Pain in the What?
Understanding the underrated role of Hip Strength
in Patellofemoral Pain Syndrome
“My doc says I can’t run anymore.” “I need to stop doing squats.” “I have my mother’s knees.” Do these common remarks sound familiar to you?
Patellofemoral pain syndrome (PFPS) is one of the most common knee conditions reported by both males and females. PFPS is a problem with pain that feels like it is mainly on the front of the knee, specifically on the underside of or somewhere around the edges of the kneecap. One or both knees can be affected. The pain is often worse when climbing stairs or hills, or after sitting for a long period of time. PFPS should be distinguished from its cousin chondromalacia, which is actual fraying and damage to the patellar cartilage.
No other joint in the human skeletal system is as big or critical for smooth, coordinated and explosive movements than the knee. With every running step, the knee absorbs and shares impact forces equivalent to at least twice one’s body mass. A common misconception is that the patella only moves in an up-down manner, when in fact, it tilts and also rotates allowing your foot to point one way while your trunk rotates in another direction. It can do this because there are several points of contact between the patella and the femur as well as a maze of connective tissue that weave together the bones and the muscles. The knee is an architectural phenomenon. However, it is also extremely vulnerable and is the most commonly injured joint in the human body.
What causes Patellofemoral Pain Syndrome?
PFPS is also known as runner’s knee and is the result of irritation in and around the kneecap. Although this condition is common, accounting for up to one quarter of all knee injuries, its cause, in the rehabilitation literature, is not well understood. Many investigators believe that abnormal alignment of the patella within the femoral trochlea may lead to the onset of PFPS. However, malalignment itself may also have several causes, compounding the question further and making it difficult to disseminate the root cause. The jury is out on this one folks. PFPS is a multi-factorial injury that can affect all types of active and even inactive people. Contributing factors may or may not include overuse and overload (in the case of the overweight person) of the patellofemoral joint, biomechanical issues, muscular dysfunction and joint mobility limitations.
Theories presented in the sport science literature have added to the lack of consensus on the cause of this ailment as well as the proper solutions to unload the joint and restore correct function in the musculoskeletal system:
“Although this condition is common, its cause is not well understood.” Boling et al. 2009
“There is no consensus on the most effective method of treatment … the indications and contraindications of each approach have not been well established.” Journal of Orthopedic and Sport Physical Therapy 1999.
“Managing patellofemoral pain syndrome is a challenge, in part because of lack of consensus regarding its cause and treatment,” and “no single biomechanical factor has been identified as a primary cause of patellofemoral pain.” American Family Physician 1999.
“No consensus on the definition, classification, assessment, diagnosis, or management has been reached.” Naslund, 2006.
And it becomes even more compounding…..Pain in the patellofemoral joint is often not associated with any identifiable degeneration, mechanical damage, trauma or dysfunction!
Possible Risk Factors
So, if we are unclear as to the cause of the problem, are there some risk factors we can identify to help lessen the changes of incurring this ailment? In the research, the positive risk factor list is extremely lengthy. Those identified included: weakness in function testing; tightness of the gastrocs, hamstrings, quadriceps and ITB; generalized ligamentous laxity; deficient hamstring and/or quadriceps strength; hip musculature weakness; an excessive Q angle; patella compression or tilting AND an abnormal VMO/VL reflex timing (Waryasz et al, 2008). It seems to be a no-brainer that these risk factors are often characteristic of those who do not follow a sound joint mobility and strengthening program and PFPS just happens to be the outcome of such. We should know that when clients present with several of these risk factors, that it is our job to take preventative measures and ensure their musculoskeletal system can handle the rigors of the activities they love to do. We strength train to make the body more resilient and strength training should address all of these risk factors in all client cases.
What the doctor or therapist often recommends…
It is also important to consider where, perhaps, our clients are seeking advice from. With the information age of the internet, the ability to access both good and poor solutions are right at our fingertips. After doing an extensive literature search in both academic and lay-person sources on the internet, it was found that the advice for treatment by both physicians and physiotherapists in the two sources did not differ greatly. Meaning, the accessible sources of information on someone’s blog site versus a peer-reviewed medical site proved to be very close in content. In the sources found on google, these general recommendations were made:
- Take a break from what aggravates your condition and activities that are high impact like jumping and jogging.
- Do ‘these’ exercises – (found on over 10 websites) The patients sits supine, propped up one’s elbows with both legs straight out in front on the floor. The ‘injured’ side must be lifted up (while keeping it straight to activate the rectus femoris) off the ground a few inches and held for 10 seconds or so. Repetitions of 10 were prescribed and this was defined as an ‘isometric’ drill to improve quadriceps strength.
- Ensure you are wearing good footwear – running shoes with good shock absorption in particular, and talk to your doctor about footwear. Replace shoes every 6 months if you are a runner.
