Category Archives: Patellofemoral Pain

Resisted Upright Side Stepping or Resisted Squat Side Stepping. That is the Question.

21 Monday Sep 2015

Posted by in Hip, Lower Extremity, Patellofemoral Pain

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The Journal of Orthopedic and Sports Physical Therapy published an article in the September 2015 issue about the differences between completed a resisted upright side step verses a resisted squat side step.  I found this article to be very interesting because I use these two exercises in my practice when trying to help patients who have hip abduction weakness and present with a hip drop or a trunk lean while walking.  Here is the synopsis of the article and hopefully it helps you achieve your goals.

The researchers studied the muscle activation of the gluteus maximus, gluteus medius, and tensor fascia lata (TFL).  The subjects were given a theraband and wrapped it around their ankles with about 110% tension in the band.  Pt participant was then instructed to start with their feet 12 inches apart and side step to about 24 inches apart  and back to 12 inches apart for 8 steps in each direction.  The two posture used were upright standing without flexion in the hips and knees and the subject’s preferred squatting position.

The researchers found that the greatest muscle activations of the gluteus maximus, gluteus medius, and TFL were found in the stance limb compared to the moving limb, the muscle activation of the TFL was less and the gluteus muslces was greater in the squatting position compared to the upright position, and their was more hip abduction excursion in the stance limb compared to the moving limb.

So when completing these exercise, it is important to consider which muscles you want to focus on and the functional goal that you would like to improve upon.

Berry JW, Lee TS, Foley HD, Lewis CL. Resisted side stepping: the effect of posture on hip abductor muscle activation. Phys Ther. September 2015; 45(9):675-682.

Nerve Mobilizations to Treat Anterior Knee Pain?

25 Saturday Jul 2015

Posted by in Nerves, Patellofemoral Pain

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PatellofemoralPain_SM

People suffering from anterior knee pain/patellofemoral pain usually will benefit from proper strengthening, stretching, and alignment during functional activities.  But some people tend to continue to have discomfort at their knee even when those deficits are corrected.  There has been recent research showing that people suffering from anterior knee pain can also be from mechanosensitivity/hypersensitivity.

Continued irritation and swelling tends to promote blood vessel and nerve proliferation.  Also, nerves can eventually adhere to structures at the knee such as the bone, ligament, fascia, etc. from injury.  Treatment for improving neurodynamics at the femoral nerve, and associated medial and lateral patellar branches, around the knee can prove beneficial.

Two studies by Lin et al. and Huang et al. examined the use of the Femoral Slump Test to assess neurotension at the knee and other predictors that an individual might benefit from nerve tensioning/gliding.

Individuals that may benefit from this type of treatment are people with symptoms at the anterior knee at the knee cap during stair climbing, squatting, kneeling, or sitting for a long time.  They will also be positive for more than 2 of these clinical tests:

Clarke’s sign – The individual is supine with their knee extended and pressure is applied to the knee cap as they contract their quadriceps.  The test is positive if there is a reproduction of their symptoms.

Waldron Test – The individual is supine with their knee slightly flexed and pressure is applied to the knee cap the knee is progressively flexed more.  The test is positive if there is a reproduction of their pain or crepitus.

Active Patellar Grind Test – The individual sits with their knee at 90 degrees and the examiner palpates the knee cap as the individual straightens their knee.  The test is positive if crepitus is felt during the motion.

Patellar Compression Test – The individual is supine with their knee extended.  Their knee cap is compressed and shifted superiorly.  The test is positive is there is a reproduction of their symptoms.

Assessment and completion of nerve tensioning/gliding is not appropriate if the individual’s anterior knee pain is due to other pathologies such as meniscus, ligaments, etc.

The Femoral Slump Test should be completed with measurement of hip flexion bilaterally when symptoms come on.

The test is positive if the individual’s anterior knee pain is reproduced and then reduced or eliminated with extension of the head.  If the individual has a history of lower back pain and there is a difference of hip flexion during the slump (>3 degrees on the affected side) then the prediction that nerve tensioning/gliding is greatly improved.

The authors of the article completed tensioning of the nerve by taking the hip into extension in the Femoral Slump Test position until the individual’s anterior knee pain is  first felt  then held for 2 seconds.  This was completed 10 times for 3 sets.  Improvement of knee pain was seen on the first session in 50% of subjects and in all subjects by the sixth session.

