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BACKGROUND AND PURPOSE: Patellofemoral joint problems are the most common overuse injury of the lower extremity, and altered femoral or hip rotation may play a role in patellofemoral pain. The purpose of this case report is to describe the evaluation of and intervention for a patient with asymmetrical hip rotation and patellofemoral pain.
CASE DESCRIPTION: The patient was a 15-year-old girl with an 8-month history of anterior right knee pain, without known trauma or injury. Prior to intervention, her score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was 24%. Right hip medial (internal) rotation was less than left hip medial rotation, and manual muscle testing showed weakness of the right hip internal rotator and abductor muscles. The intervention was aimed at increasing right hip medial rotation, improving right hip muscle strength (eg, the muscle force exerted by a muscle or a group of muscles to overcome a resistance), and eliminating anterior right knee pain.
OUTCOMES: After 6 visits (14 days), passive left and right hip medial rotations were symmetrical, and her right hip internal rotator and abductor muscle grades were Good plus. Her WOMAC score was 0%.
DISCUSSION: The patient had right patellofemoral pain and an uncommon pattern of asymmetrical hip rotation, with diminished hip medial rotation and excessive hip lateral (external) rotation on the right side. The patient's outcomes suggest that femoral or hip joint asymmetry may be related to patellofemoral joint pain.
A lot of work has been done recently on proximal control issues on PFPS ... it not all about foot orthoses and distal control issues.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I don't think this anything any of us didn't already know. Cibulka has a long history of looking at asymmetrical hip ROM and its effects on LBP and SI jt dysfunction and has quite extensively covered the topic. Only this time he looked at a case of PFD, with what he reports as an unusual pattern of restricted medial(internal) movement. No big deal. Take home message, hip ROM can influence knee symptoms. Not rocket science.
DaFlip
I was just cheking the refs on that paper an found this one from Chris Powers --- i missed it previously:
Quote:
Foot Ankle Int. 2002 Jul;23(7):634-40 Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain.
Powers CM, Chen PY, Reischl SF, Perry J.
Abnormal foot pronation and subsequent rotation of the lower extremity has been hypothesized as being contributory to patellofemoral pain (PFP). The purpose of this study was to test the hypothesis that subjects with PFP would exhibit larger degrees of foot pronation, tibia internal rotation, and femoral internal rotation compared to individuals without PFP. Twenty-four female subjects with a diagnosis of PFP and 17 female subjects without PFP participated. Three-dimensional kinematics of the foot, tibia, and femur segments were recorded during self-selected free-walking trials using a six-camera motion analysis system (VICON). No group differences were found with respect to the magnitude and timing of peak foot pronation and tibia rotation. However, the PFP group demonstrated significantly less femur internal rotation compared the comparison group. These results do not support the hypothesis that individuals with PFP demonstrate excessive foot pronation or tibial internal rotation compared to nonpainful individuals. The finding of decreased internal rotation in the PFP group suggests that this motion may be a compensatory strategy to reduce the quadriceps angle.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Tibia and rearfoot motion and ground reaction forces in subjects with patellofemoral pain syndrome during walking. Gait Posture. 2006 Feb 14;
Authors: Levinger P, Gilleard W
Quote:
Abnormal subtalar joint function and the consequent rotation of the tibia during walking are thought to contribute to patellofemoral pain syndrome (PFPS). The purpose of this study was to measure rearfoot and tibia motion, and the ground reaction force (GRF) during the stance phase of walking in subjects with PFPS and compare them to healthy subjects. A four camera motion analysis system with a single force plate was used to investigate rearfoot motion relative to the tibia in three planes, the tibial transverse plane rotation and the GRF during the stance phase of walking in 13 female subjects diagnosed with PFPS and 14 healthy females. Analysis showed significantly delayed peak rearfoot eversion (p=0.02), and earlier occurrence of peak dorsiflexion (p=0.02) for the PFPS group. Furthermore, significantly lower peak medial GRF (p=0.03), minimum vertical GRF trough (p=0.02) and the second vertical GRF peak (p=0.01) were found in the PFPS group. Tibial transverse rotation was not shown to be different in PFPS subjects. However, there was prolonged rearfoot eversion during the stance phase of walking. The earlier appearance of rearfoot dorsiflexion as well as the lower GRFs indicate altered propulsive function of the foot during supination.
Background: Previous literature has associated hip weakness with patellofemoral pain syndrome.
Hypothesis: Improvements in hip strength and flexibility are associated with a decrease in patellofemoral pain.
