The outcome of hip exercise in patellofemoral pain: A systematic review

Persons with patellofemoral pain exhibit altered hip abductor muscle recruitment while performing hip abductor exercises

INTRODUCTION

Strengthening of the hip abductors has been advocated for persons with patellofemoral pain (PFP). It is not clear if these individuals activate the hip abductor muscles appropriately to achieve the desired therapeutic effects.

OBJECTIVE

To compare activation of the hip abductor muscles between persons with and without PFP during the performance of hip abductor exercises.

METHODS

Thirty-two individuals participated (12 with PFP and 20 without PFP). The average age (± standard deviation) was 29.7 ± 5.9 years for the PFP group and 28.1 ± 6.9 for the control group. Electromyographic (EMG) signals from the gluteus medius (GMED), superior gluteus maximus (SUP-GMAX), and tensor fascia lata (TFL) were obtained using fine-wire electrodes while participants performed 11 different exercises. Normalized EMG activity of each muscle was compared between groups across all exercises.

RESULTS

When averaged across all exercises, persons with PFP exhibited significantly greater EMG activity of TFL (mean = 25.3% MVIC; 95% CI = 19.2, 31.3) compared to those without PFP (mean = 17.6% MVIC; 95% CI = 12.8, 22.4) and significantly lower EMG activity of SUP-GMAX (mean = 16.4% MVIC; 95% CI = 11.0, 22.0) compared to those without PFP (mean = 25.4% MVIC; 95% CI = 21.0, 29.8). Persons with PFP exhibited lower EMG activity of GMED, but only for 3 out of the 11 exercises evaluated (hip abduction, hip hike, step-up).

CONCLUSION

Compared to persons without PFP, those with PFP exhibited activation differences during the performance of exercises used to target the hip abductors. Our results highlight the need for activation training prior to the initiation of strengthening exercises to achieve desired therapeutic effects.

Effects of taping in patellofemoral pain syndrome: A systematic review

BACKGROUND

Patellofemoral pain syndrome (PPS) is defined as a condition in the patellofemoral joint that can present with pain, functional deficit, crepitus, and instability. Its etiology appears to lie in excessive loading of the patellofemoral joint due to mispositioning of the patella. The application of taping has recently increased, to manage PPS. However, the level of scientific evidence in this sense is unknown.

OBJECTIVE

To determine the effect of different types of taping in subjects with PPS.

METHODS

A bibliographic search was carried out in January and February 2021 in Scopus, Web of Science, PubMed, Medline, SPORTDiscus, PEDro and CINAHL.

RESULTS

A total of 13 studies were included for qualitative analysis. The mean score on the PEDro scale was 5.30 points. Most of the articles reflect a decrease in pain after the taping intervention, while variables such as functionality, muscle activity and biomechanical modification do not show positive effects.

CONCLUSION

Taping appears to have positive effects on pain in subjects with PPS. However, the evidence is contradictory with the rest of the variables studied.

Efficacy of Hip Strengthening on Pain Intensity, Disability, and Strength in Musculoskeletal Conditions of the Trunk and Lower Limbs: A Systematic Review with Meta-Analysis and Grade Recommendations

To investigate the efficacy of hip strengthening on pain, disability, and hip abductor strength in musculoskeletal conditions of the trunk and lower limbs, we searched eight databases for randomized controlled trials up to 8 March 2022 with no date or language restrictions. Random-effect models estimated mean differences (MDs) with 95% confidence intervals (CIs), and the quality of evidence was assessed using the GRADE approach. Very low quality evidence suggested short-term effects (≤3 months) of hip strengthening on pain intensity (MD of 4.1, 95% CI: 2.1 to 6.2; two trials, n = 48 participants) and on hip strength (MD = 3.9 N, 95% CI: 2.8 to 5.1; two trials, n = 48 participants) in patellofemoral pain when compared with no intervention. Uncertain evidence suggested that hip strengthening enhances the short-term effect of the other active interventions on pain intensity and disability in low back pain (MD = -0.6 points, 95% CI: 0.1 to 1.2; five trials, n = 349 participants; MD = 6.2 points, 95% CI: 2.6 to 9.8; six trials, n = 389 participants, respectively). Scarce evidence does not provide reliable evidence of the efficacy of hip strengthening in musculoskeletal conditions of the trunk and lower limbs.

