Posts

Measuring the Position and Mobility of the Patella

Measuring the position and mobility of the patella is still a very important component of my clinical examination of the knee.  It gives me a great sense of soft tissue restrictions that may be present when patellar hypomobility is noted.  This is especially common after knee surgery.  But measuring patella mobility is also important to assess generalized laxity when patellar hypermobility is observed.

The first time you feel either of these during your clinical exam, you’ll know what I mean.

But if you read through the literature, you may find conflicting results regarding the validity and reliability of assessing patella position and mobility.

The Reliability of Measuring Patella Mobility

One study that I reference often is a systematic review by Smith, who looked at the reliability of assessing patella position, specifically in the medial-lateral position.  Like any examination technique that is commonly performed, it is necessary to establish that the test has adequate intra-rater and inter-rater reliability. The test needs to be easily replicated and produce accurate results both between two different clinicians but also when repeated during re-evaluation with the same clinician.

Otherwise, the test may have limited use and not be able to provide helpful information.

The authors conclude the intra-tester reliability is good to assess medial-lateral patellar position, but inter-tester reliability was variable.  The variability is interesting to me and makes me wonder if we just aren’t standardizing how we look at patella mobility.

Another study by Herrington demonstrated that a group of 20 experienced therapists could reliably measure patellar position.  This tells me that a group of similar trained or skilled clinicians will show greater inter-tester reliability than a randomized selection of clinicians.  When I see that a test has good intra-tester and worse inter-tester reliability, I think one of two things:
The test is difficult to perform and/or is more accurate with more experience.

Reliability can be enhanced if we all use the same examination techniques. There may be subtle differences in techniques that may produce poor inter-tester reliability. This is what came to my mind when the Herrington study showed good inter-tester reliability with a group of experienced clinicians.

The Validity of Measuring Patella Mobility

In regard to validity of the measurements, the authors conclude that the criterion validity of this test is at worse moderate, based on limited evidence.  However, a couple of interesting studies were referenced.  A study by McEwan demonstrated that a lateral tilt of the patella greater than 5 degrees can be detected.  This was confirmed with MRI measurements.  The previously reported study by Herrington also reported that medial-lateral patellar position could accurately be measured as confirmed by MRI measurements.

A Simple Way to Measure Patella Mobility

It appears that clinical measurements of patellar positions can be both reliable and valid.  While intra-tester reliability, or your own ability to accurately repeat a test, appears to be more accurate, inter-tester reliability may be enhanced with a standardized examination technique.

Taking all this into consideration, I honestly do not try to “measure” patellar position.

I will assess the position but I do not try to place a label, such as millimeters or degrees, on the exact position.  If I want or need this information, I would much rather obtain this from a MRI.  I focus more on assessing the amount of hypomobility or hypermobility.

And there is a really simple way that we can do this that I think will great enhance our reliability.

To simplify this measurement, I try to just use a percentage of the patella that I feel can displace.  Here is how I do it:

  1. I break the patella down into 4 equal segments representing 25% of the width of the patella each.
  2. I visually try to establish where I believe the midline of the trochlea is located when I am measuring position.  If I am measuring displacement, I will visualize the edge of the lateral trochlea.
  3. I then measure the percentage of the patella that is positioned beyond the midline of the trochlea and then displace the patella and attempt to determine if 25%, 50%, 75%, or 100% of the patella can displace beyond the lateral edge of the trochlea, as in the image below:

Measuring the Position and Mobility of the Patella

I’ve learned over the years that knee experts, such as Dr. Frank Noyes, consider 50% displacement to be “normal.”  I use that as a frame of reference, but comparing side-to-side is probably even more important.

I feel that this provides me with plenty of information to compare to the other extremity and simplifies the process, which I hope would enhance intra- and inter-tester reliability.  If we all do it this way, I think we’ll be far more accurate.

What do you think? Is this too simple? How do you measure patellar mobility?

 

The Best and Easiest Way to Restore Knee Extension

One of the most common complications following a knee injury or surgery is not restoring full knee extension.  Losing knee extension causes a lot of issues, ranging from anterior knee pain, to altered movement patterns, to even difficulty when walking.

It’s super important to assure you restore full knee extension.