Study Design: Cohort study; Level of evidence, 2.
Methods: Thirty-five patients with patellofemoral pain syndrome, aged 33 +mn; 16 years (29 women, 6 men; 43 knees), were evaluated and placed on a 6-week treatment program. Hip flexion, abduction, and adduction strengths, Thomas and Ober test results, and visual analog scale scores for pain with activities of daily living as well as with exercise were documented on initial evaluation and again 6 weeks later. Treatment consisted of strength and flexibility exercises primarily focusing on the hip.
Results: Hip flexion strength improved by 35% +mn; 8.4% in 26 lower extremities treated successfully, compared with –1.8% +mn; 3.5% in 17 lower extremities with an unsuccessful outcome (P < .001). Before treatment, there were positive Ober test results in 39 of 43 lower extremities; positive Thomas test results were seen in 31 of 43 lower extremities. A successful outcome with a concurrent normalized Ober test result was seen in 83% (20/24) of lower extremities, and successful outcomes with normalized Thomas test results were seen in 80% (16/20) of lower extremities. A combination of improved hip flexion strength (> 20%) as well as normal Ober and Thomas test results was seen in 93% of successfully treated cases (14/15 lower extremities), compared with 0% success (0/5 lower extremities) if there was no change in hip flexion strength (< 20%) and if Ober and Thomas test results remained positive.
Conclusions: Improvements in hip flexion strength combined with increased iliotibial band and iliopsoas flexibility were associated with excellent results in patients with patellofemoral pain syndrome
Well the tissue stress folks would say that you are looking at position and not moment or force. I have not been really happy with the pronation/ internal rotation theory of patella femoral pain. Transverse plane torque would be a key variable to look at. The idea is that the tibia is internally rotated relative to the femur. A difficult measure and still not torqure. For, me the jury is still out.
Eric
Hip Muscle Activity is Altered in Patellofemoral Pain: Clinical Implications
Crossley, Kay M.; Bryant, Adam; Cowan, Sallie
Quote:
PURPOSE: It is commonly accepted that the aetiology of patellofemoral pain is mutifactorial. While many individuals have altered muscle function locally at the tibiofemoral or patellofemoral joints, it has been recognized by clinicians that hip muscle function (strength or co-ordination) may be impaired in individuals with patellofemoral pain. This study aimed to investigate whether individuals with patellofemoral pain have altered hip muscle function compared with their healthy counterparts. A further aim was to establish whether a simple clinical assessment of the single leg squat could identify individuals with altered hip muscle function
METHODS: Fifteen individuals with and without patellofemoral pain were recruited for this project. The electromyographic (EMG) of the gluteus medius muscles were collected during a stair stepping visual choice reaction time task. Anterior gluteus medius (AGM) was collected using surface electrodes, while posterior gluteus medius (PGM) was collected using fine wire electrodes. The onset of EMG activity of the gluteal muscles was assessed. Trunk side bend, hip external rotation and abduction torque were collected using a hand-held Nicholas Manual Muscle tester (model). The single leg squat performance was assessed by a panel of four experienced physical therapists. These clinicians reviewed a digital video recording of the participant performing five consecutive single leg squats. After reviewing the participants independently, the clinicians reached consensus on whether the participant could be graded as “good” or “poor”. Those participants who were classified as neither good nor poor were excluded from this analysis
RESULTS: Individuals with patellofemoral pain exhibited a later onset of both hip muscles (AGM and PGM) (p <0.05) than the healthy individuals. Interestingly, this alteration in the temporal control of the hip muscles was not associated with a deficit in hip muscle strength (p >0.05). Furthermore, individuals with poor performance on the clinical assessment of the single leg squat exhibited a delayed onset of the AGM and PGM.
CONCLUSIONS: Onsets of the AGM and PGM EMG is delayed in many individuals with patellofemoral pain. Furthermore, a simple clinical assessment tool is able to identify which individuals exhibit these temporal disruptions in hip muscle activity. In such individuals, clinicians should consider including an appropriate rehabilitation strategy
STUDY DESIGN: Cross-sectional. OBJECTIVES: To investigate whether females seeking physical therapy treatment for unilateral patellofemoral pain syndrome (PFPS) exhibit deficiencies in hip strength compared to a control group.
BACKGROUND: Decreased hip strength may be associated with poor control of lower extremity motion during weight-bearing activities, leading to abnormal patellofemoral motions and pain. Previous studies exploring the presence of hip strength impairments in subjects with PFPS have reported conflicting results.
