Patellofemoral pain and asymmetrical hip rotation

NewsBot · Jun 18, 2013

Hip Strength in Males with Patellofemoral Pain Syndrome: A Pilot Study
Deborah Strand

Master thesis 2013

Study
Design:
Cross-sectional.

Background:
Although decreased hip abduction and lateral rotation strength has been found in females with patellofemoral pain syndrome (PFPS), few studies have included males.

Aim:
To determine if hip abduction and lateral rotation strength is decreased in males with PFPS.

Methods:
Eight males participated. Isometric hip abduction and external rotation strength was measured with a hand-held dynamometer. Four subjects had unilateral patellofemoral pain (mean age = 26. 5±7.5 years) and 4 asymptomatic subjects were controls (mean age = 23 ±6.4 years). The recorded measurements from the symptomatic legs were compared with the asymptomatic legs, and also with the controls.

Results:
No significant differences in hip abduction or lateral rotation strength were found between the symptomatic and asymptomatic legs of male subjects with PFPS. The PFPS subjects did not have generally weaker hip strength compared with the asymptomatic controls.

Conclusion:
Males with PFPS do not appear to have decreased hip abduction and lateral rotation
strength. However, the sample size was too small for conclusions to be drawn. This study can be used as a preliminary step in gathering evidence about factors affecting PFPS in males, which may in turn shed light on appropriate clinical treatments.
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NewsBot · Jun 30, 2013

Hip and Knee Kinematics are Associated with Pain and Self-reported Functional Status in Males and Females with Patellofemoral Pain.
Nakagawa TH, Serrão FV, Maciel CD, Powers CM.
Int J Sports Med. 2013 Jun 14.

Altered hip and knee kinematics in the frontal and transverse planes may increase patellofemoral joint stress and contribute to the development of patellofemoral pain. The purpose of this cross-sectional study was to evaluate the association among hip and knee kinematics, pain, and self-reported functional status in males and females with patellofemoral pain. 20 males and 20 females with patellofemoral pain participated in this study. 3-dimensional hip and knee kinematics were quantified while performing a step-down task. A visual analogue scale was used to evaluate usual knee pain. The anterior knee pain scale was used to evaluate the knee functional score. For both groups combined, greater usual pain was associated with greater peak hip adduction, hip internal rotation and knee abduction (r=0.54-0.57, P<0.001). Also, modest to low correlations (r=-0.48 to - 0.37, P=0.03-0.08) were found among hip and knee kinematics and functional score. Stepwise regression revealed that peak hip internal rotation and hip adduction were significant predictors of pain, while peak hip adduction was the only predictor of function. Greater hip adduction, hip internal rotation and knee abduction are associated with higher levels of pain and reduced function in males and females with patellofemoral pain.
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NewsBot · Jul 12, 2013

Closed Kinetic Chain exercises with or without additional hip strengthening exercises in management of Patellofemoral pain syndrome: a randomized controlled trial.
Ismail MM, Gamaleldein MH, Hassa KA.
Eur J Phys Rehabil Med. 2013 Jul 2.

Background: Patellofemoral pain syndrome (PFPS) is a common musculoskeletal pain condition, especially in females. Decreased hip muscle strength has been implicated as a contributing factor. Isolated open kinetic chain hip abductors and lateral rotators exercises were added by many authors to the rehabilitation program. However, Closed Kinetic Chain (CKC) exercises focusing on hip and knee muscles were not investigated if they can produce similar effect of hip strengthening and decreasing pain without the need of isolated exercises for hip musculature.

Aim: The aim of the present study was to determine the effect of a CKC exercises program with or without additional hip strengthening exercises on pain and hip abductors and lateral rotators peak torque.

Design: Prospective randomized clinical trial.

Setting: Patients with patellofemoral pain syndrome referred to the outpatient physical therapy clinic of the faculty of physical therapy, cairo university.

Population: Thirty two patients who had patellofemoral pain syndrome with age ranged from eighteen to thirty years. Methods: Patients were randomly assigned into two groups: CKC group and CKC with hip muscles strengthening exercises as a control (CO) group. Treatment was given 3 times/week, for 6 weeks. Patients were evaluated pre- and post-treatment for their pain severity using VAS, function of knee joint using Kujala questionnaire, hip abductors and external rotators concentric/eccentric peak torque.

Results: There were significant improvements in pain, function and hip muscles peak torque in both groups (P<0.05). However, there was no statistically significant difference between groups in hip muscles torque (P<0.05) but pain and function improvements were significantly greater in the CO group (P<0.05).

Conclusion: Six weeks CKC program focusing on knee and hip strengthening has similar effect in improving hip muscles torque in patients with PFPS as a CKC exercises with additional hip strengthening exercises. However, adding isolated hip strengthening exercises has the advantage of more pain relief. Clinical Rehabilitation Impact: CKC exercises with additional hip strengthening could be more beneficial in decreasing pain in PFPS than CKC exercises alone
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NewsBot · Nov 5, 2013

PROXIMAL EXERCISES ARE EFFECTIVE IN TREATING PATELLOFEMORAL PAIN SYNDROME: A SYSTEMATIC REVIEW
Jeroen S.J. Peters and Natalie L. Tyson
Int J Sports Phys Ther. 2013 October; 8(5): 689–700.

Background:
Patellofemoral pain syndrome is a common disorder of the knee with multifactorial aetiology. Multimodal treatment, including exercise therapy, has been shown to be effective in the treatment of patellofemoral pain, although some patients continue to experience pain and dysfunction despite treatment. To address this, recent research has started to investigate the lumbo‐pelvic and hip girdle in patellofemoral pain.

Purpose:
The aim of this systematic review was to investigate the effectiveness of proximal exercises, compared with knee exercises, for patients with patellofemoral pain, in improving pain and function.

Methods:
A computer‐based search (population: patients with patellofemoral pain, intervention: proximal [hip or lumbo‐pelvic] exercises, comparator: knee exercises, outcome: self‐reported pain and/or functional questionnaire) was undertaken. Medline, Embase, CINAHL, SportsDiscus, Cochrane Library and PEDro were searched for studies published between January 2011 and January 2013. The included studies were appraised independently using the McMaster Critical Review Form for Quantitative Studies. Data was extracted for the exercise prescription and applicable outcome measures, and a descriptive analysis undertaken.

Results:
Eight studies (three randomized controlled trials, one clinical controlled trial, three cohort studies and one case series) of moderate to high methodological quality met the inclusion criteria. Proximal exercise programs showed a consistent reduction of pain and function in the treatment of patellofemoral pain. Knee exercise programs had variable outcomes.

Conclusion:
Proximal interventions provide relief of pain and improved function in the short and long term and therefore physical therapists should consider using proximal interventions for treatment of patellofemoral pain.
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NewsBot · Nov 5, 2013

RELATIONSHIP BETWEEN HIP STRENGTH AND TRUNK, HIP, AND KNEE KINEMATICS DURING A JUMP‐LANDING TASK IN INDIVIDUALS WITH PATELLOFEMORAL PAIN
Michelle Boling and Darin Padua
Int J Sports Phys Ther. 2013 October; 8(5): 661–669.

Background/Purpose:
Decreased strength of the hip musculature and altered mechanics of the lower extremity have been identified in individuals with patellofemoral pain (PFP). The aim of this study was to determine if a relationship exists between hip muscle strength and transverse and frontal plane motion at the hip and knee, and ipsilateral trunk flexion during a jump‐landing task in individuals with PFP.

Methods:
Fifteen individuals (10 females, 5 males) with PFP participated in this investigation. A three‐dimensional motion analysis system was utilized to assess trunk, hip, and knee kinematics during a jump‐landing task. An isokinetic dynamometer was utilized to assess concentric and eccentric strength of the hip musculature. Simple correlation analyses were performed to determine the relationships between hip muscle strength and peak frontal and transverse plane hip and knee kinematics and ipsilateral trunk flexion.

Results:
Decreased eccentric strength of the hip external rotators and abductors was significantly correlated to increased frontal plane motion at the hip and trunk, respectively (P<0.05).

Conclusions:
Based on these findings, eccentric strengthening exercises for the hip musculature may be an important component for clinicians to include when rehabilitating individuals with PFP who display increased frontal plane motion at the hip and trunk.
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NewsBot · Nov 5, 2013

Varied Response to Mirror Gait Retraining on Gluteus Medius Control, Hip Kinematics, Pain, and Function in 2 Female Runners With Patellofemoral Pain
Richard W. Willy, Irene S. Davis
Journal of Orthopaedic & Sports Physical Therapy; Early Access

Study Design Case report.