In this video below, Lenny Macrina, my co-owner of Champion and co-author of OnlineKneeSeminar.com, shares what he considers the best way to restore full knee extension.  Luckily, it’s not only the best in our minds but also the easiest to perform!  More importantly, he discusses why he doesn’t like one of the most common exercises that people tend to use.

 

 

Learn How We Evaluate and Treat the Knee

For those interested in learning more about how Lenny and I evaluate and treat the knee, we have an amazingly comprehensive course that covers everything you need to know to master the knee.  Our detailed examination process, all our treatment progressions, and detailed information on nonoperative and postoperative treatment of ACL, patellofemoral, meniscus, articular cartilage, osteoarthritis injuries, and so much more.

 

 

 

3 Tips for Assessing the Patellofemoral Joint

The latest Inner Circle recording on 3 Tips for Assessing the Patellofemoral Joint is now available.

3 Tips for Assessing the Patellofemoral Joint

3 Tips for Assessing the Patellofemoral Joint

This month’s Inner Circle presentation is on 3 Tips for Assessing the Patellofemoral Joint.  In this live inservice recording, I discuss a few tips that that I follow when evaluating someone with anterior knee pain, or patellofemoral pain syndrome.  Often times the patellofemoral joint gets little attention during the examination.  But, in order to treat patellofemoral pain successfully, you need to have an accurate diagnosis that is very specific.  Not all anterior knee pain is the same!

This presentation will cover:

  • How your anatomy of your trochlea can alter your ability to statically stabilize
  • How to assess the static stabilizers of the patella
  • A detailed overview of how I palpate different soft tissue structures around the knee
  • How and why you need to look both proximally and distally as well as at the knee
  • The one simple test I do with everyone to assess how proximal and distal factors xalter the forces at the knee

To access this webinar:

Should We Stop Blaming the Glutes for Everything?

Today’s guest post comes from John Snyder, PT, DPT, CSCS.  John, who is a physical therapist in Pittsburgh, has a blog that has been honored as the “Best Student Blog” by Therapydia the past two years.  He’s a good writer and has many great thoughts on his website.  John discusses some of our common beliefs in regard to the role of the proximal hip on knee pain.  I’ll add some comments at the end as well, so be sure to read the whole article and my notes at the end.  Thanks John!

 

Should We Stop Blaming the Glutes for Everything?

should we stop blaming the glutes

Anterior cruciate ligament (ACL) rupture1,2 and patellofemoral pain syndrome (PFPS)3,4,5 are two of the most common lower extremity complaints that physicians or physical therapists will encounter. In addition to the high incidence of these pathologies, with regards to ACL injury, very high ipsilateral re-injury and contralateral injury have also been reported6,7,8.

With the importance of treating and/or preventing these injuries, several researchers have taken it upon themselves to determine what movement patterns predispose athletes to developing these conditions. This research indicates that greater knee abduction moments9,10, peak hip internal rotation11, and hip adduction motion12 are risk factors for PFPS development. Whereas, for ACL injury, Hewett and colleagues13 conducted a prospective cohort study identifying increased knee abduction angle at landing as predictive of injury status with 73% specificity and 78% sensitivity. Furthermore, as the risk factors for developing both disorders are eerily similar, Myer et al performed a similar prospective cohort study finding that athletes demonstrating >25 Nm of knee abduction load during landing are at increased risk for both PFPS and ACL injury14.

 

Does Weak Hip Strength Correlate to Knee Pain?

With a fairly robust amount of research supporting a hip etiology in the development of these injuries, it would make sense that weakness of the hip musculature would also be a risk factor, right?

A recent systematic review found very conflicting findings on the topic. With regards to cross-sectional research, the findings were very favorable with moderate level evidence indicating lower isometric hip abduction strength with a small and lower hip extension strength with a small effect size (ES)15. Additionally, there was a trend toward lower isometric hip external rotation and moderate evidence indicates lower eccentric hip external rotation strength with a medium ES in individuals with PFPS15. Unfortunately, the often more influential prospective evidence told a different story. Moderate-to-strong evidence from three high quality studies found no association between lower isometric strength of the hip abductors, extensors, external rotators, or internal rotators and the risk of developing PFPS15. The findings of this systematic review indicated hip weakness might be a potential consequence of PFPS, rather than the cause. This may be due to disuse or fear avoidance behaviors secondary to the presence of anterior knee pain.

 

Does Hip Strengthening Improve Hip Biomechanics?