METHODS AND MEASURES: Twenty females, aged 12 to 35 years, participated in the study. Ten subjects with unilateral PFPS were compared to 10 control subjects with no known knee pathologies. Hip abduction, extension, and external rotation strength were tested using a handheld dynamometer. A limb symmetry index (LSI) was used to quantify physical performance for all tests.
RESULTS: The symptomatic limbs of subjects with PFPS exhibited impairments in hip strength for all variables tested. LSI values in subjects with PFPS (range, 71%-79%) were significantly lower than those in control subjects (range, 93%-101%) (P< or =.007). A secondary analysis of data normalized to body mass demonstrated that the symptomatic limbs of subjects with PFPS had 52% less hip extension strength (P<.001), 27% less hip abduction strength (P = .007), and 30% less hip external rotation strength (P= .004) when compared to the weaker limbs of control subjects.
CONCLUSION: Females aged 12 to 35 presenting with unilateral PFPS demonstrate significant impairments in hip strength compared to control subjects when LSI values or body mass normalized values are used to quantify physical performance of the symptomatic limb.
PURPOSE: Decreased hip strength has been theorized to contribute to the development of patellofemoral pain. The purpose of this study was to test for strength differences of six hip muscle groups in collegiate female athletes diagnosed with unilateral patellofemoral pain compared with the unaffected leg and noninjured sport-matched controls.
METHODS: At four Division III schools, all collegiate female athletes experiencing unilateral patellofemoral pain were recruited during the 2004-2005 academic school year. The athletes were diagnosed with patellofemoral pain by sports medicine-trained family physicians or orthopedic surgeons. Hip strength of six different muscle groups was tested using a handheld dynamometer. The highest value of two trials was used, and strength values were normalized to body weight. The measurements from the injured leg were compared with the uninvolved leg and also with uninjured control subjects matched for sport.
RESULTS: Thirteen athletes were diagnosed with unilateral patellofemoral pain. The injured-side hip abductor (P = 0.003) and external rotator muscle groups (P = 0.049) were significantly weaker than the noninjured sides. There were no significant differences in the other hip muscles tested. In addition, the injured legs were significantly weaker in five of the six hip muscle groups compared with the control group.
CONCLUSIONS: The results of this study show that hip abductors and external rotators were significantly weaker between the injured and unaffected legs of the injured athletes. In addition, injured collegiate female athletes exhibited global hip weakness compared with age- and sport-matched asymptomatic controls. Screening for hip muscle weakness and adding strengthening exercises to the affected hip muscles may be important factors in managing female athletes with patellofemoral pain.
"Tibial transverse rotation was not shown to be different in PFPS subjects. However, there was prolonged rearfoot eversion during the stance phase of walking. The earlier appearance of rearfoot dorsiflexion as well as the lower GRFs indicate altered propulsive function of the foot during supination. "
Now this is something that makes perfect sense to me. It encompasses the paper that Craig P. listed and it's findings and includes some references to the timing of eversion during stance phase.
It is amazing to me that anyone would still think that the amount of measured in- or eversion of the heel, or internal rotation of the tibia would really matter. No matter the patient, they will usually fully pronate as much as their joints will allow. It is not a matter of what position they get to, but how long they stay in that position that really matters. This paper seems to verify that issue, to me at least.
I do not find it surprising that there would be a limitation of hip ROM either as this is often a compensation brought on by a stoppage of foot motion or rotation as recorded.
Call it a chicken / egg scenario if you like, but if you do not control for the pathologic foot function, your outcomes will rarely hold just by focusing on the hip musculature alone. IMHO!
your outcomes will rarely hold just by focusing on the hip musculature alone
Bruce,
You're too young:p to remember how the PT's and Orthopedic surgeons would recommend quad strengthening exercises for "chondromalacia patella". These also worked temporarily at best.
The key is finding and treating the cause, not one of several results.
You're too young:p to remember how the PT's and Orthopedic surgeons would recommend quad strengthening exercises for "chondromalacia patella". These also worked temporarily at best.
The key is finding and treating the cause, not one of several results.
Regards,
Stanley
Stanley;
You think I am younger than I actually am! I rember those exercises from school and I think it is still in the some of the most current texts, though I could be mistaken.
Bruce
Re: Patellofemoral pain and asymmetrical hip rotation
Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run.
Dierks TA, Manal KT, Hamill J, Davis IS. J Orthop Sports Phys Ther. 2008 Aug;38(8):448-56.
Quote:
STUDY DESIGN: Cross-sectional experimental laboratory study.
