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Patellofemoral Pain & Hip Strength


Knee pain, especially patellofemoral pain (knee cap pain, aka “runners knee”) is one of the most common sporting and running injuries (1, 2). Over the past 4-6 months, with the COVID-enforced lockdown, I have see a lot more runners presenting in clinic. One of the key injury concerns I’ve seen is patellofemoral pain. Furthermore, it has been found that this injury is also prevelant in non-athletic populations. The figure below highlights the running injury incidences.







Management for patellofemoral pain syndrome (PFPS) should be multi-factorial, involving load management, education and rehabilitation (amongst others). Rehabilitation should include both hip-based (e.g. glutes) and knee based (e.g. quads) strengthening.




Evidence shows:

  • Hip and knee strengthening are both effective at rehabilitating PFPS when completed in isolation (3, 4, 7).


  • Hip and knee strengthening combined is more effective than knee strengthening in isolation (3, 6).


  • Hip-based strengthening has been found to have faster reductions in pain in the initial phase of rehabilitation for PFPS (4).


  • Higher hip abduction strength reduces the risk of getting PFPS when starting running (novice runners) (5).


  • Runners with PFPS have been shown to have reduced hip abduction strength (7).




Where does that leave us?

  • PFPS is very common

  • Rehab is important and effective

  • Including hip AND knee based strength/rehab is important (think quads and glutes)

  • Commencing rehab with hip-based (glutes) strengthening may be more effective – especially with the runner/athlete has a sore/irritable knee.


Watch the video below for some of my favourite hip-based rehab exercises. Please note that this post hasn’t addressed knee-based exercises (e.g. squat, lunge, step up, split squat, knee extension etc) which I think are crucial for PFPS rehab, or calf exercises, which are VITAL for runners (see my previous post on calf strength/raises).





References:

1. van Gent, B. R., Siem, D. D., van Middelkoop, M., van Os, T. A., Bierma-Zeinstra, S. S., & Koes, B. B. (2007). Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine.

2. Barton, C. J., Bonanno, D. R., Carr, J., Neal, B. S., Malliaras, P., Franklyn-Miller, A., & Menz, H. B. (2016). Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. British Journal of Sports Medicine, 50(9), 513-526.

3. Nascimento, L. R., Teixeira-Salmela, L. F., Souza, R. B., & Resende, R. A. (2018). Hip and knee strengthening is more effective than knee strengthening alone for reducing pain and improving activity in individuals with patellofemoral pain: a systematic review with meta-analysis. journal of orthopaedic & sports physical therapy, 48(1), 19-31.

4. Dolak, K. L., Silkman, C., McKeon, J. M., Hosey, R. G., Lattermann, C., & Uhl, T. L. (2011). Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. journal of orthopaedic & sports physical therapy, 41(8), 560-570.

5. Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High eccentric hip abduction strength reduces the risk of developing patellofemoral pain among novice runners initiating a self-structured running program: a 1-year observational study. journal of orthopaedic & sports physical therapy, 45(3), 153-161.

6. Bloomer, B. A., & Durall, C. J. (2015). Does the addition of hip strengthening to a knee-focused exercise program improve outcomes in patients with patellofemoral pain syndrome?. Journal of sport rehabilitation, 24(4), 428-433.

7. Ferber, R., Kendall, K. D., & Farr, L. (2011). Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome. Journal of athletic training, 46(2), 142-149.

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