Background The underlying mechanism of the changes in running mechanics after gait retraining is presently unknown. We report on changes in muscle coordination and kinematics during treadmill running and step ascent in 2 female runners with patellofemoral pain after mirror gait retraining.

Case Description Two female runners with chronic patellofemoral pain underwent 8 sessions of mirror gait retraining during treadmill running. Subjective measures and hip abductor strength were recorded at baseline and after the retraining phase. Changes in hip mechanics and electromyography data of the gluteus medius during treadmill running and step ascent were also assessed.

Outcomes Both runners reported improvements in pain and function that were maintained for at least 3 months. Peak contralateral pelvic drop (PRE-POST difference: Runner 1, 2.6° less and Runner 2: 1.7° less) and peak hip adduction (PRE-POST difference: Runner 1, 5.2° less and Runner 2: 6.3° less) were reduced after retraining. Kinematic reductions accompanied earlier activation of the gluteus medius relative to footstrike (PRE-POST difference: Runner 1, 12.6 ms earlier and Runner 2, 37.3 ms earlier) and longer duration of gluteus medius activity (Runner 1, 55.8 ms longer and Runner 2, 44.4 ms longer). Runner 1 transferred reduced contralateral pelvic drop to step ascent, whereas Runner 2 did not (Contralateral pelvic drop, PRE-POST difference: Runner 1, 3.6° less and Runner 2: 1.5° more; Hip adduction, PRE-POST difference: Runner 1, 3.0° less and Runner 2: 0.5° more). Both runners demonstrated earlier onset of gluteus medius activity during step ascent (PRE-POST difference, Runner 1, 48.0 ms earlier and Runner 2, 28.3 ms earlier) but only Runner 1 demonstrated longer activation duration (Runner 1, 25.0 ms longer and Runner 2, 69.4 ms shorter).

Discussion While changes in hip mechanics and gluteus medius activity during running were consistent with those noted during step ascent for Runner 1, Runner 2 failed to demonstrate similar consistency between the tasks. Earlier onset and longer duration of gluteus medius activity may have been necessary to alter step mechanics for Runner 2.
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NewsBot · Jan 21, 2014

Posterolateral Hip Muscle Strengthening verses Quadriceps Strengthening for Patellofemoral Pain: A Comparative Control Trial
Khalil Khayambashi, et al
Archives of Physical Medicine and Rehabilitation; Available online 16 January 2014

Study Design
Comparative control trial
Objective
To compare the efficacy of posterolateral hip muscle strengthening versus quadriceps strengthening in reducing pain and improving health status in persons with patellofemoral pain (PFP).
Design
Comparative control trial.
Setting
Private rehabilitation facility
Participants
Thirty-six persons with a diagnosis of PFP (18 males and 18 females).
Interventions
Male and female patients were alternately assigned to a posterolateral hip muscle strengthening group (9 males and 9 females) or a quadriceps strengthening group (9 males and 9 females). The posterolateral hip muscle strengthening group performed hip abductor and external rotator strengthening exercises while the quadriceps strengthening group performed quadriceps strengthening exercises (3 times a week for 8 weeks).
Main Outcome Measures
Pain (VAS) and health status (WOMAC) were assessed at baseline, post-intervention, and at a 6 month follow-up.
Results
Significant improvements in VAS and WOMAC scores were observed in both groups from baseline to post-intervention and from baseline to 6 month follow-up (p<.001). Improvements in VAS and WOMAC scores in the posterolateral hip exercise group were superior to those in the quadriceps exercise group post-intervention and at the 6 month follow up (p<.05).
Conclusion
Although both intervention programs resulted in decreased pain and improved function in persons with PFP, outcomes in the posterolateral hip exercise group were superior to the quadriceps exercise group. The superior outcomes obtained in the posterolateral hip exercise group were maintained 6 months post-intervention.
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NewsBot · Feb 22, 2014

Comparative evaluation of core muscles recruitment pattern in response to sudden external perturbations in patients with patellofemoral pain syndrome and healthy subjects
Zahra Rojhani Shirazi, Mana Biabani Moghaddam, Alireza Motealleh
Archives of Physical Medicine and Rehabilitation; Available online 15 February 2014

Objective
To evaluate the core muscles electromyographic activity in response to unexpected perturbations to the pelvis in patients with patellofemoral pain syndrome (PFPS) and healthy subjects.

