Hip Strength in Females With and Without Patellofemoral Pain
Hip Strength in Females With and Without Patellofemoral Pain
Patellofemoral Pain
Mary Lloyd Ireland, MD 1
John D. Willson, MSPT 2
Bryon T. Ballantyne, PT, MA 2
Irene McClay Davis, PT, PhD 3
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RESEARCH
patellofemoral joint, including
weakness in this population may assist health care professionals establish a more effective
vastus medialis obliquus insuffi-
treatment plan.
ciency, decreased hamstring,
Methods and Measures: Hip abduction and external rotation isometric strength measurements
were recorded for the injured side of 15 female subjects with patellofemoral joint pain (mean
quadriceps, or iliotibial band flex-
SD age, 15.7 2.7 years; age range, 12-21 years). These were compared with strength ibility, patella alta, and femoral
measurements from the corresponding hip of 15 age-matched female control subjects (mean SD anteversion, have received the
age, 15.7 2.7 years; age range, 12-21 years). All strength measurements were made using most attention. 7,10,18,26,29,31,37,38
hand-held dynamometers. Such factors may also contribute
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
REPORT
Results: Subjects with patellofemoral pain demonstrated 26% less hip abduction strength (P.001) to PFP through their role in caus-
and 36% less hip external rotation strength (P.001) than similar age-matched controls. ing patellofemoral malalignment,
Conclusions: The results indicate that young women with patellofemoral pain are more likely to which is a universally accepted
demonstrate weakness in hip abduction as well as external rotation than age-matched women contribution to PFP.12,31
who are not symptomatic. J Orthop Sports Phys Ther. 2003;33:671-676. Factors distal to the knee have
Key Words: anterior knee pain, hip abduction, hip external rotation, knee, also been frequently suggested to
patella contribute to patellofemoral
malalignment and pain. Numerous
Journal of Orthopaedic & Sports Physical Therapy
P
atellofemoral joint pain (PFP) remains one of the most
common orthopaedic complaints among adolescents and longed foot pronation during
young adults, with reported incidence rates among athletes functional activities and lateral
greater than 25%.2,26,31,38 It has also been reported that patellar compression syn-
females, as compared with their male counterparts, are drome.28,30,36 Specifically, consider-
significantly more likely to experience PFP.9,35 Typically, patients com- ing the screw-home mechanism
plain of generalized retropatellar symptoms that present insidiously and of the tibiofemoral joint, these au-
tend to be exacerbated by prolonged sitting or repetitive weight-bearing thors report that the tibia must be
activities over a flexed knee. Unfortunately for these individuals, this externally rotated relative to the
pain often becomes a chronic condition that may fail to respond to femur so that knee extension can
conservative measures. be achieved during the midstance
and terminal stance phases of gait.
1
However, it is hypothesized that, in
Orthopedic Surgeon, Kentucky Sports Medicine Clinic, Lexington, KY.
2
Clinical Research Coordinator, Joyner Sportsmedicine Institute, Lexington, KY. the presence of excessive or pro-
3
Associate Professor, University of Delaware, Department of Physical Therapy, Newark, DE; Clinical longed foot pronation, the tibia
Research Coordinator, Joyner Sportsmedicine Institute, Lexington, KY. remains internally rotated as the
The protocol for this study was approved by Essex Institutional Review Board, Inc.
Send Correspondence to John D. Willson, Joyner Sportsmedicine Institute, 601 Perimeter Dr., Suite 110, knee begins to extend. To com-
Lexington, KY 40517. E-mail: [email protected] pensate for this excessive tibial
measure static force ranging from 0 to 199.9 kg, with over a mark that was 5.08 cm proximal to the medial
accuracy to 0.1 kg 2%, and has been reported to malleolus. A strap around the leg and around the
have excellent interrater reliability for testing hip base of a stationary object held the dynamometer in
abduction isometric strength.11 The dynamometer place during contractions. After zeroing the dyna-
was secured between the leg and a second strap that mometer, the subject was instructed to push the leg
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was wrapped around the leg and the underside of the inward with maximal effort for 5 seconds. The force
table. The strap eliminated the effect of tester value displayed on the dynamometer was recorded
strength on this measure, which has been reported to and the device was rezeroed. One practice trial and 3
be a limitation of hand-held dynamometry.4 After experimental trials were performed with 15 seconds
zeroing the dynamometer, the subject was instructed of rest between trials. The peak value from the 3
to push the leg upward with maximal effort for 5 experimental trials was recorded.
seconds. The force value displayed on the dynamom-
eter was recorded and the device was rezeroed. One Data Analysis
practice trial and 3 experimental trials were per- We used a clinically significant strength difference
RESEARCH
formed, with 15 seconds of rest between trials. The of 15% between groups and estimates of sample
peak value from the 3 experimental trials was re- variability from previous literature3,5 to perform an a
corded. priori power analysis. This analysis suggested that 25
Hip external rotation (ER) isometric strength test- to 30 subjects would provide adequate protection
ing was performed with subjects positioned on a from type I and II errors using = .05 and = .20.
padded chair with the hips and knees flexed to 90 However, during data collection, it became evident
(Figure 2). To prevent substitution by the hip adduc- that the true difference between groups was signifi-
tors, a strap was used to stabilize the thigh of the cantly larger than the difference used in the power
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
REPORT
tested leg and a towel roll was placed between the analysis. Therefore, data analysis was performed after
subjects knees. The dynamometer was then placed 15 subjects had been tested per group. Independent t
such that the center of the force pad was directly tests were used to compare hip abduction and exter-
Journal of Orthopaedic & Sports Physical Therapy
FIGURE 1. Isometric strength testing of hip abduction using straps and hand-held dynamometer.
DISCUSSION
The role of hip strength in the etiology of knee
pain has received increased attention in recent years.
However, in the absence of objective evidence, this
relationship has been reported based on observation
and professional conjecture. The purpose of this
investigation was to compare hip strength between
females with and without PFP. While the strength test
results for the healthy control subjects in this study
are in line with established isometric norms,5,6 fe-
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RESEARCH
differences observed in this study may be the conse-
quence of disuse atrophy or altered motor recruit-
ment patterns.14 However, whether hip muscle REFERENCES
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