OBJECTIVES: To investigate the relationships between hip strength and hip kinematics, and between arch structure and knee kinematics during prolonged treadmill running in runners with and without patellofemoral pain syndrome (PFPS).
BACKGROUND: Hip weakness can lead to excessive femoral motions that adversely affect patellofemoral joint mechanics. Similarly, foot mechanics, which are influenced by foot structure, are also known to influence patellofemoral joint mechanics. Thus, proximal and distal factors should be considered when studying individuals with PFPS.
METHODS AND MEASURES: Twenty recreational runners with PFPS (5 male, 15 female) and 20 matched uninjured runners participated in the study. Hip abduction and hip external rotation isometric strength measurements were collected before and after a prolonged run, while the arch height index was recorded on all runners before the run. Lower extremity kinematic data were collected at the beginning and end of the run. Two-way repeated-measures analyses of variance (ANOVAs) were used for analysis.
RESULTS: Both groups displayed decreases in hip abductor and external rotator strengths at the end of the run. The PFPS group displayed significantly lower hip abduction strength [(kg x cm)/body mass] compared to controls (PFPS group: begin 15.3, end 13.5; uninjured group: begin 17.3, end 15.4). At the end of the run, the level of association between hip abduction strength and the peak hip adduction angle for the PFPS group was statistically significant, indicating a strong relationship (r = -0.74). No other associations with hip strength were observed in either group. Arch height did not differ between groups and no significant association was observed between arch height and peak knee adduction angle during running.
CONCLUSIONS: Runners with PFPS displayed weaker hip abductor muscles that were associated with an increase in hip adduction during running. This relationship became more pronounced at the end of the run.
Background: Recent studies have suggested that excessive hip internal rotation during dynamic tasks may be associated with patellofemoral pain. Although diminished hip-muscle strength and altered femoral morphologic characteristics have been implicated in abnormal hip rotation in persons with patellofemoral pain, no study has confirmed this hypothesis.
Hypothesis: Women with patellofemoral pain would demonstrate increased average hip internal rotation, decreased hip-muscle performance, and abnormal femoral shape compared with controls. Furthermore, measures of hip strength and femoral shape are predictive of average hip internal rotation during running.
Study Design: Cross-sectional study; Level of evidence, 3.
Methods: Nineteen women with patellofemoral pain and 19 pain-free controls participated. Lower extremity kinematics during running, hip-muscle performance, and femoral morphologic characteristics on magnetic resonance imaging were quantified. Independent t tests were used to assess group differences. Stepwise linear regression was used to determine whether measures of strength and/or structure were predictive of average hip internal rotation during running.
Results: Participants with patellofemoral pain demonstrated significantly greater average hip internal rotation (8.2° ± 6.6° vs 0.3° ± 3.6°; P < .001), reduced hip-muscle strength in 8 of 10 hip strength measurements, and greater femoral inclination (132.8° ± 5.2° vs 128.4° ± 5.0°; P = .011) compared with controls. Stepwise regression revealed that isotonic hip extension endurance was the only predictor of average hip internal rotation (r = –.451; P = .004).
Conclusion: Abnormal hip kinematics in women with patellofemoral pain appears to be the result of diminished hip-muscle performance as opposed to altered femoral structure. The results suggest that assessment of hip-muscle performance should be considered in the evaluation and treatment of patellofemoral joint dysfunction.
Tight lateral structures have been implicated in subjects presenting with patellofemoral pain syndrome (PFPS). It has been proposed that a tight iliotibial band (ITB) through its attachment of the lateral retinaculum into the patella could cause lateral patella tracking, patella tilt and compression.
Twelve subjects presenting with PFPS were compared with 12 matched control subjects. Hip adduction was measured using the Ober test in each subject as an indirect measure of ITB length. The mean values for hip adduction in the control group were 21.4 (±4.9) and 20.3 (±3.8) degrees in the left and right legs, respectively, and in the PFPS group, 17.3 (±6.1) and 14.9 (±4.2) degrees in the non-painful leg and painful leg, respectively. One way analysis of variance (ANOVA) revealed a highly significant difference between groups (F = 4.485, p = 0.008) and post-hoc analysis showed a significant difference between the painful leg in the PFPS group and the left and right legs in the control group, p = 0.002 and 0.009, respectively.
The results from this study show that subjects presenting with PFPS do have a tighter ITB. Future work should investigate this observation prospectively in order to determine whether a tight ITB is the cause or effect of PFPS.
Patellofemoral pain and asymmetrical hip rotation
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