Lateral Patellar Dislocation: A Critical Review and Update of Evidence-Based Rehabilitation Practice Guidelines and Expected Outcomes

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Nonoperative treatment of a lateral patellar dislocation produces favorable functional results, but as high as 35% of individuals experience recurrent dislocations.

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Medial patellofemoral ligament reconstruction is an effective treatment to prevent recurrent dislocations and yield excellent outcomes with a high rate of return to sport.

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Both nonoperative and postoperative rehabilitation should center on resolving pain and edema, restoring motion, and incorporating isolated and multijoint progressive strengthening exercises targeting the hip and knee.

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Prior to return to sports, both functional and isolated knee strength measurements should be used to determine leg symmetry strength and to utilize patient-reported outcome measures to assess the patient's perceived physical abilities and patellofemoral joint stability.

Treatment Options for Patellofemoral Arthritis

PURPOSE OF REVIEW

To present a synthesis of recent literature regarding the treatment of patellofemoral arthritis RECENT FINDINGS: Risk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature. Patellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.

Autoregulation in Resistance Training for Lower Limb Tendinopathy: A Potential Method for Addressing Individual Factors, Intervention Issues, and Inadequate Outcomes

Musculoskeletal disorders, such as tendinopathy, are placing an increasing burden on society and health systems. Tendinopathy accounts for up to 30% of musculoskeletal disorders, with a high incidence in athletes and the general population. Although resistance training has shown short-term effectiveness in the treatment of lower limb tendinopathy, more comprehensive exercise protocols and progression methods are required due to poor long-term outcomes. The most common resistance training protocols are predetermined and standardized, which presents significant limitations. Current standardized protocols do not adhere to scientific resistance training principles, consider individual factors, or take the importance of individualized training into account. Resistance training programs in case of tendinopathy are currently not achieving the required intensity and dosage, leading to high recurrence rates. Therefore, better methods for individualizing and progressing resistance training are required to improve outcomes. One potential method is autoregulation, which allows individuals to progress training at their own rate, taking individual factors into account. Despite the finding of their effectiveness in increasing the strength of healthy athletes, autoregulation methods have not been investigated in case of tendinopathy. The purpose of this narrative review was 3-fold: firstly, to give an overview and a critical analysis of the individual factors involved in tendinopathy and current resistance training protocols and their limitations. Secondly, to give an overview of the history, methods, and application of autoregulation strategies both in sports performance and physiotherapy. Finally, a theoretical adaptation of a current tendinopathy resistance training protocol using autoregulation methods is presented, providing an example of how the method could be implemented in clinical practice or future research.

How effective is an evidence-based exercise intervention in individuals with patellofemoral pain?

OBJECTIVES

Guidelines for a comprehensive rehabilitation programme for patellofemoral pain (PFP) have been developed by international experts. The aim of this study was to analyse the effect of such a rehabilitative exercise programme on pain, function, kinesiophobia, running biomechanics, quadriceps strength and quadriceps muscle inhibition in individuals with PFP.

DESIGN

Observational study.

SETTING

Clinical environment.

PARTICIPANTS

Twenty-seven participants with PFP.

MAIN OUTCOME MEASURES

Symptoms [numeric pain rating scale (NPRS)and the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS)], function measured by using the KUJALA scale and KOOS, kinesiophobia measured by using the Tampa scale, three-dimensional biomechanical running data, quadriceps isometric, concentric and eccentric strength and arthrogenic muscle inhibition (AMI) were acquired before and after the six-week exercise programme.

RESULTS

Although pain did not significantly improve all patients were pain-free after the six-week exercise programme (NPRS: p = 0.074). Function, kinesiophobia and quadriceps AMI improved significantly after the six-week exercise programme (KUJALA: p = 0.001, KOOS: p = 0.0001, Tampa: p = 0.017, AMI: p = 0.018). Running biomechanics during stance phase did not change after the exercise intervention. Quadriceps strength was not different after the six-week exercise programme (isometric: p = 0.992, concentric: p = 0.075, eccentric: p = 0.351).

CONCLUSION

The results of this study demonstrate that the current exercise recommendations can improve function and kinesiophobia and reduce pain and AMI in individuals with PFP. There is a need for reconsideration of the current exercise guidelines in stronger individuals with PFP.

Additional effects of core stability exercises on pain and function of patients with patellofemoral pain: A randomized controlled trial

Background/purpose:

Recently, there is more emphasis on the role of core muscles in pathogenesis and rehabilitation of patellofemoral pain (PFP). We aimed to investigate whether increased core muscle strength and endurance improve clinical outcomes.

