Effectiveness Of Hip Muscle Strengthening In Patients With Patellofemoral Pain Syndrome
INTRODUCTION:
Patellofemoral pain syndrome (PFPS) commonly causes knee pain, especially in physically active females. It refers to anterior or retro patellar pain. Anterior knee pain is a prevalent condition primarily affecting young female patients due to their wider pelvises, without any structural changes. Every year, it has an incidence rate of 22 cases per 1,000 people, with women being more affected than men, at a ratio of more than two to one. Among runners and sports medicine centres, it is the most common single diagnosis. In the office setting, 11% of musculoskeletal complaints are caused by anterior knee pain, accounting for 16 to 25% of all injuries in runners. Patellofemoral pain syndrome, which accounts for nearly 25% of all knee injuries related to sports, is multi-factorial (Nascimento et al., 2018). The combination of variables, including soft tissue tightness, excessive exercise, and lower limb biomechanics, might outcome in maximised subchondral and cartilage stress of bone, subtle or overt patellar maltracking, and patellofemoral pain. Due to the multiple forces that affect the patellofemoral joint, clinical evaluation and treating this disease are challenging.
NEED FOR THE STUDY:
- Address muscle imbalance and weakness.
- Improve movement patterns.
- Enhance neuromuscular control.
- Address multiple regions contribution to pain.
- Functional focus.
- Comprehensive rehabilitation.
IMPORTANCE OF THE STUDY:
The study proposes a qualitative textual evaluation to address the underlying cause of PFPS, improve function, and provide comprehensive rehabilitation. Strengthening hip muscles generally helps change the joint's contact pressure and reaction force. Hence, this helps minimise the applied load and patellofemoral pain syndrome while enhancing the quadriceps and patellofemoral kinematics. The study also shows that the diagnosis of patellofemoral pain syndrome is clinically made, and although the management can be found challenging and well-designed, the program of non- operative treatment basically permits the patient to return to competitive and recreational activities.
RATIONALE:
The patellofemoral joint is a vital part of the knee extensor mechanism that can affect hip muscle performance. Weak or poorly controlled quadriceps can cause pain and weakness in the hip muscles. Knee and hip strengthening is superior and effective to strengthening of me alone for declining pain and enhancing activity in individuals with patellofemoral pain. However, those results have been acquired without concurrent alteration in strength. Hip strengthening is considered a rehabilitation protocol for treating individuals with patellofemoral pain and has paid attention exclusively to the local factors like utilisation of the knee orthosis and the strengthening of quadriceps muscles.
LITERATURE REVIEW:
The study presented by Elliott et al., (2018) aim to assess the impact of hip exercises in addition to knee exercises on young women like female learners who are dealing with PFPS disorder. Prior research has indicated that patellofemoral pain syndrome (PFPS) is linked with the weakness of the hip abductor and external rotator muscles. Weak hip muscles, known as valgus, can cause increased angulation at the knee and increase patellofemoral joint stress during weight-bearing activities. The key strength of the study presented by Elliott et al., (2018) denotes the availability of suitable practice guidelines that supports hip biomechanics as well as takes an essential part within PFPS's continuity and development. These exercises had been productive for clients to enhance their functioning and pain. The major limitation of this analysis is only few studies have been capable to give emphasis on hip exercises strengthening methodology to standard care of physiotherapy for treating PFPS among patients. There was also a potential bias observed in the study mainly towards female participants where their supervising session were for an extended period of time as compared to the control group with lack of standard methodological studies quality and regulation procedure that obstructs control groups' inclination to the measure. Authors conducted a systematic search in relation to CINAHL, Cochrane, Embase, SportDiscus, PEDro and MEDLINE® where PFPS participants from the age group of 18 to 44 years were diagnosed (Elliott et al., 2018). The Program of Critical Appraisal Skills had been utilized for determining methodological quality and varying outcomes stated that there was variability on PFPS participants' outcomes on strength but they were satisfied taking the long supervising exercise sessions as their pain outcomes have been enhanced along with improving functioning among adults.
