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Anterior knee pain in female athletes
2013, iSSue 1
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Patellofemoral pain syndrome (PFPS) is the medical term for pain in the front of the knee,
usually under the kneecap. Patellofemoral pain syndrome, also referred to as anterior knee
pain or “runner’s knee,” is a common lower extremity diagnosis that physical therapists and
athletic trainers treat. It is more common in females and is usually unrelated to a specific
injury. Most patients describe an aching pain in the front of the knee with occasional sharp,
stabbing pains around or under the kneecap. Pain is typically worse with stairs, squats,
lunges, running, and sitting for a long period of time.
Most cases of PFPS are caused by excessive joint pressure at the patellofemoral joint (where
the patella sits on the femur on the front of the knee). This may be caused by abnormal
patellar tracking or abnormal positioning of the femur during dynamic activities, such
as running or going down the stairs. Treatment options for PFPS focus on improving the
dynamic positioning of the patella and femur and may include quadriceps strengthening,
hip and core muscle strengthening, hamstring and iliotibial band flexibility exercises,
patellar mobilization, patellar taping, foot orthoses, and joint mobilization of the pelvis.
Continued
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➦➦ Treatment focused on hip strengthening has led
to improvements in pain, function, and strength in
patients with PFPS.
➦➦ Important hip muscles to strengthen include:
✓✓Hip abductors: gluteus medius
✓✓Hip external rotators: gluteus maximus
✓✓Hip extensors: gluteus maximus
• Many times the way a person runs, squats, or lands from
a jump may be creating increased stress on the front
of the knee due to poor biomechanics. Strengthening
exercises alone may not be adequate to correct faulty
movement patterns. A treatment program that includes
movement re-education and neuromuscular control
exercises is important for improving mechanics of the
pelvis and lower extremities during functional
movements. Skilled practice that includes mirror
and verbal feedback on proper mechanics can lead to
improved running, squatting, and jumping mechanics
and decreased pain in females with PFPS.
Patellofemoral pain syndrome is well-studied in the field
of sports medicine. Many current research studies have
looked at risk factors and treatment options for patients
with anterior knee pain. Below are some important points
from the latest research on this topic.
• A weak quadriceps muscle is a risk factor for developing
patellofemoral pain, especially in females. Quadriceps
strengthening is therefore an important treatment
consideration for patients with PFPS.
• Many female patients with PFPS demonstrate proximal
weakness in the hip and core muscles. This weakness
may cause dynamic malalignment of the femur
(adduction and internal rotation), causing increased
stress at the patellofemoral joint, leading to pain.
• Foot orthoses (shoe inserts) may be helpful in reducing
pain in patients with PFPS. Orthoses help control
motion at the foot, specifically abnormal or excessive
pronation. An increased rate or amount of subtalar
joint pronation leads to increased internal rotation of
the tibia and a subsequent increase in adduction and
internal rotation of the femur. This malalignment of the
femur leads to increased stress at the patellofemoral
joint and the potential for pain and dysfunction.
In addition to providing biomechanical control, foot
orthoses also help with shock attenuation and sensory
feedback. Recent research indicates that both off the-shelf and custom foot orthoses may be utilized for
immediate and short-term pain relief in patients with
patellofemoral pain.
• Lumbopelvic mobilization has been proposed as
a treatment option for patients with PFPS. A clinical
prediction rule was developed to identify patients who
may benefit from a grade V mobilization. The
predictors for successful outcome include: a side-to- side
difference in hip IR > 14 deg; ankle dorsiflexion with
knee flexed > 16 deg; navicular drop > 3mm; and no self reported stiffness with sitting > 20 minutes. In patients
who met at least three of these clinical predictors
and received a grade V lumbopelvic mobilization from a
licensed physical therapist, there was a 94% success
rate for decreasing pain by at least 50% and increasing
function with squatting and stepping activities. Further
research is needed to validate the effectiveness of
lumbopelvic mobilization in patients with PFPS, but it is
an important treatment option to consider.
• Patellar taping may be used as a treatment for PFPS
but the exact mechanism by which this technique
works is still not completely known. Proposed
theories include:
can lead to decreased pain and improved function. Listed
below are exercise examples that can be used for patients
with PFPS. As with all exercise programs, it is important to
remember that everyone responds differently to exercise,
and some athletes may need to modify their activities and/
or address other areas of weakness or tightness in their
lower extremities. Exercises should be performed in a
pain-free range of motion.
➦➦ Patellar taping may improve proprioception or body
awareness. This heightened awareness improves
knee biomechanics and promotes normal knee
function during activity.