Regardless of its place as a cause or consequence, hip strengthening has proved beneficial in patients with both PFPS16,17,18 and following ACL Reconstruction19, but does it actually help to change the faulty movement patterns?

Gluteal strengthening can cause several favorable outcomes, from improved quality of life to decreased pain, unfortunately however marked changes in biomechanics is not one of the benefits. Ferber and colleagues20 performed a cohort study analyzing the impact of proximal muscle strengthening on lower extremity biomechanics and found no significant effect on two dimensional peak knee abduction angle. In slight contrast however, Earl and Hoch21 found a reduction in peak internal knee abduction moment following a rehabilitation program including proximal strengthening, but no significant change in knee abduction range of motion was found. It should be noted that this study included strengthening of all proximal musculature and balance training, so it is hard to conclude that the results were due to the strengthening program and not the other components.

 

Does Glute Endurance Influence Hip Biomechanics?

All this being said, it is possible that gluteal endurance may be more influential than strength itself, so it would make sense that following isolated fatigue of this musculature, lower extremity movement patterns would deteriorate.

Once again, this belief is in contrast to the available evidence. While fatigue itself most definitely has an impact on lower extremity quality of movement, isolated fatigue of the gluteal musculature tells a different story. Following a hip abductor fatigue protocol, patients only demonstrated less than a one degree increase in hip-abduction angle at initial contact and knee-abduction angle at 60 milliseconds after contact during single-leg landings22. In agreement with these findings, Geiser and colleagues performed a similar hip abductor fatigue protocol and found very small alterations in frontal plane knee mechanics, which would likely have very little impact on injury risk23.

 

Can We Really Blame the Glutes?

The biomechanical explanation for why weakness or motor control deficits in the gluteal musculature SHOULD cause diminished movement quality makes complete sense, but unfortunately, the evidence at this time does not agree.

While the evidence itself does not allow the gluteal musculature to shoulder all of the blame, this does not mean we should abandon addressing these deficits in our patients. As previously stated, posterolateral hip strengthening has multiple benefits, but it is not the end-all-be-all for rehabilitation or injury prevention of lower extremity conditions. Proximal strength deficits should be assessed through validated functional testing in order to see its actual impact on lower extremity biomechanics on a patient-by-patient basis. Following this assessment, interventions should be focused on improving proximal stability, movement re-education, proprioception, fear avoidance beliefs, graded exposure, and the patient’s own values, beliefs, and expectations.

 

John SnyderJohn Snyder, PT, DPT, CSCS received his Doctor of Physical Therapy degree from the University of Pittsburgh in 2014. He created and frequently contributes to SnyderPhysicalTherapy.com (Formerly OrthopedicManualPT.com), which is a blog devoted to evidence-based management of orthopedic conditions.  

 

Mike’s Thoughts

John provides an excellent review of many common beliefs in regard to the influence of the hip on knee pain.  While it is easy to draw immediate conclusions from the result of one study or meta-analysis, one must be careful with how they interpret date.

I think “anterior knee pain,” or even PFPS, is just too broad of a term to design accurate research studies.  It’s going to be hard to find prospective correlations with such vague terminology.  Think of it as watering down the results.  Including a large sample of people, including men, women, and adolescents and attempting to correlate findings to “anterior knee pain” is a daunting task.

Imagine if we followed a group of adolescents from one school system for several years.  Variations in gender, sport participation, recreational activity, sedentary level, and many more factors would all have to be considered.  Imagine comparing the development of knee pain in a 13 year old sedentary female that decided she wanted to run cross country for the first time with an 18 year old male basketball player that is playing in 3 leagues simultaneously.  Two different types of subjects with different activities and injury mechanisms.  But, these two would be grouped together with “anterior knee pain.”

What do we currently know?  We know hip weakness is present in people with PFPS and strengthening the hips reduces symptoms.  As rehabilitation specialists, that is great, we have a plan.  I’m not sure we can definitely say that hip weakness will cause knee pain, but I’m also not sure we can say it won’t.  Designing a prospective study to determine may never happen, there are just too many variables to control.

John does a great job presenting studies that require us to keep an open mind.  I’m not sure we can make definitive statements from these results, but realize that there are likely many more variables involved with the development of knee pain.  Hip strength and biomechanics may just be some of them.  Thanks for sharing John and helping us to remember that it’s not always the glutes to blame!

 

 

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]

 

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: