The progression of eccentric multiplanar practice is critical to the successful recovery of PFP.
Movement is essential for the successful treatment of patellofemoral pain (PFP). Programs often include simple local knee strengthening and move on to proximal exercises that target the hips and pelvis. This is because RCTs show that this leads to short-term improvement in pain and function. That being said, long-term recovery from PFP is mixed with up to 50% of patients having an adverse recovery after 5-8 years. This is likely due to the complex etiology of the disease, but is also likely due to the lack of consensus on an optimal exercise regime.
Learn with the expert | Claire Robertson
It is possible that the variability in exercise management is due to the clinical interpretation of the proximal strengthening. For some, these are simple hip-focused exercises, for others, more dynamic movements may be involved. There is a growing argument that the correct approach is to base exercise choice on the pathomechanics associated with PFP. Examples could be targeted exercises to reduce excessive or under-controlled internal rotation of the femur.
This would shift rehab from simple exercises to a more task-specific approach in which the exercises are continued through specificity and loading principles. This would include exposing patients to limb loading, eccentric strengthening, and multi-level movements. Although there have been numerous reviews examining PFP management, none have specifically examined the individual content of exercise programs. The aim of this systematic review was to assess the exercise content of RCTs that implement a proximal approach to the management of PFP.
Results
19 studies followed the screening and eligibility process of the review protocol. The average score of the included studies was PEDro 6.2, with the most common limitation being a lack of blinding. A total of 178 exercises were extracted from the 19 studies of these:
22.9% were multiplanar
The sagittal / frontal plane was used in 58.9% of the multiplanar exercises
Saggital / transversal only 5 exercises
Frontal / transversal only 6 exercises
Only 5 triplanar exercises
The sagittal plane was used and displayed in 67.4% of all exercises, with the most common exercise being standing hip extension in an open chain
The frontal plane was used and represented in 38.8% of all exercises, the most common exercise being the open-chain hip abduction
The transverse plane was used in 20.8% of the exercises, and the most common exercise was the seated external rotation
11.2% of the exercises were eccentric, with quads being the target group
It is fair to say that most of the exercises for proximal strengthening of PFP in the literature are simple and tend to be isolated on the sagittal plane with concentric loading in a non-stressful position. This does not follow a pathomechanical approach to treating the disease. Especially when you consider that the hip muscles need to slow down the lower limbs quickly when walking and running, the most common causes of pain.
Clinical implications
PFP exercise programs should focus on strengthening the proximal hip, which focuses on neuromotor control and eccentric loading of the glutes and deep lateral hip rotators. Yes, simple single or multi-plan exercises can be used in the early stages, but there could be a progression of exercises with an emphasis on function.
Become an expert in the differentiation of patellar pain
The knee joint consists of the patellofemoral and the tibiofemoral joint. There are a variety of structures in both joints that can cause pain in and around the knee joint. Distinguishing between patellofemoral and tibiofemoral joint as a source of symptoms helps treat a person's symptoms effectively. Information can be obtained from the subjective and objective examination in order to obtain a comprehensive clinical picture. In this course, Claire Robertson describes the various assessment results that can be used to determine whether the person's knee pain is due to tibiofemoral or patellofemoral structures.
Learn with the expert | Claire Robertson
