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.