As per the point-of-view of Fredericson & Yoon (2006), the primary measure outcome consisted of three limb hop tests, one leg squat test, and step down test to assess the function at follow-up visits, whereas Collado H et al., (2010) signifies the secondary outcome measures consisted of Trendelenburg and muscle tightness test that were compared before and after the therapy as positive or negative test results. However, the group that performed hip and knee exercises showed more significant improvement in pain levels during rest, standing, walking, running, squatting, and climbing stairs at weeks 6 and 12 (P<0>
Nascimento et al. (2018) indicates patellofemoral pain is mainly featured as pain behind, under, and around the patella during activities that maximise stress on PFJ
(Patellofemoral Joint), like extended sitting, jumping, and running, stair climbing, squatting, and flexed knees for a long time. This is considered among the most common kinds of lower and knee extremity pain, with a prevalence annually of nearly 23 per cent in the general population as well as 29 per cent among adolescents. Although no definite clinical test to carry out diagnosis of PFPS is there, squat manoeuvring was found to trigger the issue of PFPS among 80% of individuals. In comparison, palpation of parallel ligament generally triggers PFPS in approximately 75% of people (Nascimento et al., 2018). Previously cause of this disease was sought primarily in the performance of the muscle of quadriceps, as the local imbalance between the muscles within the knee area shall make a contribution to the maximised load of the patellofemoral joint.
Evidences from Petersen et al. (2013) suggest that the approach of combined exercise resulted in a more significant reduction of pain when compared with the knee exercise program. It has been suggested that the superior relief of pain in the combined program of knee and hip exercise is because of the reduced loading of PFJ as compared to the program of knee exercise. Some recent systematic analysis with the concept of meta-analysis mainly confirms this outcome and indicates the importance of the program of exercise paying attention to the group of muscles contiguous to the knee in patellofemoral pain in order for attaining the suitable plausible outcome. Additionally, although the program of knee and hip showed more considerable relief of pain, functional enhancement and strength of hip muscle increases compared to the knee exercise program (Petersen et al., 2013). Patellofemoral pain syndrome or PFPS can be considered among the most basic disability of joints in the knee within the context of sports medicine.
Santos et al. (2015) has added to the fact that several non-operative approaches have been established to treat this disease; however, none of the interventions has been stated for being the most effective. For several years, the non-operative treatment initiative has been addressed as the tracking of abnormal patellar or wrong alignment, and this technique comprises quadriceps strengthening, stretching, soft tissue mobilisation, taping, and patellar bracing. Various researchers have recognised that hip strength is much more important in the condition of PFPS. Patients with the disability of patellofemoral pain illustrated major weakness within the hip flexor during the seated testing of strength concerning hip flexion. Those findings suggested the possible ability of a hip muscle to regulate the rotation of the femoral during activities that leads to PFPS. The weakness of the hip flexor might not offer pelvis having stability adequately during Gate for obstructing the pelvis from moving to femoral rotation of concomitant as well as interior pelvic tilt internally. In addition to this, the muscle of iliopsoas is considered the external rotator of secondary femoral, and the weakness might permit the femur for taking a position in the relative rotation that happens internally, misaligning the groove of trochlear obtaining the patella (Santos et al., 2015).
Nascimento et al., (2018) suggests that the patellar subluxation during the weight- bearing exercises might be the outcome of the femur rotating under the patella in the transverse plane. Addiction, abduction, and hip flexion strengths have been evaluated with the hand-held dynamometer. Hip flexion has been tested with a concept that would be by following a sitting position. It was asked for heightening the 58 inches right from the table area as well as maintaining that position. However, a pressure was applied manually obtaining a hand-held dynamometer for breaking the contraction of muscle. The force which was applied for breaking the contraction of muscle was noted accurately in newtons (Nascimento et al., 2018). The research methodology performed within this systematic review has been based on controlled and randomized trials. People with PFPS symptoms were mainly included along with carrying out experimental intervention so that knee and hip strengthening can take place efficiently. It was highlighted through results that knee and hip strengthening was effective to decrease pain along with enhanced activity in comparison to no placebo or training (Nascimento et al., 2018). Maintenance of results was extended beyond the period of intervention. At the same time, no potential changes were showed by meta-analyses in strength particularly for any kind of intervention.
The major strength of the paper is obtained as its ability to correctly determine treatment effects of hip strengthening exercises among patients dealing with PFPS. It has been able to outline recommendations by focusing on a standard evidence level and comprising on controlled and randomized trials. It has been highly effective to work on knee strengthening by lowering intensity of pain as well as enhancing activity among PFPS individuals. The study's main limitation is assessed as the scale score of PEDro has faced complexities to bind participants or therapists and highlighting moderate quality in findings. Potential bias was also found due to less reporting process with regards to concealed allocation along with having a doubt of whether a purpose to treat review had been carried out (Nascimento et al., 2018). Also, due to reduction in participants' number in one group, the findings were obtained as small-trial bias. Further, it can be suggested that suitable sample-size calculations are delivered by randomized clinical trials in the future in order to enable systematic reviews to plan for depending on overall participants' number.
