Patellofemoral Pain Syndrome and Hip Strength: Difference between revisions

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Introduction
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The patella is a unique structure that plays a central role in the normal biomechanics of the knee. Unfortunately the patella remains the enigma of sports medicine and sports physical therapy. Across all sports and all age, it is probabily the single most common cause of pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Patellofemoral pain syndrome is defined as retropatellar or peripatellar pain, or both, that results from physical and biomechanical changes in the patellofemoral joint.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Patellofemoral pain syndrome is a common source of anterior knee pain in young and active individuals. It accounts for 25% to 40% of all knee pain problems in sports medicine centers. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Incidence
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In General Population, females have a higher incidence of patellofemoral pain than male (3:2). There are clear structural, biomechanical, sociological and hormonal difference between women and men that contribute to an increase incidence of PFPS in women. This high incidence in women has been attributed to the gender difference in muscle strength, conditioning and anatomic structure especially increased Q angle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

11% of musculoskeletal complaints in the office setting are caused by anterior knee pain (which most commonly results from PFPS), and PFPS constitutes 16 to 25 percent of all injuries in runners. Patellofemoral pain syndrome (anterior knee pain) is experienced by over 2.5 million Americans while statistics for other countries may be higher.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^[1]This condition is diagnosed at a higher frequency in female atheletes when compared to male athletes.^[2]

Despite its frequent occurrence, Patellofemoral pain syndrome remains a difficult and often frustrating condition for all of us to treat, it is not only difficult to treat but also difficult to assess its gravity of pathology. In patellofemoral pain syndrome, identification of the underlying pathophysiology is difficult, though the classic picture in patellofemoral is easily identifiable. The patients complains of retropatellar or peripatellar (mainly medial side) precipitated by prolonged sitting and the pain is proportional to the activity, particularly evident when squatting or descending stairs.

Generally onset is insidious and progression slow. Patellar grind test is positive and the patient complains of discomfort on palpation of medial and lateral borders of patella. Giving way and instability is also common.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Anatomy[edit | edit source]

Patellofemoral joint is one of the most important joint in lower extremity which plays a major role in weight bearing activities. This joint is made up of by articulation of patella with femur. The knee joint has two part and patellofemoral joint is one of it. The patella and femur forms the patellofemoral joint. The patellofemoral joint is also the least congruent joint of the human body.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It is shaped like a shield, with the ape pointing distally and has an anterior and posterior surface and three borders. The articular surface can be divided into medial and lateral facet seperated by central ridge and with an odd medial facet. While the hight and width are nearly constant the thickness of the cartilage and bones varies. The articular cartilage of the patella is thicker than any where else in the body.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The total articular surface is much smaller than the femoral trochlear surface, and the material properties of the patellar surface vary throughout the articular surface as well as from the properties of the opposing trochlear cartilage20. The posterior surface of the patella is covered by articular cartilage and divided by a vertical ridge. The ridge may situated approximately in the centre of patella, dividing the articular surface in to two equal size, medial and lateral patellar facet. Occasionally the ridge may situated slightly towards the medial border of the patella, making the medial facet smaller than lateral.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The patellar surface of the femur is the intercondylar groove or femoral sulcus on the anterior aspect of the distal femur. This groove or sulcus corresponds to the vertical ridge on the patella, dividing the femoral surface in the lateral and medial portion. The femoral surfaces are concave side to side but convex top to bottomCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The patella is a common attachment site for vastus intermedius, vastus lateralis, vastus medialis and rectus femoris20,25. The quadriceps tendon fibres, after enveloping the patella, join to become the patella ligament. It is the patella ligament that attaches the patella to the tibial tuberosity.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Soft tissue stabilizers:

Passive stabilizers:

