Management of Patellofemoral Pain Targeting Hip, Pelvis, and Trunk Muscle Function: 2 Case Reports
Management of Patellofemoral Pain Targeting Hip, Pelvis, and Trunk Muscle Function: 2 Case Reports
P
Study Design: Case report. atellofemoral pain
Objective: To describe an alternative treatment approach for patellofemoral pain. (PFP) is recognized as
Background: Weakness of the hip, pelvis, and trunk musculature has been hypothesized to one of the most com-
influence lower-limb alignment and contribute to patellofemoral pain. Two patients who had a mon lower-extremity
chief complaint of patellofemoral pain and demonstrated lack of control of the hip in the frontal disorders encountered
and transverse planes during functional movements were treated with an exercise program
by orthopaedic physical thera-
targeting the hip, pelvis, and trunk musculature.
pists.28,59 Despite its prevalence,
Methods and Measures: The patients presented in these 2 case reports did not exhibit obvious
however, the etiology of this pain
patellar malalignment or tracking problems; however, on qualitative assessment, both demon-
strated excessive hip adduction, internal rotation, and knee valgus during gait and while
syndrome and specific treatment
performing a step-down maneuver. In addition, both patients exhibited weakness of the hip of this condition remain vague
abductors, extensors, and external rotators, as demonstrated by hand-held dynamometry testing. and controversial.
Downloaded from www.jospt.org by 141.226.217.93 on 04/18/18. For personal use only.
Treatment in both cases occurred over a 14-week period and focused on recruitment and The premise behind most treat-
endurance training of the hip, pelvis, and trunk musculature. Functional status, pain, muscle force ment approaches is that PFP is the
production, as well as subjective and objective assessment of lower-extremity kinematics during result of abnormal patellar track-
gait and a step-down maneuver were assessed preintervention and postintervention. ing and/or malalignment. Given
Results: Both patients experienced a significant reduction in patellofemoral pain, improved as such, interventions are often
lower-extremity kinematics during dynamic testing, and were able to return to their original levels focused locally, and typically in-
of function. Gluteus medius force production improved by 50% in patient A and 90% in patient B, clude quadriceps strengthening,
while gluteus maximus force production improved 55% in patient A and 110% in patient B. patellar taping, patellar bracing,
Objective kinematic improvements in the step-down task also were demonstrated in patient A. stretching, and soft tissue mobiliza-
Conclusion: Assessment and treatment of the hip, pelvis, and trunk musculature should be tion.6,19,46,59 Despite the longevity
J Orthop Sports Phys Ther 2003.33:647-660.
considered in the rehabilitation of patients who present with patellofemoral pain and demonstrate of such treatment approaches,
abnormal lower-extremity kinematics. J Orthop Sports Phys Ther 2003;33:642-660. with papers as early as 1922 advo-
CASE REPORT
Key Words: case study, knee pain, lower-extremity rehabilitation, therapeutic cating quadriceps strengthening
exercise exercises,35 intervention outcomes
have been mixed.2,11,29,30 In addi-
tion, the 2001 Philadelphia Panel
systematic review failed to find a
1
Staff Physical Therapist, Kern and Associates Physical Therapy, Santa Monica, CA. At the time these sufficient number of high-quality
cases were managed, Catherine Mascal was a resident in the Orthopaedic Physical Therapy Residency randomized control trials to rec-
Program at the University of Southern California, Los Angeles, CA. ommend any clinically important
2
Associate Professor of Clinical Physical Therapy, Department of Biokinesiology and Physical Therapy,
University of Southern California, Los Angeles, CA.
benefit from exercise, massage,
3
Associate Professor and Director, Musculoskeletal Biomechanics Research Laboratory, Department of heat, or combined therapies for
Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA. patients with PFP.44
Send correspondence to Christopher M. Powers, Department of Biokinesiology and Physical Therapy, One possible reason for the rela-
University of Southern California, 1540 E. Alcazar Street, CHP 155, Los Angeles, CA 90089-9006. E-mail:
[email protected]
tively poor outcomes associated
The methods described in this paper are standard care for patients seen in this clinic. Therefore, with the treatment of PFP may be
Institutional Review Board approval was not necessary for these case reports. related to the assumption that
part-time student and also worked three 10-hour days cluded rest and Naproxen. Patient B stated that she
a week as a waitress in a restaurant. Patient B was a enjoyed walking for 30 to 45 minutes, 3 to 4 times a
37-year-old female with a BMI of 27 (somewhat week; however, she had not been able to do this for
overweight). She worked full time as an accounts the last 3 weeks due to the increased severity of her
assistant in a hospital finance department. pain.
Patient A’s goals were to commence a jogging
program and to be able to work at the restaurant
History of Presenting Condition pain free, without the use of her neoprene support.