Methods:

In a randomized controlled trial, 60 patients (M/F: 25/35, age = 32.28 (5.9) years) with PFP were randomly allocated into two groups of routine exercise (control) and combined core plus routine exercise (intervention). Home exercise was scheduled at least 5 times/week for 12 weeks. We assessed the outcomes of pain (Visual analogue scale) and function (Anterior knee pain score) before and immediately after interventions.

Results:

Significant improvements were reported in both groups (P < 0.001). There were significant between-group differences in both outcomes in favor of the intervention (Pain: 12.4, CI 95%: 7.1–17.8, P < 0.001; Function: 6.4, CI 95%: 2.2–10.5, P = 0.003).

Conclusion:

Outcome improvements were significantly greater in intervention group. Inclusion of core stability exercises may lead to additional benefits.

Hip Muscle Strengthening for Knee Osteoarthritis: A Systematic Review of Literature

BACKGROUND AND PURPOSE

Osteoarthritis (OA) of the knee joint results in chronic pain and functional decline among older adults. Hip muscle weakness has been observed in persons with knee OA and is claimed to increase the medial compartment loading on the knee joint. Although individual studies are available, no review has yet integrated the literature on the benefits of hip muscle strengthening for persons with knee OA. This review aims to systematically summarize the current evidence on the effectiveness of hip muscle strengthening on knee pain, lower extremity function, and biomechanical measures of the knee in persons with knee OA.

METHODS

An extensive electronic literature search was conducted in the databases PubMed, Scopus, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and Physiotherapy Evidence Database (PEDro) to identify the published trials in the English language from January 1990 to August 2017. Randomized controlled trials that studied the effectiveness of hip muscle strengthening in persons with knee OA on knee pain, physical function, and biomechanical measures of the knee were considered for inclusion. The key word combinations were knee osteoarthritis, degenerative arthritis, arthralgia, muscle strengthening, and resistance training using the Boolean operators AND, OR. Two reviewers independently performed the study selection, and a third reviewer intervened when the consensus was not attained. Quality assessment of the included studies was carried out using the PEDro scale.

RESULTS AND DISCUSSION

The search produced 774 results, from which 81 full-text articles were studied. Five randomized controlled trials of good methodological quality, including 331 participants, were included in the review. The effectiveness of hip muscle strengthening was assessed in isolation, combination, and comparison with other lower extremity exercise. Overall, the studies reported clear benefits of hip muscle strengthening on knee pain, physical function, and hip muscle strength. However, hip muscle strengthening was ineffective in improving the biomechanical measures such as dynamic alignment and knee adduction (also known as valgus) moment.

CONCLUSION

The current review identified strong, high-quality evidence to recommend hip muscle strengthening in the conservative management of persons with knee OA. Further research is needed to establish the underlying mechanisms for the clinical benefits.

Association Between Hip Rotation and Activation of the Quadriceps and Gluteus Maximus in Male Runners

Background:

Although running can provide health benefits, knee joint injuries are frequently reported by recreational runners. To date, the precise mechanism responsible for anterior knee pain remains elusive, and the source of symptoms is debated. Inconsistencies are found in the literature pertaining to the relationship between hip mechanics and activity in the quadriceps and gluteus maximus (GMax) during the running gait.

Purpose/Hypothesis:

To investigate the correlations between hip rotation and the activity in the quadriceps and GMax during running. We hypothesized that increased hip rotation is correlated with decreased activity in these muscles.

Study Design:

Descriptive laboratory study.

Methods:

A cohort of 30 healthy recreational runners volunteered to participate in the study (mean ± SD age, 28.8 ± 5.66 years; height, 1.73 ± 0.05 m; mass, 69 ± 6.3 kg; body mass index, 23.02 ± 1.42 kg/m²). Surface electromyography (EMG) data were obtained from the GMax, vastus medialis obliquus (VMO), and vastus lateralis obliquus (VLO). These data were synchronized with a motion capture system during a level-surface running activity at a speed of 3.2 m/s.

Results:

A significantly strong, negative correlation was found between the hip internal rotation angle and EMG activity of the GMax and the VMO. However, the VLO showed a significant, moderate, and positive correlation of activity with the hip internal rotation angle.

Conclusion:

The present study showed that during level-surface running, decreased GMax activity may be the cause of distal joint injuries and alteration in quadriceps muscle activity.