Inferiorly, the patella tendon limits the proximal ascent of the patella from the tibia. It is often slightly oblique laterally from proximal to distal, which adds to the tendency towards lateral displacement of patella. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The lateral peripatellar retinaculum is comprised of two major components, the superficial oblique retinaculum and the deep transverse retinaculum. Superficial oblique retinaculum is rather thin and runs superficially from the iliotibial band to the patella. Deep transverse retinaculum provides superolateral static support for the patella.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Medially, capsular condensations from the tough fibrous layer that that inserts into the superior two-thirds of the posterior part of the medial border of the patella. This medial patellofemoral ligament links the patella to the medial femoral epicondyle and passively limits lateral patella excursionCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Above the patella is the central quadriceps tendon expansion of the quadrices muscle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Active stabilizers:

The four main muscular elements (rectus femoris, vastus medialis and lateralis, and vastus intermedius) of the quadriceps fuse distally into the quadriceps tendon, which can still be identified as three separate layers at their insertion into the patella.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Biomechanics[edit | edit source]

Patellofemoral joint reaction forces:

The quadriceps tendon pulls on the patella simultaneously superiorly and by the patella tendon inferiorly. When the pulls of these two structures are verticle or in line with each other, the patella may be suspended between them, making little or no contact with femur.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title this is in the case when the knee joint is in full extension. Even a strong contraction of the quadriceps in full extension will produce little or no patellofemoral compression. This is the rational for use of straight leg raising exercise with hip in neutral position as a way of improving quadriceps muscle strength without creating or exacerbating patellofemoral problems. As knee flexion proceeds from full extension, the pull of the quadriceps tendon and the pull of the patellar ligament become increasingly oblique, compressing the patella into femur. The contact force on lateral side always exceeds that of the medial side from 0⁰ to 100⁰ flexion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title the peak pressures during passive knee flexion were higher on the lateral facet near full flexion and full extension.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The increase in compression caused by the quadriceps mechanism with increased joint flexion occurs whether the muscle is active or passive. If the quadriceps muscle is inactive, the elastic tension increases with increased knee joint flexion. If the quadriceps muscle is active, both the active tension and passive elastic tension will contribute increasingly to compression as the knee flexion angle increases. The compression creates a joint reaction force across the patellofemoral joint. The total joint reaction force is influenced both the magnitude of active and passive pull of the quadriceps and by the angle of knee flexion. The highest tensile stress is concentrated beneath theinsertion of the patellar ligament.

The patellofemoral joint reaction forces found in gait when the foot first contacts the ground and the knee flexes slightly 10⁰ to 50⁰ is 50% of the body weight. The incresed knee flexion and quadriceps muscle activity seen with stair climbing or with running uphill may increase the patellofemoral joint reaction force 3.3 times body weight at 60⁰ Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The joint reaction force may reach 7.0 times the body weight at 130⁰ of knee joint flexion in activities such as jumping when knee flexion is extreme and a strong quadriceps contraction is required.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

At the patellofemoral joint, the medial facet bears the brunt of the compressive force and several mechanisms help minimize or dissipate the patellofemoral joint compression on the patella in general and on the medial facet specifically.

Because there is essentially no compressive force on the patella in full extension, no compensatory mechanism is necessary. Conversely the joint reaction force increases as the knee extends from 95⁰ to 45⁰ and then decreases with increases with increasing extension.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The adaptive mechanism of the patella in which the high joint reaction forces appears to be fairly successful.
Although some cartilaginous deterioration is commom at both the odd and the medial facet, it bears restritction that these changes rarely causes problems.

During full extension of the knee, the lower border of the patella is in contact with the supra patellar pad of the distal femur and is under little or no loadCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. If the quadriceps is isometrically in this position, the patella moves proximally with a small lateral shift. The lateral shift is limited by the medial retinaculam, the patellofemoral and mesiscopatellar ligament. With flexion to 20⁰ the tibia derotates(internal rotation)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title decreasing the lateral vector and in turn the patella is allowed to move into the trochlear grooveCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. When the convex medial border of patella comes in contat with the concave femex femoral articular cartilage, it creates a high unit load to further enhance the compressive force causing lateral tethering by patellofemoral ligament. The contact zones widen as it proceeds proximally, facilitating distribution of joint reaction forces. At 90⁰ of flexion patella demonstrate a lateral movement, and the medial femoral condyle is uncovered. As movement continues to 135⁰ of flexion, the lateral shift continues such that at its completion, the medial patellar surface lies free in the intercondylar notchCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and the odd facet contacts the lateral aspect of medial femoral condyle.