➦➦ Patellar taping puts a stretch over tight lateral
knee structures that may be causing the patella to
improperly track lateral during activity. A tight
iliotibial band or lateral retinaculum can pull
the patella laterally, so applying tape that correctly
positions the patella will cause a low load, long
duration stretch of these restricted structures.
➦➦ Patellar taping may decrease the ability of pain
signals to travel to the brain. These pain signals
are thought to inhibit, or shutdown, the quadriceps
muscles, especially the vastus medialis obliquus
(VMO), which plays an important role in stabilizing
and controlling the patella during movement.
➦➦ Patellar taping may improve the timing of VMO firing.
Specifically, taping is thought to restore the ability of
the VMO to fire and contract before the vastus
lateralis. This allows the patella to be properly
centered in the trochlear groove.
➦➦ Patellar taping may improve the faulty position
of the patella. The three components addressed in
patellar orientation include glide (whether the
patella is centered on the femur), tilt (the difference
in the heights of the medial and lateral borders
of the patella), and rotation (internal or external
rotation). Based on the altered position assessed,
the tape will be applied in a manner to return the
patella to its neutral position and allow it to track
and move properly with activity.
In conclusion, it is important to identify and consider
contributing factors to PFPS. This may include deficits in
proximal control of the hip and pelvis, distal influences
of the foot, knee and lower extremity biomechanics, poor
flexibility, and quadriceps muscle dysfunction. Physical
therapy treatment that includes hip, core, and quad
strengthening and neuromuscular re-education exercises
•Non weight-bearing exercises:
➦➦ Bridges
✓✓With isometric hip abduction
✓✓With alternation knee extension
✓✓Single leg
➦➦ Clamshells
➦➦ Side (abduction) leg raises
•Weight-bearing exercise:
➦➦ Single-leg stance and balance exercises
✓✓With contralateral isometric hip abduction into
wall
✓✓With hip IR/ER
✓✓With contralateral hip abduction
✓✓With pelvic drop/hip hike
➦➦ Body weight squat
✓✓With isometric hip abduction
Continued
SaVe tHe date
CONTINUED FROM PAGE 3
REFERENCES
Barton CJ, Menz HB, Crossley KM. The immediate effects of foot orthoses
on functional performance in individuals with patellofemoral pain
syndrome. Br J Sports Med. 2011;45(3): 193-197.
Dolak KL, et al. Hip strengthening prior to functional exercises reduces pain
sooner than quadriceps strengthening in patients with patellofemoral pain
syndrome: A randomized clinical trial. J orthop Sports Phys ther. 2011;41(8):
560-570.
Earl JE, Hoch AZ. A proximal strengthening program improves pain,
function, and biomechanics in women with patellofemoral pain syndrome.
Am J Sports Med. 2011;39(1): 154-163.
Fukuda TY, et al. Short-term effects of hip abductors and lateral rotators
strengthening in females with patellofemoral pain syndrome: A randomized
controlled clinical trial. J orthop Sports Phys ther. 2010; 40(11): 736-742.
Hossain M et al. Foot orthoses for patellofemoral pain in adults. Cochrane
database Syst Rev. 2011; Jan 19(1).
Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the
treatment of patients with patellofemoral pain syndrome: Development of a
clinical prediction rule. JOSPT. 2008;38(6):297-312.
Khayambashi K, et al. The effects of isolated hip abductor and external
rotator muscle strengthening on pain, health status, and hip strength in
females with patellofemoral pain: A randomized controlled trial. J orthop
Sports Phys ther. 2012; 42(1): 22-29.
Lan TU, et al. Immediate effect and predictors of effectiveness of taping
for patellofemoral pain syndrome. Am J Sports Med. 2010; 38(8): 1626-1630.
Mascal CL, Landel R, Powers C. Management of patellofemoral pain
targeting hip, pelvis, and trunk muscle function: 2 case reports. J orthop
Sports Phys ther. 2003;33:647-660.
•Weight-bearingexercise(CONTINUED):
➦ Single-leg deadlift
Mintkin P, McPoil T. “When should manual therapy and foot orthoses be
added to the physical therapy plan of care?” Presented at APTA Combined
Sections Meeting, January 22, 2013.
Nakagawa, TH, et al. The effect of additional strengthening of hip abductor
and lateral rotator muscles in patellofemoral pain syndrome: A randomized
controlled pilot study. Clin Rehabil. 2008;22:1051-1060.
➦ Single-leg mini-squat
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all photos iStockphoto® (excluding all exercise examples & athletic trainer Photos): ©thomas_eyedesign, Physical therapist examming a Patient’s Knee; ©eraxion, Painful Knee illustration; ©Floortje, Pastry: Brownie