Clinical Relevance:

Because GMax activity is important for controlling the lower body mechanics during running, evaluating GMax activity and internal hip rotation angle is important to prevent the running-related knee injuries that are linked to quadriceps deficits, such as patellofemoral pain. Additionally, clinicians and trainers should consider strengthening the GMax while rehabilitating running-related knee injuries.

Medical Interventions for Patellofemoral Pain and Patellofemoral Osteoarthritis: A Systematic Review

Patellofemoral pain (PFP) and patellofemoral osteoarthritis (PFOA) are common, persistent conditions that may lie along a pathological spectrum. While evidence supports exercise-therapy as a core treatment for PFP and PFOA, primary care physicians commonly prescribe medication, or refer for surgical consults in persistent cases. We conducted a systematic review of medical interventions (pharmaceutical, nutraceutical, and surgical) for PFP and PFOA to inform primary care decision making. Methods: Following protocol registration, we searched seven databases for randomized clinical trials of our target interventions for PFP and PFOA. Our primary outcome was pain. We assessed risk of bias, calculated standardized mean differences (SMDs) and determined the level of evidence for each intervention. Results: We included 14 publications investigating pharmaceutical or nutraceutical interventions, and eight publications investigating surgical interventions. Two randomized control trials (RCTs) provided moderate evidence of patellofemoral arthroplasty having similar pain outcomes compared to total knee arthroplasty in isolated PFOA, with SMDs ranging from −0.3 (95% CI −0.8, 0.2, Western Ontario McMaster Pain Subscale, 1 year post-surgery) to 0.3 (−0.1, 0.7, SF-36 Bodily Pain, 2 years post-surgery). Remaining studies provided, at most, limited evidence. No efficacy was demonstrated for oral nonsteroidal anti-inflammatories or arthroscopic surgery. Conclusions: Pharmaceutical and nutraceutical prescriptions, and surgical referrals are currently being made with little supporting evidence, with some interventions showing limited efficacy. This should be considered within the broader context of evidence supporting exercise-therapy as a core treatment for PFP and PFOA.

Do exercises for patellofemoral pain reflect common injury mechanisms? A systematic review

OBJECTIVES

Current best evidence has reported that therapeutic exercise programs that are designed to treat patellofemoral pain (PFP) should include both hip and knee specific exercises. The purpose of this review was to (1) examine the quality/comprehensiveness of exercise reporting in this field; (2) quantify the extent to which individual exercises comprised task-specific elements (single limb stance; eccentric control of the hip; rotational z-axis control) most likely to address key pathomechanics associated with PFP.

DESIGN

Systematic review: a systematic survey of RCTs.

METHODS

PubMed, CINAHL, Medline, Physiotherapy Evidence Database (PEDro) and SPORT Discus databases were searched for randomized controlled trials that addressed PFP utilizing a proximal control hip focused rehabilitation paradigm. The therapeutic exercise programs were evaluated, and each individual exercise was extracted for analysis. Quality assessments included the PEDro Scale and the Consensus on Exercise Reporting Template (CERT) was utilized to score the reporting of the interventions.

RESULTS

19 studies were included in the final analysis. 178 total exercises were extracted from the proximal hip and knee rehabilitation programs. The exercises were analyzed for the inclusion of elements that align with reported underlying biomechanical mechanisms.

CONCLUSIONS

The vast majority of the exercises were sagittal plane, concentric, non-weight bearing exercises, whereas multiplanar exercises, single limb weightbearing, and exercises where loading was directed around the longitudinal z-axis, were considerably under-represented. Current exercises for PFP utilize simplistic frameworks that lack progression into more task specific exercise, and are not reflective of the complex injury etiology.

Addition of specific hip strengthening exercises to conventional rehabilitation therapy for low back pain: a systematic review and meta-analysis

OBJECTIVE

To examine the effectiveness of hip strengthening exercises in reducing pain and disability in persons with low back pain.

METHODS

We searched for randomized controlled clinical trials on MEDLINE, the Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, LILACS, Scielo and CINAHL from the earliest date available to June 2020. Studies that included hip strengthening exercises for persons with low back pain and included pain and/or disability as an outcome measure were evaluated by two independent reviewers. Mean difference (MD), and 95% confidence interval (CI) were estimated by random effect models.

RESULTS

Five studies met the eligibility criteria (309 patients). Four studies included hip strengthening in conjunction with other interventions, while one study evaluated hip strengthening as a standalone intervention. Hip strengthening exercises improved pain (MD -5.4 mm, 95% CI: -8.9 to -1.8 mm), and disability (MD -2.9; 95% CI: -5.6 to -0.1) in persons with low back pain compared to interventions in which hip strengthening was not utilized. The quality of evidence for the pain outcome, was assessed as being moderate. The quality of evidence for the outcome of self-reported disability, was assessed as being low.

CONCLUSION

Addition of specific hip strengthening exercises to conventional rehabilitation therapy may be beneficial for improving pain and disability in persons with low back pain.

Hip morphology and its relationship with hip strength, mobility and lower limb biomechanics: a systematic review in adults

Abstract This systematic review (PROSPERO registration n.43640) aimed to summarise and determine the quality of evidence relating hip bone morphology to (i) hip strength, (ii) mobility and (iii) lower limb biomechanics during functional activities. A standardized search on MEDLINE/PubMed, Web of Science, ScienceDirect and Scopus resulted in 17 papers that met inclusion criteria: i) original investigations with a minimal sample of n=10, ii) studies on humans and iii) presence of at least one quantitative hip morphological parameter and one hip functional (i.e. strength and mobility) and/or one lower limb biomechanical parameter. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool with adaptations. Sixteen out of the 17 included studies showed high risk of bias. We observed that primary evidence pointed to the influence of hip morphology on hip mobility in the transverse plane. Specifically, positive correlations between femoral anteversion angle and range of internal hip rotation in physical examination were observed. Regarding biomechanical parameters, no clear evidence of association between hip morphology, and kinematic and kinetic parameters were found. Our results point to a field that is currently under explored and future studies with low risk of bias addressing these relationships are required.

The effects of gluteal squeezes compared to bilateral bridges on gluteal strength, power, endurance, and girth

BACKGROUND

Hip extension weakness is correlated with low back, hip, and knee pathology. Isometric gluteal squeezes have been shown to elicit high electromyographic gluteal activity. However, there is little research regarding the specific effects of isometric gluteal squeezes on hip strength and functional outcomes. The purpose of this study was to identify the effects of gluteal squeezes on hip extension strength, vertical jump, broad jump, single-leg bridge endurance, and gluteal girth compared to bilateral gluteal bridging.

METHODS

A total of 32 healthy university students (mean age 23.28 ± 2.15 years) were randomly assigned to perform either gluteal squeezes or bilateral bridges daily. Subjects were tested at baseline and after 8 weeks of training. Subjects' hip extension strength, vertical jump, broad jump, single-leg bridge endurance, and gluteal girth were tested.

RESULTS

No statistically significant differences were found between the bridge and squeeze groups after 8 weeks of training. Both groups significantly improved hip extension strength bilaterally (p = 0.000-0.011). The squeeze group significantly increased gluteal girth at the level of the greater trochanter (p = 0.007), but no significant girth increase was seen in the bridge group (p = 0.742). Although increases were seen in both groups for the endurance and jump tasks, no statistically significant changes occurred for those outcomes. All outcome measurements demonstrated high reliability (ICC = 0.93-0.99).

CONCLUSION

Gluteal squeezes were as effective as bilateral bridges for increasing hip extension strength. Gluteal squeezes also significantly increased girth at the level of the greater trochanter. These results provide clinical and aesthetic reasons to perform gluteal squeezes.

Electromyographic activity of the quadriceps and gluteus medius muscles during/different straight leg raise and squat exercises in women with patellofemoral pain syndrome

Patellofemoral pain syndrome (PPS) is characterized by anterior knee pain and affects young female adults. Physiotherapy is the most indicated treatment. The objective of the study was to analyze electromyographic activity of the quadriceps and gluteus medius muscles during different open and closed kinetic chain exercises in women with PPS. Twenty-two clinically healthy women and 24 women with symptomatic PPS were assessed through surface electromyography of the quadriceps and gluteus medius during the following exercises: straight leg raise with and without lateral hip rotation; squats; squats with adduction and hip abduction; and squats combined with lateral hip rotation. When comparing the groups, only the quadriceps muscle showed higher activity in the PPS group. In the comparisons between the exercises, in relation to gluteus medius and quadriceps muscle activity, the straight leg raise and straight leg raise with lateral hip rotation exercises showed more activity than squats in both groups. Among the squats, squats with adduction generated more gluteus medius activity in both groups, and no difference was noted among the squats for the quadriceps muscle. Therefore, rehabilitation programs that include exercises such as straight leg raises, straight leg raises with lateral hip rotation, and squats with adduction may be used for PPS patients.