Many contributing factors have been suggested as a possible cause of patellofemoral pain, including an increased Q angle, patella alta, abnormal or excessive foot pronation, quadriceps femoris (vastus medialis) muscle weakness, diminished flexibility of the hamstring and rectus femoris muscles, malalignment of the femur, and weakness of the hip.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The mechanism of patellofemoral pain syndrome is not well understood; however, it has been suggested that the condition may arise from abnormal muscular and biomechanical factors that alter tracking of the patella within the femoral trochlear notchCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title contributing to increased patellofemoral contact pressures that result in pain and dysfunction.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

It should be distinguished from chondromalacia, which is actual fraying and damage to the underlying patellar cartilage.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Fixed rotation of the femur has a significant influence on the patellofemoral joint contact areas and pressures. This is due to the anatomic asymmetry in the knee with respect to all planes, as well as the laterally directed force vector that naturally exists in bipedal lower-limb biomechanics.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The most commonly accepted hypothesis of the cause of patellofemoral pain syndrome is that abnormal patellar tracking increases patellofemoral joint stress and causes suubsequent wear on the articular cartilage.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Clinical Manifestations[edit | edit source]

The Classical Symptomes of patellofemoral pain syndromes includesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Pain on ascending and descending to stairs, Pain on sitting(Moviegoer’s knee), Pain on squatting, Crepitus, Giving way, Pseudo locking and Swelling.

The patellar glide, patellar tilt, and patellar grind tests, Mc Connell’s test, lateral pull test should be performed as part of the routine assessment of patients with anterior knee pain. Positive results on these tests are consistent with the diagnosis of PFPS.

Abnormal motion of the tibia and femur in the transverse and frontal planes is believed to have an effect on patellofemoral joint mechanics and, therefore, patellofemoral pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Many research has proposed that lower-extremity torsional and angular malalignment is a major cause of anterior and peripatellar knee pain and it directly influence the patellofemoral joint mechanicsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Strength of hip abductors and external rotators in individuals with Patellofemoral Pain Syndrome
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During ambulation hip abductors and external rotator muscle group act eccentrically to control the motion of hip adduction and hip internal rotation, respectively.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Weakness in the abductors may allow for excessive femoral adduction and this, in turn, may lead to more abducted, or valgus, position of the knee. Knee valgus is believed to increase the lateral force acting on the patella.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Weakness of the hip external rotators may allow for excessive femoral internal rotation and this may lead to increased contact pressure between the lateral femoral condyle and the lateral facet of the patella. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Hip external rotators and abductors are also contributing in pelvic stability and leg alignment by eccentrically controlling femoral internal rotation and influencing hip adduction during weight bearing activities.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Weakness of these muscles may increase medial femoral rotation, valgus knee moments, or cause a gluteus medius gait. These deviations may alter the adduction/abduction moments at the hip or lead to an increased Q-angle, which may subsequently alter tracking of the patella, increase compressive forces on the patellofemoral joint, and ultimately lead to knee pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Theoretically, weakness of the abductors and external rotators may be associated with poor control of eccentric femoral adduction and internal rotation during weight-bearing activities, leading to misalignment of patellofemoral joint as the femur medially rotates underneath the patella.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

EVIDENCE OF RELATIONSHIP BETWEEN THE STRENGTH OF HIP ABDUCTORS AND EXTERNAL ROTATORS IN INDIVIDUALS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME
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A study shows that patients with patellofemoral pain syndrome showed no significant difference when compared to control group. The difference of isometric strength of hip external rotators in PFPS group and control group are less compared to the isometric strength of hip external rotators. Women are more affected with PFPS compared to men.^[3]

An abstract from the above study is:

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 patellofemoral pain syndrome have reported conflicting results.

