • Hamstring
  • Iliotibial band
  • Gastrocnemius

patellofemoral stretches

The strengthening exercises used body weight and progressed from 3 sets of 10 repetitions to 3 sets of 14 repetitions over the course of the 14 week program.  The isometric hip abduction exercise began with 3 sets of 1 repetition of 10 seconds and progressed to 20 seconds over 14 week.s  Stretches were held for 3 repetitions of 20 seconds over the entire 14-week duration.  Strengthening exercises were performed prior to the basic training program, while stretching exercises were performed afterward.

If we break down the exercises, we basically have a few generic stretches, an isometric exercise, and three quad exercises, one emphasizing eccentric lowering and another emphasizing concomitant glute contraction.  Pretty simple and basic.

 

Simple Exercises Can Reduce Patellofemoral Pain

The study intentionally characterized patellofemoral pain vaguely, which was fine with me.  Basically any type of patellofemoral pain or anterior knee pain.   Results of the study showed that 4.8% of people in the control group (i.e. no exercises) developed patellofemoral pain versus only 1.3% of people in the exercise group, or a reduction of incidence of developing patellofemoral pain by 75%.  That is a pretty strong reduction in patellofemoral pain.

 

What is the Take Home Message?

My first thought after reading this article was, “wow, pretty good results with such simple exercises.”  So what is the take home here?  Should we all be integrating the above exercises into our programming?  No, probably not.  My take home from all of this is actually very simple:

By performing even simple exercises, you can have a dramatic reduction in the incidence of patellofemoral pain

That is it.  I wouldn’t try to read too much into this article.  In fact, I probably would have picked 8 different exercises if I were going to design a program to prevent patellofemoral pain, wouldn’t you have?  But the results were still great.  We can only imagine what a comprehensive program would do.  Perhaps one that integrates more advanced strengthening, more emphasis on the hip, and more emphasis on balance and neuromuscular control?

Regardless, I thought this would be interesting to share and discuss to show that any exercise, even simple, is better than no exercise.

Learn more about the patellofemoral joint by downloading my eBook on Solving the Patellofemoral Mystery, free to anyone who subscribes to my newsletter – fill out the box below:

Ankle Dorsiflexion Mobility Impairs the Lateral Step Down Test

Deficits with ankle dorsiflexion mobility can have a dramatic impact on functional movements such as deep squatting, lunging, and the lateral step down.  If you are familiar with the functional movement screen, you know that this is taken into consideration when a person does not grade out with a perfect score on many of the tests.

The Lateral Step Down Test

lateral step down testOne component that I have always felt is missing from the functional movement screen (FMS) is assessing the lateral step down.  I understand that the FMS needs to be applicable to a large variety of people and that the hurdle step test is included, but I have always felt I gain additional information from using the lateral step down test, especially in high level people.

I feel that the lateral step down test is an important test to include in your movement screening as it is often a movement that is dysfunctional in people with patellofemoral pain, patellar tendonitis, ACL injuries, and other lower extremity injuries.  During the lateral step down movement, the body is challenged in a very dynamic position to produce a combination of lower extremity strength, foot and ankle stability, core stability, and probably most importantly the ability to eccentrically control or decelerate the weight of the body.

A common finding during the test is the person that can’t resist medial displacement of the knee, resulting in hip adduction, hip internal rotation, and pronation at the subtalar joint.  This places the individual in a very disadvantageous position and makes them more susceptible to lower extremity injuries.  When analyzing people with this dysfunctional movement pattern, weakness of hip abduction and external rotation is commonly found.

Ankle Dorsiflexion Tightness Alters the Lateral Step Down

Ankle Dorsiflexion TightnessA recent study in JOSPT has found that ankle dorsiflexion restrictions can also cause poor quality of movement during the lateral step down test.  Examiners studied 29 healthy women and coached them through the lateral step down test.  The subjects were graded on the quality of their lateral step down with a 6 point scale.  Results showed that subjects that performed poorly in the lateral step down test had a significant amount of ankle dorsiflexion mobility restrictions when measured in both weightbearing and nonweightbearing.  Dorsiflexion was ~10 degrees more in subjects that scored well on the lateral step down test.

Interestingly, the authors did not find a correlation between hip abduction and hip external rotation strength with poor movement quality during the test.  I was surprised by this finding but realize that there were some limitations of the study, such as the use of healthy subjects that were coached well on technique.  I continue to believe this as experience and other past research has shown this, perhaps the limitations of the study can help explain.

In my experience, the three areas that I have focused on when someone does not score well on the lateral step down test are:

  1. Hip weakness, specifically hip abduction and hip external rotation
  2. Subtalar pronation
  3. Core stability

But the results of this study are going to make me assess ankle dorsiflexion a little more closely.  It makes sense that if ankle mobility is limited, the body would have to compensate to perform the task.  In this example, to achieve greater depth of motion while stepping down, the hip strategy observed was potentially due to the lack of ankle dorsiflexion.

In your experience have you seen this?  How many people incorporate the lateral step down test in their functional movement screen, and why or why not?  The results of this study should show us that ankle mobility, specifically ankle dorsiflexion tightness, can have a profound effect on the lateral step down test.