The Effect of Strengthening Exercises of the Hip Extensor and External Rotator Muscles on Patellofemoral Pain Syndrome

  • Sirous Azizi Assistant Professor, Department of Physical Medicine and Rehabilitation, Imam Reza Hospital, AJA University of Medical Sciences, Tehran, Iran http://orcid.org/0000-0002-3251-6322
  • Morvarid Elahi General Practitioner, Tehran University of Medical Sciences, Tehran, Iran http://orcid.org/0000-0002-3379-7015
  • Afsaneh Dadarkhah MSc in Physical Therapy, Department of Physical Medicine and Rehabilitation, Imam Reza Hospital, AJA University of Medical Sciences, Tehran, Iran http://orcid.org/0000-0002-0103-7046
  • Elahe Shirzadi Resident, Department of Physical Medicine and Rehabilitation, Imam Reza Hospital, AJA University of Medical Sciences, Tehran, Iran http://orcid.org/0000-0002-5108-4449
  • Zahra Rezasoltani Associate Professor, Department of Physical Medicine and Rehabilitation, Imam Reza Hospital, AJA University of Medical Sciences, Tehran, Iran http://orcid.org/0000-0003-1864-9388
  • Fateme Abdorrazaghi Resident, Department of Physical Medicine and Rehabilitation, Imam Reza Hospital, AJA University of Medical Sciences, Tehran, Iran
Keywords: Patellofemoral pain syndrome; Quadriceps muscle; Exercise therapy

Abstract

Background: Patellofemoral pain syndrome (PFPS) is one of the most common knee disorders generally causing knee pain in active youth, particularly in runners. The main symptom of this complication is a gradual-onset vague pain in the anterior region of the knee and the posterior surface of the patella. In the current study, we aimed to assess the knee pain improvement following hip extensor and external rotator muscles’ strengthening exercises.

Methods: This randomized case-control clinical trial was conducted on 40 patients diagnosed with PFPS. The study group participated in the therapeutic strengthening exercise program for 8 weeks. The knee pain at rest, on running, stairs climbing, and during Scott exercise was measured at the beginning of the study and after completing the strengthening exercise.

Results: A total of 54 individuals were enrolled, out of which 14 were excluded due to insufficient patient data. The remaining 40 patients (all men) with the mean age of 26 ± 2 years were divided into two groups of 20 patients. The mean of the pain scores at the beginning of the study was 8.6 ± 0.8 and 8.2 ± 0.5 in the study group and the control group, respectively. The mean of pain scores decreased significantly to 6.0 ± 0.7 in the study group (P < 0.01). We had significant pain improvement on running, stairs climbing, and during Scott exercise following the strengthening exercise (P < 0.01).

Conclusion: Therapists can recommend this strengthening training program not only for the treatment of PFPS, but also for other knee disorders.