OBJECTIVE: To compare the strength of hip abductor and hip external rotators in subjects with and without patellofemoral pain syndrome.

METHOD: 30 subjects, aged 20-60, participated in the study.15 subjects with PFPS were compared with 15 control group with no known history of knee pathology. Hip abductor and external rotator strength were tested using hand-held dynamometer.

RESULTS: Comparison of isometric hip strength between group A and group B is done using unpaired t-test. Patients with patellofemoral pain syndrome showed no significant difference when compared to control group. The difference of isometric strength of hip external rotators in PFPS group and control group are less compared to the isometric strength of hip external rotators. Women are more affected with PFPS compared to men.

CONCLUSION: There is no significant difference of isometric strength of hip abductor and hip ER between patient and control group.

Recent Related Research (from Pubmed)[edit | edit source]

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References
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↑ Garrick JG. Anterior knee pain (chondromalacia patella). Physician Sportsmed 1989;17:75-84.
↑ DeHaven KE, Linter DM. Atheletic injuries: comprision by age, sport, and gender. Am J Sports Med. 1986;14:218-224.
↑ Ajay Upadhyay. Lap Lambert Publication. Hip muscles strength and Patellofemoral pain syndrome: Comparison of strength of hip abductors and external rotators in individuals with &amp;amp; without PFPS. http://www.amazon.com/muscles-strength-Patellofemoral-pain-syndrome/dp/3659180866

[1] Garrick JG. Anterior knee pain (chondromalacia patella). Physician Sportsmed 1989;17:75-84.

[2] DeHaven KE, Linter DM. Atheletic injuries: comprision by age, sport, and gender. Am J Sports Med. 1986;14:218-224.

[3] Ajay Upadhyay. Lap Lambert Publication. Hip muscles strength and Patellofemoral pain syndrome: Comparison of strength of hip abductors and external rotators in individuals with &amp; without PFPS. http://www.amazon.com/muscles-strength-Patellofemoral-pain-syndrome/dp/3659180866

