Comparison of the Effect of Hip and Knee Strengthening with Internal Instruction Exercises on Pain and Dynamic Knee Valgus in Patients with Patellofemoral Pain Syndrome

Document Type : Original Articles

Authors

1 MSc Student, Department of Biomechanics and Sport Injuries, School of Physical Education and Sport Sciences, Kharazmi University of Tehran, Tehran, Iran

2 Assistant Professor, Department of Biomechanics and Sport Injuries, School of Physical Education and Sport Sciences, Kharazmi University of Tehran, Tehran, Iran

10.22122/jrrs.v15i2.3408

Abstract

Introduction: Patellofemoral pain syndrome (PFPS) is one of the most common musculoskeletal disorders, and is related to biomechanical factors of the lower extremities. Hip and knee muscle strengthening is a well-known method for the treatment of PFPS, but there is insufficient evidence for its effectiveness in combination with other effective interventions. The purpose of this study was to compare the effect of hip and knee strengthening with internal instruction exercises on pain and dynamic knee valgus in patients with PFPS.Materials and Methods: The present study was a quasi-experimental intervention. 50 men and women with PFPS (18 to 45 years) participated in this study. Subjects were assigned to experimental (n = 25) and control (n = 25) groups. Evaluation of pain was conducted using visual analog scale (VAS) questionnaire, and dynamic knee valgus by two-dimensional video camera. Subjects in the control group received hip and knee strengthening exercises, and in the experimental group performed hip and knee strengthening with internal instruction exercise for six weeks, three sessions per week and each session for 45 minutes. Independent and dependent t tests were used for statistical analysis.Results: Adding internal focus instruction on hip and knee strengthening exercises affected the dynamic knee valgus angle of the patients with PFPS, and significantly reduced the dynamic knee valgus angle (P < 0.001). Moreover, there was no significant statistical effect on pain with the addition of internal focus on hip and knee strengthening exercises.Conclusion: Hip and knee strengthening with internal instructions exercises seem to be more effective in improving dynamic knee valgus than exercises that focus solely on strengthening the hip and knee muscles.

