Posts tagged patellofemoral pain
What Are The Best Treatments For Patellofemoral Pain?

Patellofemoral pain syndrome or pain under the knee cap is the most common diagnosis in the knee and a frequent reason patients seek out the care of their primary care physician or Physical Therapist. Patient’s with this condition often experience aching or sharp pain under or around the knee cap (patella) during squatting, running, jumping, stair climbing, hiking, and prolonged sitting. Pain results from abnormal contact between the knee cap and thigh (femur). Prior thoughts on this condition believed the knee cap was responsible for the abnormal contact and interventions were designed to target the patella.

Outdated theories including balance between the outer and inner quadriceps muscle have been replaced by better research indicating the hip may play a more significant role in the condition. The hip musculature including the gluts contribute significantly to the alignment of the thigh under the knee cap. As the alignment improves a greater portion of the joint surface area is able to distribute the forces across the knee reducing joint pressure and pain. The quadriceps function to dissipate the forces across the knee and should be targeted along with the hip musculature in this condition.

The Journal of Orthopedic Sports Physical Therapy recently published their clinical practice guidelines including the best available medical evidence and expert opinion on how to effectively diagnosis and treat this condition (Willy et al. 2019). Authors reviewed 4500 scientific articles on this condition between 1960 and present day. They selected 271 articles for the review and broke down their findings into the most supported risk factors, examination tests, diagnosis, treatments, and prognostic factors. Authors found most individuals with this condition improve with Physical Therapy interventions including activity modification and strength training. Patients may also benefit from short term (< 6 weeks) utilization of foot orthotics and taping for pain relief. Authors reported manual therapy and dry needling were not shown to be useful for this condition.

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Strengthening Exercises For Patellofemoral Pain

Patellofemoral pain, or pain around the kneecap, is one of the most common types of knee pain we treat at MEND. It impacts up to 23% of the general population and 40% of those people have persistent symptoms that can last for years! Exercise programs targeting the hip and the knee have been proven effective in managing hip and knee pain.  Most of the exercise programs studied to date have either not provided sufficient exercise progression to improve strength and power or have not been extended long enough to sustain gains in strength or power (which may result in recurrence of symptoms).

 A recent study (Barton et al 2019) reported significant improvements in patellofemoral pain, function and hip muscle capacity with a 12-week progressive strengthening program that can easily be performed at the gym. The key differentiator of this study was that the exercises were progressive – either the challenge of the exercise increased (ie: 2-leg squat to 1-leg squat) or the resistance of the exercise was progressed to ensure participants stayed in a perceived exertion range of 7-9 (which typically means you are only able to perform 1-2 reps in your set).

The exercises included in this study were:

1.     Bridging – 3 sets of 12 repetitions

Double to Single leg

2.     Hip abduction - 3 sets of 12 repetitions

a.     Sidelying to Standing Progression

3.     Plank progressions 3 x 60 sec

a.     Front and Side Planks

4.     Optional quad exercises including squats and single leg squats.

5.     Hamstring Strengthening including body weight and machine.

Authors concluded the 12 week progressive resistance training program was safe and effective for improving pain and function in patients with patellofemoral pain. Stay tuned to our social media for an exercise videos.

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Which Muscle's Weakness Predicts Future Knee Pain?

Patellofemoral Pain Syndrome, pain under the knee cap, is the most common diagnosis of knee pain affecting both sedentary and active individuals. Muscle weakness in the hip and knee are often present in individuals with this diagnosis, but a cause and effect relationship between strength and knee pain has been difficult to established. In short, the research is divided on this relationship especially within the variable of hip weakness. Thus questions remain on which muscle imbalances may predispose an otherwise pain free individual for future patellofemoral pain.

A recent systematic review of the available evidence on the development of patellofemoral pain syndrome reviewed 18 studies of 4818 research participants (Neal et al. Br J Sp Med. 2019). Authors found three common groups of research subjects including military recruits, adolescents, and runners. They reported moderate to strong evidence body mass index, age, and leg alignment were not predictive of future knee pain. Interestingly, although common in clinical patients, moderate evidence reported hip weakness was not predictive of future knee pain. Authors reported quadricep weakness, especially among military recruits, was associated with future onset of knee pain.

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Reducing Your Risk for Knee Pain

Patellofemoral pain (PFP) is characterized by diffuse pain behind or around the patella or knee cap. It occurs when the knee is loaded and bent with activities such as: running, jumping, squatting or ascending/descending stairs. The prevalence of PFP is 22.7% in both adults and adolescents, and with the inherit link between PFP and Knee Osteoarthritis, further investigation is warranted to look at the factors contributing to PFP in order to develop successful injury prevention programs. A recent article was published on predictive variables for future development PFP (Bradley et al. BJSM 2018).

The authors reviewed 18 prospective studies, including over 4,800 participants (Military, Runners, Adolescents) to investigate factors contributing to PFP. Factors contributing included: weakness in quadriceps and increased baseline hip abduction strength. Contrary to past evidence, there is no change in likelihood of developing PFP with sex, BMI or Q angle of hips and knees.  Targeting quadriceps and hip strengthening exercises, as well as, assessing movement mechanics are appropriate interventions and preventative treatments for PFP.

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Is My Hip Or Knee More To Blame For My Knee Pain?

The knee is a vulnerable joint at times due to its' location adjacent to the two long levers of our thigh and leg bones.  The length of the levers allows the ankle and hip to exert a high amount of forces across the knee.  The importance of treating these adjacent joints in patients with knee pain is reflected in our current understanding of functional movements including walking, stair climbing, hiking, and running.  Patient's who experience knee pain during these movements frequently demonstrate hip weakness and an inability to control their knee position during single limb loading.  The increased load under the knee cap is due to abnormal pressure and contact area on the thigh (femur).  A recent biomechanical analysis quantifies the knee cartilage stresses at the patellofemoral joint highlighting the importance of analyzing the hip in patients with knee pain.

Liao and colleagues analyzed cartilage stresses between the knee cap and thigh during squatting tasks with varying degrees of thigh and shin rotation (Clin Biomech. 2018).  The authors found a progressively greater cartilage stresses with increasing degrees of thigh rotation, but found a decrease in cartilage stress with progressive shin rotation.  Additionally, progressive thigh movement toward the midline of the body also was shown to increase knee cartilage loading.  The authors concluded thigh internal rotation and movement toward the midline had the greatest impact on knee cartilage forces.  These findings support prior research studies highlighting the importance of examining and treating the hip in patients with knee pain.

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Muscle Weakness Differs Between Males and Females with Knee Pain
knee-pain-patellofemoral pain-exercises

Patellofemoral pain syndrome (pain around the knee cap) is the most frequent cause of knee pain and the most common diagnosis seen in sports medicine and physical therapy clinics.  The condition is often the result of a change in the dynamic alignment of the leg and knee joint during functional activities such as squatting, stair climbing, and running.  Contributing factors often include a loss of ankle mobility, as well as, hip weakness.  Many people assume the hip abductors or glut medius musculature is to blame, but without a thorough assessment most important muscle impairments are missed.  A new article reports on which muscle groups are weakest among males with patellofemoral pain syndrome. 

The International Journal of Sports Physical Therapy reported on the strength differences between males and females with knee pain (Hoglund et al. 2018).  Authors recruited 36 asymptomatic males and 36 males with patellofemoral pain syndrome into their study and examined the strength of their hip and knee joints.  The authors found significant differences in gluteus maximus or hip extensor strength between the two male groups.  Interestingly, no differences were noted between gluteus medius or hip abductor strength.  This study highlights strength differences between females, frequently hip abductor weakness, and males with knee pain.  

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