References:

  1. Lin PL, Shih YF, Chen WY, Ma HL. Neurodynamic response to the femoral slump test in patients with anterior knee pain syndrome. J Ortho Phys Ther. May 2014; 44(5):350-357.
  2. Huang BY, Shih YF, Chen WY, Ma HL. Predictors for identifying patients with patellofemoral pain syndrome responding to femoral nerve mobilization. Arch Phys Med Rehabil. 2015; 96:920-927.

The Importance of Ankle Range of Motion for Knee Pain

25 Thursday Dec 2014

Posted by in Ankle, Patellofemoral Pain, Uncategorized

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Knee Mechanics

It is important to assess multiple areas of the body when treating knee pain and more specifically patellofemoral pain (PFP).  One major contributor to knee pain is hip strength.  Good hip strength is important to aid in appropriate knee alignment and mechanics.  Another important contributor is foot alignment.  Many individuals with PFP exhibit over pronation of the midfoot/flatfoot.  This will cause the lower leg to turn in and place more stress of the patella on the femur.

But one aspect that I believe needs more consideration is ankle range of motion; specifically ankle dorsiflexion range of motion.

download

A study by Rabin et al. found that individuals with PFP had less than optimal movement during a lateral step down test and exhibited significantly less ankle dorsiflexion range of motion (4.7° in weight bearing and 5.3° in non-weight bearing) than individuals with optimal movement and without pain.  More specifically, they found that men had a significant difference of 8.5° with non-weight bearing measurements.

Could this limitation in ankle dorsiflexion range of motion be a precursor for maladaptive behavior found at the foot, knee, and hip?  The researchers proposed that the limitation in ankle dorsiflexion will cause less forward movement of the tibia when walking, running, and going up and down stairs.  This may cause excessive compensatory movement of the midfoot, such as over pronation, in order to get the needed range to complete those tasks.  This will also cause the knee to turn and place more force of the patella on the femur.

A recommendation to improve ankle dorsiflexion for people with PFP is to complete a stretch against the wall or counter holding for 30 seconds and completing 2 times.  Use this stretch (presented in the video below) until knee discomfort subsides and a lunge position with the knee on the floor can be tolerated.

A more dynamic lunge stretch (shown in the video below) can be completed to further improve ankle dorsiflexion range of motion.  Hold this position for 5 seconds and complete 20 times.  These motions should be completed on both sides even of you do not have discomfort at both legs.

 

Limitations of the study:

  1. It was not possible to determine whether limited ankle dorsiflexion range of motion is the cause of abnormal lower quality of movement or a consequence.
  2. The findings are limited to visual assessment of the quality of movement during the lateral step down test.
  3. The subgroup analysis was not preplanned and they completed the analysis only after observing abnormal tendencies in the subjects.
  4. The examiners were not completely blinded to the quality of movement assessment.
  5. The sample of subjects were younger than other populations of people with patellofemoral pain so results should not be generalized to all individuals.

Reference: Rabin A, Kozol Z, Moran U, Efergan A, Geffen Y, Finestone AS. Factors associated with visually assessed quality of movement during a lateral step-down test among individuals with patellofemoral pain. J Orthop Sports Phys Ther. 2014; 44(12): 937-946.

Patellofemoral Joint Pain Rehabilitation: How to Strengthen the Quadriceps and Limiting Joint Stress

20 Thursday Nov 2014

Posted by in Patellofemoral Pain

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knee_patella

Patellofemoral Joint (PFJ) pain is the most common knee problem and accounts for 25% of all knee injuries and is more common in females than males.(1)  Conservative treatments may consist of stretching, strengthening, balance exercises, and working on biomechanics.  But the individual dealing with the injury or the person treating that individual should consider appropriate interventions while avoiding exacerbation of symptoms and injury.

In this article, I will focus on quadriceps muscle strengthening as one aspect of conservative treatment.  Usually during a pain flareup an individual will more likely avoid certain positions leading to weakness of the leg muscles and eventually poor mechanics.  To avoid the progressive weakening of the quadriceps muscles it is important to complete exercises.  What exercises would be okay to complete without overly stressing the patellofemoral joint?