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 == Introduction<br>  ==
@@ Line 11: / Line 10: @@
 Patellofemoral pain syndrome is defined as retropatellar or peripatellar pain, or both, that results from physical and biomechanical changes in the patellofemoral joint.<ref name="55">Ota S, Nakashima T, Morisaka A, Ida K, Kawamura M. Comparison of patellar mobility in female adults with and without patellofemoral pain. J Orthop Sports Phys Ther. 2008 Jul;38(7):396-402. Epub 2008 Mar 12.</ref>
-Patellofemoral pain syndrome is a common source of anterior knee pain in young and active individuals. It accounts for 25% to 40% of all knee pain problems in sports medicine centers. <ref name="2">Baquie P, Brukner P. Injuries presenting to an australian sports medicine centre: a 12-month study. Clin J Sport Med. 1997;7:28-31.</ref><ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="4">Chesworth BM, Culham EG, Tata GE, Peat M. Validation of outcome measures in patients with patellofemoral pain syndrome. J Ortop Sports Phys Ther. 1993; 10:302-308.</ref><ref name="5">Rubin B, Collins R. Runner’s Knee. Phys Sports Med. 1980;8:49-58.</ref><ref name="6">Insall J. Current Concepts Review: patellar pain. J Bone Joint Surg Am. 1982;64:147-152.</ref><br><br>
+Patellofemoral pain syndrome is a common source of anterior knee pain in young and active individuals. It accounts for 25% to 40% of all knee pain problems in sports medicine centers. <ref name="2">Baquie P, Brukner P. Injuries presenting to an australian sports medicine centre: a 12-month study. Clin J Sport Med. 1997;7:28-31.</ref><ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="4">Chesworth BM, Culham EG, Tata GE, Peat M. Validation of outcome measures in patients with patellofemoral pain syndrome. J Ortop Sports Phys Ther. 1993; 10:302-308.</ref><ref name="5">Rubin B, Collins R. Runner’s Knee. Phys Sports Med. 1980;8:49-58.</ref><ref name="6">Insall J. Current Concepts Review: patellar pain. J Bone Joint Surg Am. 1982;64:147-152.</ref><br><br>
 == Incidence<br>  ==
@@ Line 37: / Line 36: @@
 Passive stabilizers:
-Inferiorly, the patella tendon limits the proximal ascent of the patella from the tibia. It is often slightly oblique laterally from proximal to distal, which adds to the tendency towards lateral displacement of patella. <ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp; wilkins;1997.</ref><br>The lateral peripatellar retinaculum is comprised of two major components, the superficial oblique retinaculum and the deep transverse retinaculum. Superficial oblique retinaculum is rather thin and runs superficially from the iliotibial band to the patella. Deep transverse retinaculum provides superolateral static support for the patella.<ref name="11">Fulkerson JP, Gossling H R. Anatomy of the knee joint lateral retinaculum. Clin Orthop 1980; 153:183.</ref>
+Inferiorly, the patella tendon limits the proximal ascent of the patella from the tibia. It is often slightly oblique laterally from proximal to distal, which adds to the tendency towards lateral displacement of patella. <ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><br>The lateral peripatellar retinaculum is comprised of two major components, the superficial oblique retinaculum and the deep transverse retinaculum. Superficial oblique retinaculum is rather thin and runs superficially from the iliotibial band to the patella. Deep transverse retinaculum provides superolateral static support for the patella.<ref name="11">Fulkerson JP, Gossling H R. Anatomy of the knee joint lateral retinaculum. Clin Orthop 1980; 153:183.</ref>
-Medially, capsular condensations from the tough fibrous layer that that inserts into the superior two-thirds of the posterior part of the medial border of the patella. This medial patellofemoral ligament links the patella to the medial femoral epicondyle and passively limits lateral patella excursion<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp; wilkins;1997.</ref>.<br>Above the patella is the central quadriceps tendon expansion of the quadrices muscle.<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp; wilkins;1997.</ref>
+Medially, capsular condensations from the tough fibrous layer that that inserts into the superior two-thirds of the posterior part of the medial border of the patella. This medial patellofemoral ligament links the patella to the medial femoral epicondyle and passively limits lateral patella excursion<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; wilkins;1997.</ref>.<br>Above the patella is the central quadriceps tendon expansion of the quadrices muscle.<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; wilkins;1997.</ref>
 Active stabilizers:
-The four main muscular elements (rectus femoris, vastus medialis and lateralis, and vastus intermedius) of the quadriceps fuse distally into the quadriceps tendon, which can still be identified as three separate layers at their insertion into the patella.<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="12">Koskinen SK, Kujala UM. Patellofemoral relationships and distal insertion of vastus medialis muscle: A Magnetic resonance imaging study in nonsymptomatic subjects and in patients with patellar dislocation. Arthroscopy 1992;8(4):465-468.</ref><br><br>
+The four main muscular elements (rectus femoris, vastus medialis and lateralis, and vastus intermedius) of the quadriceps fuse distally into the quadriceps tendon, which can still be identified as three separate layers at their insertion into the patella.<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="12">Koskinen SK, Kujala UM. Patellofemoral relationships and distal insertion of vastus medialis muscle: A Magnetic resonance imaging study in nonsymptomatic subjects and in patients with patellar dislocation. Arthroscopy 1992;8(4):465-468.</ref><br><br>