Keywords

  1. Espi-Lopez GV, Serra-Ano P, Vicent-Ferrando J, Sanchez-Moreno-Giner M, Arias-Buria JL, Cleland J, et al. Effectiveness of inclusion of dry needling in a multimodal therapy program for patellofemoral pain: A randomized parallel-group trial. J Orthop Sports Phys Ther 2017; 47(6): 392-401.
  2. Jayaseelan DJ, Scalzitti DA, Palmer G, Immerman A, Courtney CA. The effects of joint mobilization on individuals with patellofemoral pain: A systematic review. Clin Rehabil 2018; 32(6): 722-33.
  3. Scali K, Roberts J, McFarland M, Marino K, Murray L. Is multi-joint or single joint strengthening more effective in reducing pain and improving function in women with patellofemoral pain syndrome? A systematic review and meta-analysis. Int J Sports Phys Ther 2018; 13(3): 321-34.
  4. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther 2003; 33(11): 671-6.
  5. Piva SR, Goodnite EA, Childs JD. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther 2005; 35(12): 793-801.
  6. Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther 2007; 37(5): 232-8.
  7. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: A theoretical perspective. J Orthop Sports Phys Ther 2003; 33(11): 639-46.
  8. Dix J, Marsh S, Dingenen B, Malliaras P. The relationship between hip muscle strength and dynamic knee valgus in asymptomatic females: A systematic review. Phys Ther Sport 2019; 37: 197-209.
  9. Salsich GB, Yemm B, Steger-May K, Lang CE, Van Dillen LR. A feasibility study of a novel, task-specific movement training intervention for women with patellofemoral pain. Clin Rehabil 2018; 32(2): 179-90.
  10. Cheung RT, Davis IS. Landing pattern modification to improve patellofemoral pain in runners: a case series. J Orthop Sports Phys Ther 2011; 41(12): 914-9.
  11. Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. The 'Best Practice Guide to Conservative Management of Patellofemoral Pain': Incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med 2015; 49(14): 923-34.
  12. Clijsen R, Fuchs J, Taeymans J. Effectiveness of exercise therapy in treatment of patients with patellofemoral pain syndrome: Systematic review and meta-analysis. Phys Ther 2014; 94(12): 1697-708.
  13. Kooiker L, Van De Port IG, Weir A, Moen MH. Effects of physical therapist-guided quadriceps-strengthening exercises for the treatment of patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther 2014; 44(6): 391-402, B1.
  14. Lack S, Barton C, Sohan O, Crossley K, Morrissey D. Proximal muscle rehabilitation is effective for patellofemoral pain: A systematic review with meta-analysis. Br J Sports Med 2015; 49(21): 1365-76.
  15. van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SM, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev 2015; 1: CD010387.
  16. Teyhen DS, Robertson J. Knee pain: strengthen my hips? But it's my knees that hurt! J Orthop Sports Phys Ther 2011; 41(8): 571.
  17. Nascimento LR, Teixeira-Salmela LF, Souza RB, Resende RA. 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. J Orthop Sports Phys Ther 2018; 48(1): 19-31.
  18. Baldon RM, Serrao FV, Scattone SR, Piva SR. Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: A randomized clinical trial. J Orthop Sports Phys Ther 2014; 44(4): 240-A8.
  19. Munro A, Herrington L. The effect of videotape augmented feedback on drop jump landing strategy: Implications for anterior cruciate ligament and patellofemoral joint injury prevention. Knee 2014; 21(5): 891-5.
  20. Jeon H, Thomas AC. Efficacy of feedback on running gait retraining in patients with patellofemoral pain: A critically appraised topic. Int J Athl Ther Train 2019; 24(1): 9-14.
  21. 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): 154-63.
  22. Graci V, Salsich GB. Trunk and lower extremity segment kinematics and their relationship to pain following movement instruction during a single-leg squat in females with dynamic knee valgus and patellofemoral pain. J Sci Med Sport 2015; 18(3): 343-7.
  23. dos Reis AC, Correa JC, Bley AS, Rabelo ND, Fukuda TY, Lucareli PR. Kinematic and kinetic analysis of the single-leg triple hop test in women with and without patellofemoral pain. J Orthop Sports Phys Ther 2015; 45(10): 799-807.
  24. de Oliveira Silva D, Briani RV, Pazzinatto MF, Ferrari D, Aragao FA, de Azevedo FM. Reduced knee flexion is a possible cause of increased loading rates in individuals with patellofemoral pain. Clin Biomech (Bristol, Avon) 2015; 30(9): 971-5.
  25. Clark DI, Downing N, Mitchell J, Coulson L, Syzpryt EP, Doherty M. Physiotherapy for anterior knee pain: A randomised controlled trial. Ann Rheum Dis 2000; 59(9): 700-4.
  26. Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician 2007; 75(2): 194-202.
  27. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods. Pain 1986; 27(1): 117-26.
  28. Laprade JA, Culham EG. A self-administered pain severity scale for patellofemoral pain syndrome. Clin Rehabil 2002; 16(7): 780-8.
  29. DiCesare CA, Bates NA, Myer GD, Hewett TE. The validity of 2-dimensional measurement of trunk angle during dynamic tasks. Int J Sports Phys Ther 2014; 9(4): 420-7.
  30. Munro A, Herrington L, Carolan M. Reliability of 2-dimensional video assessment of frontal-plane dynamic knee valgus during common athletic screening tasks. J Sport Rehabil 2012; 21(1): 7-11.
  31. Riel H, Matthews M, Vicenzino B, Bandholm T, Thorborg K, Rathleff MS. Feedback leads to better exercise quality in adolescents with patellofemoral pain. Med Sci Sports Exerc 2018; 50(1): 28-35.
  32. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther 2010; 40(2): 42-51.
  33. Noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in patellofemoral pain. Med Sci Sports Exerc 2013; 45(6): 1120-4.
  34. Nakagawa TH, Muniz TB, Baldon RM, Dias MC, de Menezes Reiff RB, Serrao FV. 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(12): 1051-60.
  35. Ferber R, Kendall KD, Farr L. Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome. J Athl Train 2011; 46(2): 142-9.
  36. Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther 2011; 41(9): 625-32.
  37. Thomson C, Krouwel O, Kuisma R, Hebron C. The outcome of hip exercise in patellofemoral pain: A systematic review. Man Ther 2016; 26: 1-30.
  38. Emamvirdi M, Letafatkar A, Khaleghi TM. The effect of valgus control instruction exercises on pain, strength, and functionality in active females with patellofemoral pain syndrome. Sports Health 2019; 11(3): 223-37.
  • Receive Date: 27 November 2019
  • Revise Date: 23 May 2022
  • Accept Date: 22 May 2022