An article I just reviewed assessed the force of the patella on the femur during common rehabilitation exercises for the knee; the squat and seated knee extension.  The study showed that completing a squat from 0-45 degrees of knee flexion and seated knee extension from 90-45 degrees of knee flexion would be optimal to avoid overly stressing the PFJ.  Complete 10 repetitions 2-3 times a day and increase 5 repetitions every two weeks until you are able to complete 25 repetitions of each exercise without pain.  These exercises should be incorporated into the initial stages of PFJ rehabilitation until an individual is able to go up and down stairs or transitioning from sitting to standing from a chair without pain.  Then these exercises may be progressed to the full ranges.

Squats from 0-45 Degrees of Knee Flexion

Seated Knee Extension from 90-45 Degrees of Knee Flexion

images2

1. Sueki D, Brechter J. Orthopedic Rehabilitation Clinical Advisor. Maryland Heights, MO: Mosby, Inc.; 2010.

(Click the link below for access to the article)

Patellofemoral Joint Stress During Weight-Bearing and Non-Weight-Bearing Quadriceps Exercises

Purpose: To compare patellofemoral joint stress among weight bearing and nonweight bearing quadriceps exercises.

Methods: They assessed the knee musculature of squatting exercise (weight bearing) and two nonweight bearing knee extension exercises (seated knee extensions with variable resistance and seated knee extensions with constant resistance).  They used 10 subjects (5 male and 5 female) who did not have knee pain.

Results: They found that the squat produced significantly higher PFJ stress from 90-60 degrees knee flexion.  They reported that the two nonweight bearing exercises had significantly higher stresses from 30-0 degrees knee flexion.  And more specifically that the variable resistance produced significantly less stress than the constant resistance.

Limitations: There were 5 limitations with this study.  First, they only studied healthy individuals so the results should not be generalized to other populations.  They did not compare the exercises to a gold standard.  The researchers did not control the trunk position during the squat exercise which could change the muscle activity of the quadriceps.  They considered the segmental accelerations during the nonweight bearing exercises negligible and were not factored into the calculations.  Finally, they only studied concentric muscle activation and recommended that future studies assess eccentric muscle contractions.

Patellofemoral Pain

11 Sunday May 2014

Posted by in Patellofemoral Pain

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So I’ve been having difficulty with treating people with patellofemoral pain.  A lot of the patients that I work with will see improvements but will have flare ups when they increase their physical activity and recreational activity intensities.  I found this research article that I have been using with my patients.  The rehab protocol incorporates hip and trunk stabilization to reduce abnormal accessory motions at the knee(s).  This article has not helped to eliminate that pain in all of my patients but their frequency and intensity of flare ups have reduced.  Here is a short summary of the article and if you want the protocol (with pictures of the exercises) just let me know and I will send it your way.

Baldon RM, Serrao FV, Silva RS, Piva SR. Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2014; 44(4):240-251.(Click on the link for access to the article)

Purpose: To compare a treatment focused on hip muscle strengthening and lower limb and trunk movement control (functional stabilization training) to a treatment focused primarily on quadriceps strengthening (standard training) by their effects on knee pain and function, lower limb and trunk kinematics, trunk muscle endurance, and eccentric hip and knee strength.

Protocol: The loads for the exercises were progressed when the patients could perform the whole exercise without exacerbation of knee pain, excessive fatigue, and local muscle pain local muscle pain 48 hours after the previous training session.

8 Week Protocol

Weeks 1-2: enhance motor control of trunk and hip muscles

  • Transverse abdominis and multifidus muscle training in quadruped and prone (2 sets of 15 reps with 10 second isometric cocontractions)
  • Sitting on the Swiss ball with single leg knee extension, TA contraction, and multifidus contractions (5 reps with 20 second isometric cocontractions)
  • Isometric hip abduction/lateral rotation in standing (2 sets of 20 reps with 5 second isometric contraction
  • Swiss ball
    Isometric hip abduction/lateral rotation in standing (2 sets of 20 reps with 5 second isometric contraction
  • Isometric hipHip abduction/lateral rotation/extension in sidelying (2 sets of 20 reps with 5 second isometric contractions with an ankle weight consisting of 20% of 1 rep max)
  • Hip Extension/lateral rotation in prone (2 sets of 20 reps with 5 second isometric contractions with an ankle weight consisting of 20% of 1 rep max)
  • Side-lying clams (2 sets of 20 reps with 5 second isometric contractions with an elastic band or theraband)
  • Prone knee flexion (2 sets of 20 reps using 50% of 1 rep max)
  • Seated knee extension (2 sets of 20 reps using 50% of 1 rep max and staying in the 90-45 degree knee flexion range)
  • Single leg standing on an unstable platform with emphasis on hip flexion and forward trunk lean and contraction of TA and multifidus (3 sets of 30 seconds)