 == Biomechanics  ==
@@ Line 61: / Line 60: @@
 During full extension of the knee, the lower border of the patella is in contact with the supra patellar pad of the distal femur and is under little or no load<ref name="26">Brunnstroms: Clinical Kinesiology. 5th ed;310-312.</ref><ref name="27">David C, Reid. Sports injury and assessment and rehabilitation. Churchill Livingston. 1992,345-398.</ref><ref name="28">I.A. Kapanji. The physiology of joints. 5th ed;2,100-101.</ref>. If the quadriceps is isometrically in this position, the patella moves proximally with a small lateral shift. The lateral shift is limited by the medial retinaculam, the patellofemoral and mesiscopatellar ligament. With flexion to 20<sup>0</sup> the tibia derotates(internal rotation)<ref name="20">Cynthia C. Norkin, Pamela K. Levangie. Joint structure and function: A comprehensive analysis. 3rd ed, jaypee brothers.3rd ed;326-366</ref> decreasing the lateral vector and in turn the patella is allowed to move into the trochlear groove<ref name="20">Cynthia C. Norkin, Pamela K. Levangie. Joint structure and function: A comprehensive analysis. 3rd ed, jaypee brothers.3rd ed;326-366</ref><ref name="26">Brunnstroms: Clinical Kinesiology. 5th ed;310-312.</ref>. When the convex medial border of patella comes in contat with the concave femex femoral articular cartilage, it creates a high unit load to further enhance the compressive force causing lateral tethering by patellofemoral ligament. The contact zones widen as it proceeds proximally, facilitating distribution of joint reaction forces. At 90<sup>0</sup> of flexion patella demonstrate a lateral movement, and the medial femoral condyle is uncovered. As movement continues to 135<sup>0</sup> of flexion, the lateral shift continues such that at its completion, the medial patellar surface lies free in the intercondylar notch<ref name="26">Brunnstroms: Clinical Kinesiology. 5th ed;310-312.</ref><ref name="27">David C, Reid. Sports injury and assessment and rehabilitation. Churchill Livingston. 1992,345-398.</ref> and the odd facet contacts the lateral aspect of medial femoral condyle.
-Many contributing factors have been suggested as a possible cause of patellofemoral pain, including an increased Q angle, patella alta, abnormal or excessive foot pronation, quadriceps femoris (vastus medialis) muscle weakness, diminished flexibility of the hamstring and rectus femoris muscles, malalignment of the femur, and weakness of the hip.<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="49">Carson WG Jr, James SL, Larson RL, et al. Patellofemoral disorders: physical and radiographic evaluation, part II: radiographic examination. Clin Orthop.1984; 185:178–186.</ref><ref name="50">James SL. Chondromalacia of the patella in the adolescent. In: Kennedy JC, Eds. The Injured Adolescent Knee. Baltimore, Md: Williams &amp;amp;amp;amp;amp;amp; Wilkins; 1979:205–251.</ref><ref name="51">Fulkerson JP. The etiology of patellofemoral pain in young, active patients: a prospective study. Clin Orthop.1983; 179:129–133.</ref>
+Many contributing factors have been suggested as a possible cause of patellofemoral pain, including an increased Q angle, patella alta, abnormal or excessive foot pronation, quadriceps femoris (vastus medialis) muscle weakness, diminished flexibility of the hamstring and rectus femoris muscles, malalignment of the femur, and weakness of the hip.<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="49">Carson WG Jr, James SL, Larson RL, et al. Patellofemoral disorders: physical and radiographic evaluation, part II: radiographic examination. Clin Orthop.1984; 185:178–186.</ref><ref name="50">James SL. Chondromalacia of the patella in the adolescent. In: Kennedy JC, Eds. The Injured Adolescent Knee. Baltimore, Md: Williams &amp;amp;amp;amp;amp;amp;amp; Wilkins; 1979:205–251.</ref><ref name="51">Fulkerson JP. The etiology of patellofemoral pain in young, active patients: a prospective study. Clin Orthop.1983; 179:129–133.</ref>
-The mechanism of patellofemoral pain syndrome is not well understood; however, it has been suggested that the condition may arise from abnormal muscular and biomechanical factors that alter tracking of the patella within the femoral trochlear notch<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="18">McConnell J, Fulkerson JP. The Knee: patellofemoral and soft tissue injuries. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic injuries and rehabilitation. Philadelphia, PA: W.B. Saunders Co; 1996:693-728.</ref> contributing to increased patellofemoral contact pressures that result in pain and dysfunction.<ref name="17">Kendall FP, Mc Creary EK, Provance PG. Muscles testing and function.4th ed. Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; Wilkins; 1993.</ref>
+The mechanism of patellofemoral pain syndrome is not well understood; however, it has been suggested that the condition may arise from abnormal muscular and biomechanical factors that alter tracking of the patella within the femoral trochlear notch<ref name="3">Fulkerson JP, Hungerford DS. Disorders of the patellofemoral joint. 3rd ed Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp;amp; wilkins;1997.</ref><ref name="18">McConnell J, Fulkerson JP. The Knee: patellofemoral and soft tissue injuries. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic injuries and rehabilitation. Philadelphia, PA: W.B. Saunders Co; 1996:693-728.</ref> contributing to increased patellofemoral contact pressures that result in pain and dysfunction.<ref name="17">Kendall FP, Mc Creary EK, Provance PG. Muscles testing and function.4th ed. Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp;amp; Wilkins; 1993.</ref>