The effects of hip-targeted physical therapy interventions on low back pain: A systematic review and meta-analysis

PURPOSE

To investigate the effects of physical therapy interventions of the hip on outcomes of pain and disability in patients with low back pain.

DATA SOURCES

PubMed, CINAHL, Scopus, Web of Science, and SPORTDiscus were searched from inception to 18 April 2018.

STUDY SELECTION/ELIGIBILITY CRITERIA

The following inclusion criteria were required to be met: (1) randomized controlled trials; (2) populations with diagnosed low back pain; and (3) interventions that target the hip joint. Two researchers independently screened titles, abstracts, and full texts for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data was extracted for information related to patient demographics, specific interventions, and outcomes assessed. When studies demonstrated homogeneity on outcome measures, the mean differences or standardized mean differences with 95% confidence interval were calculated and pooled in a meta-analysis.

RESULTS

Six articles with a total of 387 participants were included in the review and meta-analysis. Specific intervention categories that were found in the search included: hydrotherapy (n = 1); exercise therapy (n = 4); and manual therapy (n = 2). Trivial effect size was found for the pain outcomes and small effect size was found for disability. All of these studies were found to have high risk of bias according the Cochrane Risk of Bias tool.

CONCLUSION

The meta-analyses from the pooled studies did not result in statistically significant reductions in either pain or disability with the addition of hip-targeted physical therapy interventions to patients with LBP.

Hip kinematics during functional tasks in females with patellofemoral pain: Modification following rehabilitation and correlation with clinical improvement

OBJECTIVES

To compare hip kinematics during two functional tasks in females with and without patellofemoral pain (PFP), and to determine if hip kinematics and, symptoms and functional limitations were improved after a rehabilitation program.

DESIGN

Cross sectional and longitudinal.

PARTICIPANTS

Sixteen females with and 15 without PFP.

SETTING

Laboratory and physical therapy clinic.

MAIN OUTCOME MEASURES

Hip adduction (HADD) and medial rotation (HMR) peak angles, time integrals and inter-movement variability during step-down and vertical drop jump, symptoms and functional limitations evaluated using the Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS).

RESULTS

At baseline, no significant differences were found in step-down and vertical drop jump between PFP and controls. Following rehabilitation, significant improvements were reported in KOS-ADLS (p < 0.001). There was a significant decrease in HADD and HMR variability (p < 0.05), a trend for decreased peak HMR (p = 0.06) during step-down, and a significant decrease in HADD variability (p < 0.05) during vertical drop jump. These kinematic changes did not correlate with changes in KOS-ADLS (all p > 0.05).

CONCLUSION

Females with and without PFP demonstrated no hip kinematic differences during functional tasks. A rehabilitation program improved symptoms and functional status, and modified hip kinematics in females with PFP; however these changes were not correlated.

A 6-week hip muscle strengthening and lumbopelvic-hip core stabilization program to improve pain, function, and quality of life in persons with patellofemoral osteoarthritis: a feasibility pilot study

Background

Patellofemoral joint (PFJ) osteoarthritis (OA) is prevalent in middle-aged and older adults. Despite this, there are minimal studies which have examined conservative interventions for PFJ OA. Weakness of proximal lower extremity muscles is associated with PFJ OA. It is unknown if a hip muscle strengthening and lumbopelvic-hip core stabilization program will improve symptoms and function in persons with PFJ OA. This study examined the feasibility and impact of a 6-week hip muscle strengthening and core stabilization program on pain, symptoms, physical performance, peak muscle torques, and quality of life in persons with PFJ OA.

Methods

Ten females with PFJ OA and ten age- and sex-matched controls participated in baseline tests. PFJ OA participants attended ten twice-a-week hip strengthening and core stabilization exercise sessions. Outcome measures included questionnaires, the Timed-Up-and-Go, and peak isometric torque of hip and quadriceps muscles. Data were tested for normality; parametric and non-parametric tests were used as appropriate.