Patient A described a history of right patel- Patient B’s goals were to return to her previous level
lofemoral pain, which commenced after traumatically of walking, go dancing once a week, and ascend/
dislocating her patella twice, 9 and 2 years prior. In descend stairs pain free.
both instances, the mechanism was described as an
awkward fall onto a twisted knee, and the patella was TESTS AND MEASURES
self-reduced following the trauma. After the last
dislocation in November 2000, she underwent an As regular clinical service was being provided for
unsuccessful course of physical therapy that consisted these 2 patients, both were exempt from requiring
of a progressive aerobic walking program and Institutional Review Board approval.
rearfoot, tibiofemoral joint, hip joint, and lumbar medial retinaculum. She had pain on resisted knee
spine were assessed. Clinical tests as described in extension from 20° to 0° knee flexion, and had
Magee36 were carried out to eliminate these struc- normal passive patellar mobility with slight pain at
tures as potential sources of the subjects’ symptoms. end range medial and lateral translation.
This screening examination revealed no abnormali- Quadriceps strength was assessed using a Microfet2
ties and both patients demonstrated a full pain-free hand-held dynamometer (Hoggan Health Industries,
range of knee motion. Negative test results were also Inc., Draper, UT). This method of measuring muscle
found for the following conditions: ligamentous insta- strength has been validated and the intertester reli-
bility of the knee; intracapsular knee pathology; ability has been shown to be good to excellent.3-5
patellar tendonitis; pes anserine bursitis; iliotibial Quadriceps muscle strength testing was performed in
J Orthop Sports Phys Ther 2003.33:647-660.
band friction syndrome; and referred pain from the the position recommended by Kendall31; however, the
hip, sacroiliac region, or lumbar spine. knee was maintained in 30° of flexion to avoid
CASE REPORT
TABLE. Hand-held dynamometry, preintervention and postintervention results. Values given are the average of 3 trials. Numbers in pa-
rentheses are subjective muscle strength ratings based on an isometric break test where 5/5 is maximal strength (ie, unable to ‘‘break’’
the muscle’s isometric hold).38
Patient A Patient B
Pretest Posttest Increase Pretest Posttest Increase
Force (N) Force (N) (%) Force (N) Force (N) (%)
Quadriceps 155.8 (3+/5) 186.9 (3+/5) 20 267.0 (4/5) 293.7 (4/5) 10
Gluteus maximus 129.0 (4⫺/5) 200.0 (4/5) 55 89.0 (3+/5) 186.9 (4/5) 110
Gluteus medius 53.4 (3+/5) 80.1 (4⫺/5) 50 44.5 (3+/5) 84.6 (4/5) 90
Hip lateral rotator group 26.7 (3+/5) 111.3 (4/5) 317 120.1 (4⫺/5) 138.0 (4⫺/5) 15
Hip medial rotator group 84.6 (4⫺/5) 120.1 (4/5) 42 62.3 (4⫺/5) 106.8 (4/5) 71
ASSESSMENT
0
Given the subjective and objective information
0 20 40 60 80 100
obtained in the examination, it was our impression
that neither patient demonstrated significant abnor- Stance (%)
malities specific to the patellofemoral joint that could
account for subjective complaints of PFP. Both pa- C
tients, however, demonstrated significant weakness of Pretreatment
the hip and abdominal musculature, and a reduced 3 Posttreatment
ability to control hip and pelvis motion during
dynamic testing. We theorized that this poor 2
Pelvic Obliquity (degree)
J Orthop Sports Phys Ther 2003.33:647-660.
Foundations for Treatment FIGURE 2. Kinematic plots demonstrating patient A’s lower-
extremity motion (preintervention and postintervention) during the
Both patients were scheduled to attend physical step-down task. (A) Hip internal rotation. (B) Hip adduction. (C)
therapy once or twice a week over a 3-month period. Frontal plane pelvic motion of the contralateral pelvis.
When a stable spinal position could be maintained of interest during non–weight-bearing exercises, they
while performing concurrent hip and knee flexion were progressed to weight-bearing exercises, which
CASE REPORT
with alternate legs, and the progression criteria were included isometric and dynamic exercises in single-
achieved for isometric gluteus maximus and medius limb stance. At this time the patients were introduced
contractions, the patients were progressed to dynamic to the concept of neutral lower-extremity alignment
exercises. This occurred at week 3 for patient A, and as described by McConnell.38 This involved alignment
week 4 for patient B. The subsequent program of of the lower extremity such that the ASIS and knee
dynamic hip-strengthening exercises for the lateral remained positioned over the second toe, with the
rotators and the abductors of the hip predominately hip positioned in approximately 10° of external
targeted the gluteus medius and maximus. rotation.
Gluteus medius exercises were done in sidelying, The patients were then instructed to stand next to
with hips and knees flexed, performing hip abduc- a wall with the stance limb furthest from the wall.
tion with external rotation, while maintaining a They were asked to contract their transversus
neutral spinal position by coactivating the transversus abdominus and gluteal muscles and then to assume a
abdominus (Figure 3B). The patients were instructed single-limb stance position by flexing the contralateral
to keep both feet together and lift the uppermost knee with the hip in a neutral position (Figure 4A).
knee as high as possible, while concurrently palpating Patients then performed isometric external rotation
A B C D
J Orthop Sports Phys Ther 2003.33:647-660.