 It should be distinguished from chondromalacia, which is actual fraying and damage to the underlying patellar cartilage.<ref name="14">Insall J, Falvo. Chondromalacia patellae. J. Bone Joint Surg. 1976;58:1-8.</ref>
@@ Line 85: / Line 84: @@
 Weakness of the hip external rotators may allow for excessive femoral internal rotation and this may lead to increased contact pressure between the lateral femoral condyle and the lateral facet of the patella. <ref name="9">Powers CM. The influence of altered lower extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Ortop Sports Phys Ther. 2003; 33:639-646.</ref>
-Hip external rotators and abductors are also contributing in pelvic stability and leg alignment by eccentrically controlling femoral internal rotation and influencing hip adduction during weight bearing activities.<ref name="17">Kendall FP, Mc Creary EK, Provance PG. Muscles testing and function.4th ed. Baltimore, MD: Williams &amp;amp;amp;amp;amp; Wilkins; 1993.</ref><ref name="18">McConnell J, Fulkerson JP. The Knee: patellofemoral and soft tissue injuries. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic injuries and rehabilitation. Philadelphia, PA: W.B. Saunders Co; 1996:693-728.</ref>
+Hip external rotators and abductors are also contributing in pelvic stability and leg alignment by eccentrically controlling femoral internal rotation and influencing hip adduction during weight bearing activities.<ref name="17">Kendall FP, Mc Creary EK, Provance PG. Muscles testing and function.4th ed. Baltimore, MD: Williams &amp;amp;amp;amp;amp;amp; Wilkins; 1993.</ref><ref name="18">McConnell J, Fulkerson JP. The Knee: patellofemoral and soft tissue injuries. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic injuries and rehabilitation. Philadelphia, PA: W.B. Saunders Co; 1996:693-728.</ref>
 Weakness of these muscles may increase medial femoral rotation, valgus knee moments, or cause a gluteus medius gait. These deviations may alter the adduction/abduction moments at the hip or lead to an increased Q-angle, which may subsequently alter tracking of the patella, increase compressive forces on the patellofemoral joint, and ultimately lead to knee pain.<ref name="19">Powers CM, Chen PY, Reichl SF, Perry J. Comparision of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot Ankle Int. 2002; 23:634-640.</ref>
@@ Line 93: / Line 92: @@
 == EVIDENCE OF RELATIONSHIP BETWEEN THE STRENGTH OF HIP ABDUCTORS AND EXTERNAL ROTATORS IN INDIVIDUALS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME<br>  ==
-A study shows that patients with patellofemoral pain syndrome showed no significant difference when compared to control group. The difference of isometric strength of hip external rotators in PFPS group and control group are less compared to the isometric strength of hip external rotators. Women are more affected with PFPS compared to men.<ref>Ajay Upadhyay. Lap Lambert Publication. Hip muscles strength and Patellofemoral pain syndrome: Comparison of strength of hip abductors and external rotators in individuals with &amp;amp;amp; without PFPS. http://www.amazon.com/muscles-strength-Patellofemoral-pain-syndrome/dp/3659180866</ref><br>
+A study shows that patients with patellofemoral pain syndrome showed no significant difference when compared to control group. The difference of isometric strength of hip external rotators in PFPS group and control group are less compared to the isometric strength of hip external rotators. Women are more affected with PFPS compared to men.<ref>Ajay Upadhyay. Lap Lambert Publication. Hip muscles strength and Patellofemoral pain syndrome: Comparison of strength of hip abductors and external rotators in individuals with &amp;amp;amp;amp; without PFPS. http://www.amazon.com/muscles-strength-Patellofemoral-pain-syndrome/dp/3659180866</ref><br>
-An abstract from the above study is:<br>
+An abstract from the above study is:<br>
+<br>
 '''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 patellofemoral pain syndrome have reported conflicting results.
 <br>'''OBJECTIVE:''' To compare the strength of hip abductor and hip external rotators in subjects with and without patellofemoral pain syndrome.
 <br>'''METHOD: '''30 subjects, aged 20-60, participated in the study.15 subjects with PFPS were compared with 15 control group with no known history of knee pathology. Hip abductor and external rotator strength were tested using hand-held dynamometer.
 <br>'''RESULTS:''' Comparison of isometric hip strength between group A and group B is done using unpaired t-test. Patients with patellofemoral pain syndrome showed no significant difference when compared to control group. The difference of isometric strength of hip external rotators in PFPS group and control group are less compared to the isometric strength of hip external rotators. Women are more affected with PFPS compared to men.
+<br>
+'''CONCLUSION: '''There is no significant difference of isometric strength of hip abductor and hip ER between patient and control group.<br>
-'''CONCLUSION: '''There is no significant difference of isometric strength of hip abductor and hip ER between patient and control group.<br>
+<br>
-[[Image:Measurement_of_Hip_External_Rotators_with_help_of_Dynamometer.png|left|350x400px]][[Image:Measurement_of_Hip_Abduction_strength_with_dynamometer.png|right|350x400px]]<br>
 == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
+<div class="researchbox"><rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1bo4uOs-bB_ULMdlUAPkCl22pJJtB6PvLWGCXuEdzv3CfTkM69|charset=UTF-8|short|max=10</rss></div>
-<div class="researchbox"><rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1bo4uOs-bB_ULMdlUAPkCl22pJJtB6PvLWGCXuEdzv3CfTkM69|charset=UTF-8|short|max=10</rss></div>
 == References<br>  ==