Results

At baseline, the PFJ OA group had significantly worse symptoms, slower Timed-Up-and-Go performance, and lower muscle torques than control participants. PFJ OA group adherence to supervised exercise sessions was adequate. All PFJ OA participants attended at least nine exercise sessions. Five PFJ OA participants returned 6-month follow-up questionnaires, which was considered fair retention. The PFJ OA participants' self-reported pain, symptoms, function in daily living, function in sport, and quality of life all improved at 6 weeks (P < 0.05). Timed-Up-and-Go time score improved at 6 weeks (P = 0.005). Peak hip external rotator torque increased (P = 0.01). Improvements in pain and self-reported function were no longer significant 6 months following completion of the intervention.

Conclusions

PFJ OA participants were adherent to the supervised sessions of the intervention. Improvement in symptoms, physical performance, and muscle torque were found after 6 weeks. Participant retention at 6 months was fair, and significant changes were no longer present. Our findings suggest that a hip strengthening and core stabilization program may be beneficial to improve symptoms, function, and physical performance in persons with PFJ OA. Future studies are needed, and additional measures should be taken to improve long-term adherence to exercise.

Trial registration

ClinicalTrials.gov NCT02825238. Registered 6 July 2016 (retrospectively registered).

Patellofemoral pain in athletes: clinical perspectives

Patellofemoral pain (PFP) is a very common problem in athletes who participate in jumping, cutting and pivoting sports. Several risk factors may play a part in the pathogenesis of PFP. Overuse, trauma and intrinsic risk factors are particularly important among athletes. Physical examination has a key role in PFP diagnosis. Furthermore, common risk factors should be investigated, such as hip muscle dysfunction, poor core muscle endurance, muscular tightness, excessive foot pronation and patellar malalignment. Imaging is seldom needed in special cases. Many possible interventions are recommended for PFP management. Due to the multifactorial nature of PFP, the clinical approach should be individualized, and the contribution of different factors should be considered and managed accordingly. In most cases, activity modification and rehabilitation should be tried before any surgical interventions.

Patellofemoral pain in athletes

Patellofemoral pain (PFP) is a frequent cause of anterior knee pain in athletes, which affects patients with and without structural patellofemoral joint (PFJ) damage. Most younger patients do not have any structural changes to the PFJ, such as an increased Q angle and a cartilage damage. This clinical entity is known as patellofemoral pain syndrome (PFPS). Older patients usually present with signs of patellofemoral osteoarthritis (PFOA). A key factor in PFPS development is dynamic valgus of the lower extremity, which leads to lateral patellar maltracking. Causes of dynamic valgus include weak hip muscles and rearfoot eversion with pes pronatus valgus. These factors can also be observed in patients with PFOA. The available evidence suggests that patients with PFP are best managed with a tailored, multimodal, nonoperative treatment program that includes short-term pain relief with nonsteroidal anti-inflammatory drugs (NSAIDs), passive correction of patellar maltracking with medially directed tape or braces, correction of the dynamic valgus with exercise programs that target the muscles of the lower extremity, hip, and trunk, and the use of foot orthoses in patients with additional foot abnormalities.

Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial

Design

Single-blind randomised clinical trial.

Objective

To compare the effects of three 8-week rehabilitation programmes on symptoms and functional limitations of runners with patellofemoral pain (PFP).

Methods

Sixty-nine runners with PFP were randomly assigned to one of three intervention groups: (1) education on symptoms management and training modifications (education); (2) exercise programme in addition to education (exercises); (3) gait retraining in addition to education (gait retraining). Symptoms and functional limitations were assessed at baseline (T0), and after 4, 8 and 20 weeks (T4, T8 and T20) using the Knee Outcome Survey of the Activities of Daily Living Scale (KOS-ADLS) and visual analogue scales (VASs) for usual pain, worst pain and pain during running. Lower limb kinematics and kinetics during running, and isometric strength were also evaluated at T0 and T8. The effects of rehabilitation programmes were assessed using two-way analysis of variance.

Results

No significant group × time interactions (p<0.447) were found for KOS-ADLS and VASs. All three groups showed similar improvements at T4, T8 and T20 compared with T0 (p<0.05). Only the exercises group increased knee extension strength following rehabilitation (group × time: p<0.001) and only the gait retraining group (group × time: p<0.001) increased step rate (+7.0%) and decreased average vertical loading rate (−25.4%).

Conclusion

Even though gait retraining and exercises improved their targeted mechanisms, their addition to education did not provide additional benefits on symptoms and functional limitations. Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP.

Trial registration number

ClinicalTrials.gov (NCT02352909).