FIGURE 4. Weight-bearing exercises (weeks 6-10). (A) Isometric hip abduction performed in weight bearing against a wall. (B)
Upper-extremity activities performed in a single-leg stance. (C) Bilateral standing hip abduction performed on the Clinical Reformer. The
patient’s right leg is on a platform that moves to the right against spring resistance as she concurrently pushes both legs apart against
resistance, while maintaining a stable pelvic position. (D) Holding Theraband and rotating the body medially while maintaining a static
lower extremity produces relative external rotation at the hip.
RESULTS
J Orthop Sports Phys Ther 2003.33:647-660.
Functional Status
The postintervention functional assessment scores
increased from 76 to 85 and from 70 to 84 for
patients A and B, respectively.
CASE REPORT
FIGURE 6. Computer-generated skeletal representation of patient A’s lower-extremity kinematics. (A) Prior to intervention. (B) Postinterven-
tion. Reduced hip adduction and internal rotation of the hip can be observed in B.
stair descent, especially during the last 85% of the that this difference was clinically meaningful. For
stance phase. In the preintervention test, patient A example, hip adduction would move the patella
demonstrated excessive hip adduction during the last medially with respect to the ASIS, thereby increasing
80% of stance phase, suggesting inadequate strength the dynamic Q angle.45 Theoretically, any decrease in
of the gluteus medius. As can be seen by the the hip adduction angle could result in a decrease in
postintervention data (Figure 2B), hip adduction was the dynamic Q angle, thereby reducing the lateral
reduced, especially during the last 80% of the step- force acting on the patella.45
down cycle, suggesting an improved control of this The gluteus maximus muscle has been shown to be
motion. a powerful external rotator of the hip,12 and the
Although the measured changes in hip adduction function of its upper fibers have been found by Lyons
during the step-down maneuver were relatively small et al34 to be similar to that of gluteus medius during
(6.4° averaged across the stance phase), we believe gait and stair ascent. The substantial changes found
ness and PFP, and to identify patients who will best ments obtained with four tests for patellofemoral align-
respond to this treatment approach. ment. Phys Ther. 1995;75:84-90; discussion 90-82.
18. Grelsamer RP, McConnell J. The Patella: A Team
Approach. Gathersburg, MD: Aspen Publishers; 1998.
ACKNOWLEDGMENTS 19. Henry JH. Conservative treatment of patellofemoral
subluxation. Clin Sports Med. 1989;8:261-278.
The authors wish to thank Yu-Jen Chen, PT, MS, 20. Hodges PW, Richardson CA. Contraction of the ab-
for assisting in the collection and processing of the dominal muscles associated with movement of the
kinematic data, and the staff at USC Physical Therapy lower limb. Phys Ther. 1997;77:132-142; discussion
142-134.
Associates, where these patients received their care.
21. Huberti HH, Hayes WC. Patellofemoral contact pres-
sures. The influence of q-angle and tendofemoral con-
tact. J Bone Joint Surg Am. 1984;66:715-724.
22. Hvid I, Andersen LI. The quadriceps angle and its
REFERENCES relation to femoral torsion. Acta Orthop Scand.
1982;53:577-579.
1. Beckman SM, Buchanan TS. Ankle inversion injury and 23. Inman VT. Functional aspects of the abductor muscles
hypermobility: effect on hip and ankle muscle of the hip. J Bone Joint Surg Am. 1947;53:577-579.
electromyography onset latency. Arch Phys Med 24. Insall J. Current Concepts Review: patellar pain. J Bone
Rehabil. 1995;76:1138-1143. Joint Surg Am. 1982;64:147-152.
tion to the Pathogenesis and the Surgical Treatment of three parts of the gluteus medius muscle during func-
Osteoarthritis. New York, NY: Springer-Verlag; 1984. tional activities. Phys Ther. 1978;58:691-696.
38. McConnell J. Patellofemoral joint complications and 57. Steinkamp LA, Dillingham MF, Markel MD, Hill JA,
considerations. In: Ellenbecker TS, ed. Knee Ligament Kaufman KR. Biomechanical considerations in patel-
Rehabilitation. New York, NY: Churchill Livingstone; lofemoral joint rehabilitation. Am J Sports Med.
2000:202-224. 1993;21:438-444.
39. McFadyen BJ, Winter DA. An integrated biomechanical 58. Taylor JR, O’Sullivan P. Lumbar segmental instability:
analysis of normal stair ascent and descent. J Biomech. pathology, diagnosis, and conservative management. In:
1988;21:733-744. Physical Therapy of the Low Back. New York, NY:
40. Messier SP, Davis SE, Curl WW, Lowery RB, Pack RJ. Churchill Livingstone; 2000:201-247.
Etiologic factors associated with patellofemoral pain in 59. Thomee R, Augustsson J, Karlsson J. Patellofemoral pain
runners. Med Sci Sports Exerc. 1991;23:1008-1015. syndrome: a review of current issues. Sports Med.
J Orthop Sports Phys Ther 2003.33:647-660.
41. Nadler SF, Malanga GA, Bartoli LA, Feinberg JH, 1999;28:245-262.
Prybicien M, Deprince M. Hip muscle imbalance and
60. Ward SR, Powers CM, Fredericson M, Guillet M,
low back pain in athletes: influence of core strengthen-
CASE REPORT