Santos et al. (2015) further relates the strength of hip abduction has been determined within the side-lying area; a breaking pressure was implemented distally, that is 1 inch additional to the lateral malleolus. The position of side lying has been utilized for testing the strength of abduction. In the same position, the patient has been asked to make his leg straight and thereafter to lift the legs straight up to 12nches of the table. Again, breaking force has been implemented 1 inch greater than the medial malleolus. This paper stated that the correlation coefficient of test- retest of 0.84 to 0.99 for the measurement of hip strength, therefore, indicates high reproduction ability. The treatment that consists of closed and open flexibility and strength exercises applying the Kinetic chain for the portion of hip is considered under therapeutic interventions.
The primary strength of the paper is been determined as three major studies have been successful to showcase that strengthening of hip muscle program has been effective to eliminate moderate to excessive pain among clients suffering from PFPS. But the study's key weakness is found to be that there are only fewer evidences available according to the results' obtained where participants have not been able to ensure that this muscle strengthening exercise contains the capability for increasing strength of muscles (Santos et al., 2015). Well-known databases like MEDLINE, Google Scholar, SciELO, LILACS and PEDro had been used to obtain accurate
In a study by Ferber et al. (2015)., approximately 66 per cent of the PFPS affected patients had obtained positive outcomes after a protocol time period of six weeks considering therapeutic exercise emphasising the flexibility and strength of hip musculature. Further, the protocol of treatment has been found effective in enhancing the flexibility within the illiopsoas and the iliotibial region of the band and in enhancing addiction, abduction, and strength of hip flexion. The treatment is connected to the enhancement in band flexibility of iliotibial and iliopsoas and the strength of hip flexion. The potential enhancement in this strength of hip flexion among 35% of patients with positive results has shown a variance with no alteration in this strength of reflection in 1.8% of patients who did not get successful outcomes (Ferber et al., 2015). Enhancement in Hip adoption and abduction strength are relevant between the patients with unsuccessful and successful outcomes. Both the groups should enhance the strength of hip abduction, which is 18% and 28%, respectively, and the strength of adoption, which is 24% and 40%, respectively. The review used multi-centered and single-blind RCT all over four laboratories of clinical research. These included regions such as Alberta, Calgary, Illinois, Chicago, Georgia, Augusta, Wisconsin and Milwaukee.
The key limitation of the paper has been understood as a particular control group has not been included for the treatment course, therefore it cannot be concluded that knee-or-hip oriented strengthening of muscle was enhanced as compared to no treatment specifically for the six weeks. Secondly, the application of various other pain and functional measures which are self-reported in characteristics like the Functional Index Questionnaire, the Global Improvement Scale, Life Scale Quality, can be offered further reflection into differences formed between the protocols of rehabilitation. Follow-up was the lacking feature in the current study within the RCT evaluation of physiotherapy and foot orthosis for PFP's treatment. The study's major strength is that it has been effective to draw higher enhancements in functioning and pain for clients engaged within the protocol of HIP as compared to those engaged within the protocol of KNEE (Ferber et al., 2015). The review presented rehabilitation program that was knee-focused in characteristics and lead to enhanced outcomes as compared to the knee program.
CONCLUSION:
To sum up, when rehabilitating PFPS, it is more effective to build up the hip abductors and external rotators in addition to the knees. This approach allows muscle training at the same time when reducing pain, increasing overall function, and improving muscle strength. Based on this study, it is strongly recommended that patients with PFPS perform hip and knee-strengthening exercises. It shall be concluded from findings that when ligamentous laxity generalised is examined, hypermobile or hypermobile patella; mediolateral displacement's tenderness lowers quadriceps and ITB's flexibility. Additionally, weaknesses formed about the external rotator, hip abductor, and quadricepses are suggested to highlight factors that contribute to the malalignment of patellofemoral and PFPS. The RCT methodological technique applied also made evident the strengthening of hip muscles is pivotal in treating and caring for PFPS clients as this can improve the functioning of daily activities. Nevertheless, there were equivocal findings that denoted the capability of these treatments for improving the strength of muscles. Researchers are advised to utilise this data for future planning studies and get support and assistance to make clinical decisions. This is because they assist in strengthening hip muscles' inclusion within patients' treatment dealing with PFPS. The outcomes obtained can further be applied by clinical for elaborating the goals of the treatment to clients as well as maximising their follow-up to the treatment process. Moreover, an individual care and treatment plan should be adopted by a physician for every client based on the root pathology cause.
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