Weeks 3-5: increase strength of trunk and hip muscles and improve motor control in WB positions

  • Lateral planks and normal planks all on knees (5 sets of 30 second holds)
  • Trunk extension  on a Swiss Ball performed with arms crossed on thorax (3 sets of 12 reps)
  • SB trunk extension
    Hip abduction/lateral rotation/extension in sidelying (3 sets of 12 reps with 5 second isometric contractions with an ankle weight consisting of 75% of 1 rep max)
  • Hip Extension/lateral rotation in prone (3 sets of 12 reps with 5 second isometric contractions with an ankle weight consisting of 75% of 1 rep max)
  • Side-lying clams (3 sets of 12 reps with 5 second isometric contractions with an increased elastic band or theraband difficulty)
  • Pelvic drop in standing (3 sets of 12 reps with an ankle weight consisting of 75% of 1 rep max)
  • Hip Hikes
    Hip lateral rotation in closed kinetic chain (3 sets of 12 reps with an elastic band)
  • SLS rotation
    Single Leg Dead Lift (3 sets of 12 reps with an elastic band)
  • single leg deal lift
    Prone knee flexion (3 sets of 12 reps using 75% of 1 rep max)
  • Seated knee extension (3 sets of 12 reps using 75% of 1 rep max and staying in the 90-45 degree knee flexion range)
  • Single leg standing on an unstable platform with emphasis on hip flexion and forward trunk lean and contraction of TA and multifidus (3 sets of 30 seconds with external perturbation from a medicine ball)

Weeks 6-8: increase difficulty of WB activities with hips at neutral frontal alignment and avoid quadriceps dominance by leaning the trunk forward.

  • Lateral planks and normal planks performed on toes (5 sets of 45 to 60 seconds)
  • Trunk extension  on a Swiss Ball performed with hands behind neck (3 sets of 12 reps)
  • Hip abduction/lateral rotation/extension in sidelying (3 sets of 12 reps with 5 second isometric contractions with an ankle weight consisting of 75% of 1 rep max)
  • Hip Extension/lateral rotation in prone (3 sets of 12 reps with 5 second isometric contractions with an ankle weight consisting of 75% of 1 rep max)
  • Side-lying clams (3 sets of 12 reps with 5 second isometric contractions with an increased elastic band or theraband difficulty)
  • Pelvic drop in standing (3 sets of 12 reps with an ankle weight consisting of 75% of 1 rep max)
  • Hip lateral rotation in closed kinetic chain (3 sets of 12 reps with an elastic band)
  • Single Leg Dead Lift (3 sets of 12 reps with an elastic band)
  • Single Leg Squat with elastic band around the knee of the support limb to encourage hip abduction and lateral rotation and hip flexion and forward lean emphasized (3 sets of 12 reps)
  • Single leg squat
    Forward Lunge with elastic band around the anterior knee to encourage hip abduction and lateral rotation with an emphasis on hip flexion and forward trunk lean
  • Forward lunge
    Prone knee flexion (3 sets of 12 reps using 75% of 1 rep max)
  • Seated knee extension (3 sets of 12 reps using 75% of 1 rep max and staying in the 90-45 degree knee flexion range)
  • Single leg standing on an unstable platform with emphasis on hip flexion and forward trunk lean and contraction of TA and multifidus (3 sets of 30 seconds with external perturbation from a medicine ball)

Results:  The patients in the functional stabilization group had significantly less pain at the 3 month follow-up.  They had significantly less ipsilateral trunk movement, less contralateral pelvic drop, less hip adduction, and less knee abduction during a single leg squat.  They also presented with greater pelvic anteversion and hip flexion movement also during a single leg squat.  The functional stabilization group had significantly greater eccentric hip abductor and knee flexor strength and greater trunk muscle endurance.

Thoughts: Any other ideas on what has helped with patients suffering from patellofemoral pain?