References

1. Cutbill JW, Ladly KO, Bray RC, Thorne P, Verhoef M. Anterior knee pain: A review. Clin J Sport Med 1997; 7(1): 40-5.
2. Kannus P, Aho H, Jarvinen M, Niittymaki S. Computerized recording of visits to an outpatient sports clinic. Am J Sports Med 1987; 15(1): 79-85.
3. Sanchis-Alfonso V. Anterior knee pain and patellar instability. 1st ed. London, UK: Springer-Verlag; 2006.
4. Earl JE, Vetter CS. Patellofemoral pain. Phys Med Rehabil Clin N Am 2007; 18(3): 439-58, viii.
5. Khademi-Kalantari K, Mahmoodi AS, Akbarzadeh BA, Rezayi M, Rahimi A, Naimee S. Effects of non-surgical joint distraction in the treatment of severe knee osteoarthritis. J Bodyw Mov Ther 2014; 18(4): 533-9.
6. Dastmenash S, Van den Tillaar R, Jacobs P, Shafiee GH, Shojaedin SS. The effect of whole body vibration, pnf training or a combination of both on hamstrings range of motion. World Appl Sci J 2010; 11(6): 744-51.
7. Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. J Orthop Sports Phys Ther 2003; 33(11): 647-60.
8. Stuart MJ, Meglan DA, Lutz GE, Growney ES, An KN. Comparison of intersegmental tibiofemoral joint forces and muscle activity during various closed kinetic chain exercises. Am J Sports Med 1996; 24(6): 792-9.
9. Minoonejad H, Rajabi R, Ebrahimi-Takamjani E, Alizadeh MH, Jamshidi AA, Azhari A, et al. Combined open and closed kinetic chain exercises for patellofemoral pain syndrome: A randomized controlled trial. World J Sport Sci 2012; 6(3): 278-85.
10. Smith AD, Stroud L, McQueen C. Flexibility and anterior knee pain in adolescent elite figure skaters. J Pediatr Orthop 1991; 11(1): 77-82.
11. Rubin BD, Collins HR. Runner's knee. Physician Sportsmed 1980; 8(6): 47-58.
12. Green ST. Patellofemoral syndrome. J Bodyw Mov Ther 2005; 9(1): 16-26.
13. Leardini A, Stagni R, O'Connor JJ. Mobility of the subtalar joint in the intact ankle complex. J Biomech 2001; 34(6): 805-9.
14. Brody LT, Thein JM. Nonoperative treatment for patellofemoral pain. J Orthop Sports Phys Ther 1998; 28(5): 336-44.
15. Mohammadi E, Rajabi R, Alizadeh MH. Comparison of the torso stabilizer muscles endurance infemale athletes with and without patellofemoral pain syndrome. World J Sport Sci 2012; 7(3): 149-53.
16. Akuthota V, Ferreiro A, Moore T, Fredericson M. Core stability exercise principles. Curr Sports Med Rep 2008; 7(1): 39-44.
17. Brechter JH, Powers CM. Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. Gait Posture 2002; 16(2): 115-23.
18. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: A 5.7-year retrospective follow-up study of 250 athletes. Acta Orthop Belg 1998; 64(4): 393-400.
19. Ng GY, Zhang AQ, Li CK. Biofeedback exercise improved the EMG activity ratio of the medial and lateral vasti muscles in subjects with patellofemoral pain syndrome. J Electromyogr Kinesiol 2008; 18(1): 128-33.
20. Dye SF. The pathophysiology of patellofemoral pain: A tissue homeostasis perspective. Clin Orthop Relat Res 2005; (436): 100-10.
21. Thomee R, Augustsson J, Karlsson J. Patellofemoral pain syndrome: A review of current issues. Sports Med 1999; 28(4): 245-62.
22. Draper CE, Besier TF, Gold GE, Fredericson M, Fiene A, Beaupre GS, et al. Is cartilage thickness different in young subjects with and without patellofemoral pain? Osteoarthritis Cartilage 2006; 14(9): 931-7.
23. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther 2003; 33(11): 639-46.
24. Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician 2007; 75(2): 194-202.
25. LaBella C. Patellofemoral pain syndrome: Evaluation and treatment. Prim Care 2004; 31(4): 977-1003.
26. Sanchis-Alfonso V, Rosello-Sastre E. Anterior knee pain in the young patient--what causes the pain? "Neural model". Acta Orthop Scand 2003; 74(6): 697-703.
27. Rodeo SA. Knee pain in competitive swimming. Clin Sports Med 1999; 18(2): 379-87, viii.
28. Martens M, Wouters P, Burssens A, Mulier JC. Patellar tendinitis: Pathology and results of treatment. Acta Orthop Scand 1982; 53(3): 445-50.
29. Grelsamer RP. Patellar malalignment. J Bone Joint Surg Am 2000; 82(11): 1639-50.
30. Cowan SM, Crossley KM. Does gender influence neuromotor control of the knee and hip? J Electromyogr Kinesiol 2009; 19(2): 276-82.
31. Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG. Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome. Arch Phys Med Rehabil 2006; 87(11): 1428-35.
32. Piva SR, Goodnite EA, Childs JD. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 2005; 35(12): 793-801.
33. Nouri F, Raeissadat SA, Eliaspour D, Rayegani SM, Rahimi MS, Movahedi B. Efficacy of high-power laser in alleviating pain and improving function of patients with patellofemoral pain syndrome: A single-blind randomized controlled trial. J Lasers
Med Sci 2018; 10(1): 37-43.
34. Bizzini M, Childs JD, Piva SR, Delitto A. Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. J Orthop Sports Phys Ther 2003; 33(1): 4-20.
35. Kettunen JA, Harilainen A, Sandelin J, Schlenzka D, Hietaniemi K, Seitsalo S, et al. Knee arthroscopy and exercise versus exercise only for chronic patellofemoral pain syndrome: A randomized controlled trial. BMC Med 2007; 5: 38.
36. Fagan V, Delahunt E. Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Br J Sports Med 2008; 42(10): 789-95.
37. Bolgla LA, Boling MC. An update for the conservative management of patellofemoral pain syndrome: a systematic review of the literature from 2000 to 2010. Int J Sports Phys Ther 2011; 6(2): 112-25.
38. Fredericson M, Powers CM. Practical management of patellofemoral pain. Clin J Sport Med 2002; 12(1): 36-8.
39. Witvrouw E, Werner S, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G. Clinical classification of patellofemoral pain syndrome: Guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc 2005; 13(2): 122-30.
40. Natri A, Kannus P, Jarvinen M. Which factors predict the long-term outcome in chronic patellofemoral pain syndrome? A 7-yr prospective follow-up study. Med Sci Sports Exerc 1998; 30(11): 1572-7.
41. Barton CJ, Webster KE, Menz HB. Evaluation of the scope and quality of systematic reviews on nonpharmacological conservative treatment for patellofemoral pain syndrome. J Orthop Sports Phys Ther 2008; 38(9): 529-41.
42. Clark DI, Downing N, Mitchell J, Coulson L, Syzpryt EP, Doherty M. Physiotherapy for anterior knee pain: A randomised controlled trial. Ann Rheum Dis 2000; 59(9): 700-4.
43. Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical therapy for patellofemoral pain: A randomized, double-blinded, placebo-controlled trial. Am J Sports Med 2002; 30(6): 857-65.
44. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther 2003; 33(11): 671-6.
45. Nijs J, Van GC, Van der auwera C, Van de V. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther 2006; 11(1): 69-77.
46. 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; 34(4): 630-6.
47. Kisner C, Colby LA. The hip. In: Kisner C, Colby LA, editors. Therapeutic exercise: Foundations and techniques. Philadelphia, PA: F.A. Davis; 1996. p. 709-63.
48. Grabiner MD, Koh TJ, Draganich LF. Neuromechanics of the patellofemoral joint. Med Sci Sports Exerc 1994; 26(1): 10-21.
49. Akbari A, Hosseinifar M, Kheirabadi N, Jahanshahi Javaran P. Comparison of the effect of exercise therapy with transcutaneous electrical nerve stimulation on improvement of pain and function in patients with patellofemoral pain syndrome. Armaghane-danesh 2008; 13(1): 15-27. [In Persian].
50. Bolgla LA, Malone TR, Umberger BR, Uhl TL. Hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 2008; 38(1): 12-8.
51. McMullen W, Roncarati A, Koval P. Static and isokinetic treatments of chondromalacia patella: a comparative investigation. J Orthop Sports Phys Ther 1990; 12(6): 256-66.
52. Thomee R. A comprehensive treatment approach for patellofemoral pain syndrome in young women. Phys Ther 1997; 77(12): 1690-703.
53. Heegaard J, Leyvraz PF, Curnier A, Rakotomanana L, Huiskes R. The biomechanics of the human patella during passive knee flexion. J Biomech 1995; 28(11): 1265-79.
54. Besier TF, Draper CE, Gold GE, Beaupre GS, Delp SL. Patellofemoral joint contact area increases with knee flexion and weight-bearing. J Orthop Res 2005; 23(2): 345-50.
55. Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 2004; 36(6): 926-34.
56. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: Sex differences. J Athl Train 2007; 42(1): 76-83.
Published
2019-06-01
Section
Original Article(s)