- Ice your knees for 10-20 minutes after activity
- Perform static stretches for the hamstrings, the iliotibial band, the buttocks and the calves (before exercise)
Look beyond the pain
In the case of PFPS, as well as other knee pain related to overuse & overload, the knee should be viewed as a reservoir where pain collects. It is not the knee who is the culprit that causes the pain. Instead, it is an innocent bystander, a victim, and the result of issues that originate elsewhere in the kinetic chain. In fact, PFPS may be related to poor stability at the hip but present as knee pain (Powers, 2003). A knee-focused approach to treatment of PFPS, such as the doctor’s orders listed above, is in fact, a symptom-based approach or a band-aid solution, no different than bracing a sprained ankle and neglecting to restore its range of motion and function. Most conventional treatments have centered on trying to reduce the pain at the pain site with various passive modalities (ice, taping, ultrasound, massage etc.). In other words modern treatment often focuses on relieving the symptoms versus trying to identify and eliminate the cause(s). The difference is whether or not the problem is permanently solved or temporarily alleviated.
The treatment for PFPS must be focused on a long-term solution.
The reality is what is necessary is an aggressive strengthening program centered around the core and hips and down the kinetic chain, with particular emphasis aimed on the eccentric control of knee flexion, adduction and internal rotation (Boyle, 2010). The Ireland study (Ireland et al. 2003) states that “females presenting with patella-femoral pain demonstrate significant hip abduction and external rotation weakness (piriformis, obturator internus and externus, gemellus superior and inferior and quadrates femoris) when compared to non-symptomatic age matched controls.” More specifically, weakness in the gluteus medius muscle is believed to increase hip adduction and knee valgus angles (Boling et al., 2009). The gluteus maximus may also play a role in controlling frontal plane and transverse plane motions of the hip during functional tasks (Boling, 2009). Based on these findings, it is weakness in the hip muscles that can lead to malalignment of the patella within the femoral trochlea because of the excessive movements in the femur in hip adduction and internal rotation.
What the worlds top strength coaches and physical therapists are doing
Physiotherapists and chiropractors still prescribe endless exercises and bracing devices to improve knee tracking — which good science and anecdotal evidence has now shown to be difficult at best and likely irrelevant. Instead, lower extremity strengthening done with emphasis on hip control in combination with a program of progressive single leg strength and power development to address the eccentric and neural stability components may allow many patients to experience long-term and permanent relief. It seems clear that the key to solving anterior knee pain lies strengthening the hip musculature in the frontal and transverse planes and as well as the glutes, hamstring and quads, combined with consistent joint mobility of the anterior hip as well. Having adequate mobility in the anterior hip is critical to allow the posterior chain (glutes and hamstrings) to do it job in controlling aberrant motion.
The following training program is recommended for patella-femoral pain syndrome:
Phase 1
Perform progressive range of motion exercise on the anterior hip (hip flexors, TFL, Quadriceps)
and perform soft tissue work to glute medius with tennis ball and foam roll or by a qualified therapist, trainer etc. if available.
Resource: Super Joints DVD by Pavel Tsatsouline, Founder of the RKC
*Ensure adequate ROM before progressing to Phase 2
Phase 2
Gray Cook, a world reknowned Physical Therapist recommends the use of Reactive Neuromuscular Training for the hip abductors in conjunction with a strengthening
program for the knee and hip extensors focusing on single leg unsupported exercises and progressive range of motion if necessary. Cook’s concept of Reactive Neuromuscular Training involves applying a stress to a joint in opposition to the action of the muscles (Boyle 2010). In other words to effectively target the hip abductors a band is placed around the knee and the leg is pulled with an adduction force. The addition of the adduction force will in effect “turn on” the abductors (Boyle).
Resource: Athletic Body in Balance by Gray Cook
Phase 3
Strengthen the posterior chain: the hip extensors, external rotators and hamstrings in both bilateral and unilateral patterns. Perform deadlifts, single leg deadlifts, lateral squats and glute bridging variations. Do not perform glute bridging with two legs. Instead always use one leg for maximum benefit and unilateral strength and core development (Bott & Keller, 2008). At this phase, the core can also be integrated using uneven loads, and pulleys. It is not necessary to do endless planks and other face-down ground based drills. These often undo some of the great progress you made in phase one. A heavy deadlift will often take care of the ‘core’ as will a loaded lateral squat or overhead squat.
Phase 4
Do not forget about conditioning. In fact, this does not have to be Phase 4. You can implement these drills right away, at Phase 1. If you are training gait-based athletes, such as runners, cross training is important for balance in the body. Instead of unloading them with the exercise bike, which can often lead to postural problems, be more creative and teach them Kettlebell Swings or prowler pushes. Another great drill is to put the treadmill on an incline, at a slow speed and have them walk backwards on it to work on eccentric endurance. Retrograde treadmill walking is another excellent exercise for the athlete or client with patella femoral pain. They can be progressed by increasing the incline and adding speed to this drill, plus lengthening the intervals.
Once your clients have progressed through each phase and are pain and symptom free, ensure they continue to strength train twice per week. It is important they maintain the gains they have made and ‘buy in’ to the relationship between a strong set of hips and healthy, resilient knees.
Happy training from coach Bott.
August 6th, 2010 at 11:27 am
Hi buddy would it be ok if we took some info from here to use on one of my websites? cheers mate
September 13th, 2010 at 12:43 am
Kettlebells are the very best approach to get fit. I by no means bother with any other gear nowadays, just a couple of kettlebells and I appear in top form.
October 26th, 2010 at 5:51 pm
Nice. Thanks for posting this. It is always great to see someone give back to the community.