Patellofemoral Pain Syndrome and Hip Strength: Difference between revisions

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Introduction
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Incidence
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Strength of hip abductors and external rotators in individuals with Patellofemoral Pain Syndrome
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EVIDENCE OF RELATIONSHIP BETWEEN THE STRENGTH OF HIP ABDUCTORS AND EXTERNAL ROTATORS IN INDIVIDUALS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME
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Patellofemoral Pain Syndrome and Hip Strength: Difference between revisions

Revision as of 14:54, 17 August 2013

Introduction[edit | edit source]

Incidence[edit | edit source]

Anatomy[edit | edit source]

Biomechanics[edit | edit source]

Clinical Manifestations[edit | edit source]

Strength of hip abductors and external rotators in individuals with Patellofemoral Pain Syndrome[edit | edit source]

EVIDENCE OF RELATIONSHIP BETWEEN THE STRENGTH OF HIP ABDUCTORS AND EXTERNAL ROTATORS IN INDIVIDUALS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME[edit | edit source]

Recent Related Research (from Pubmed)[edit | edit source]

References[edit | edit source]

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Introduction
[edit | edit source]

Incidence
[edit | edit source]

Strength of hip abductors and external rotators in individuals with Patellofemoral Pain Syndrome
[edit | edit source]

EVIDENCE OF RELATIONSHIP BETWEEN THE STRENGTH OF HIP ABDUCTORS AND EXTERNAL ROTATORS IN INDIVIDUALS WITH AND WITHOUT PATELLOFEMORAL PAIN SYNDROME
[edit | edit source]

References
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