Design
Case-control study.

Setting
Center for Human Motion Science Research.

Participants
54 women aged 18-40 years, including 27 subjects diagnosed with PFPS and 27 healthy controls, participated in this study.

Intervention
An unexpected perturbation was applied to the lateral side of the pelvis by pulling a one-kilogram medicine ball back to an angle in which releasing the pendulum applies the energy of 20% of the subject’s Body Mass Index (BMI). This intervention was repeated thrice with the minimum of 30 s rest between the trials.

Main Outcome Measure(s)
Electromyographic onsets and durations of the Transversus abdominis(TrA)/Internal oblique(IO), erector spinae(ES), and gluteus medius(GM) muscles were recorded in response to the unexpected lateral perturbation to the pelvis.

Results
Core muscles recruitment pattern was different between the two groups. In the PFPS subjects, the abdominal muscles and the ES activated significantly earlier and longer, whereas the GM muscle responded significantly later than the controls. The duration of the GM activity was not significantly different between the groups.

Conclusions
The results of this investigation propose that the core muscles are recruited differently in PFPS subjects to provide core stability. It appears that core neuromuscular improvement could be an effective strategy in rehabilitation of patients with PFPS.
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NewsBot · Feb 25, 2014

A proximal perspective on patellofemoral pain

NewsBot · Apr 4, 2014

Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis
M S Rathleff, C R Rathlef, K M Crossley, C J Barton
Br J Sports Med doi:10.1136/bjsports-2013-093305

Objective To evaluate and synthesise the literature on hip strength among patients with patellofemoral pain (PFP) to address the following: (1) differentiate between hip strength as a risk factor and associated deficit in PFP; (2) describe hip strength in men and women with PFP across different age ranges; (3) investigate the effects of hip strengthening on biomechanical knee variables associated with PFP development.

Methods MEDLINE, CINAHL, Web of Science, SportDiscus and Google Scholar were searched in November 2013 for studies investigating hip strength among patients with PFP. Two reviewers independently assessed papers for inclusion and quality. Means and SDs were extracted from each included study to allow effect size calculations and comparisons of results.

Results Moderate-to-strong evidence from prospective studies indicates no association between isometric hip strength and risk of developing PFP. Moderate evidence from cross-sectional studies indicates that men and women with PFP have lower isometric hip musculature strength compared to pain-free individuals. Limited evidence indicates that adolescents with PFP do not have the same strength deficits as adults with PFP.

Conclusions This review highlights a possible discrepancy between prospective and cross-sectional research. Cross-sectional studies indicate that adult men and women with PFP appear to have lower hip strength compared to pain-free individuals. Contrary to this, a limited number of prospective studies indicate that there may be no association between isometric hip strength and risk of developing PFP. Therefore, reduced hip strength may be a result of PFP rather than the cause.
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NewsBot · May 20, 2014

Propulsion Phase of the Single Leg Triple Hop Test in Women with Patellofemoral Pain Syndrome: A Biomechanical Study
Andre Serra Bley, João Carlos Ferrari Correa, Amir Curcio Dos Reis, Nayra Deise Dos Anjos Rabelo, Paulo Henrique Marchetti, Paulo Roberto Garcia Lucareli
PLoS ONE 9(5): e97606. doi:10.1371/journal.pone.0097606

Asymmetry in the alignment of the lower limbs during weight-bearing activities is associated with patellofemoral pain syndrome (PFPS), caused by an increase in patellofemoral (PF) joint stress. High neuromuscular demands are placed on the lower limb during the propulsion phase of the single leg triple hop test (SLTHT), which may influence biomechanical behavior. The aim of the present cross-sectional study was to compare kinematic, kinetic and muscle activity in the trunk and lower limb during propulsion in the SLTHT using women with PFPS and pain free controls. The following measurements were made using 20 women with PFPS and 20 controls during propulsion in the SLTHT: kinematics of the trunk, pelvis, hip, and knee; kinetics of the hip, knee and ankle; and muscle activation of the gluteus maximus (GM), gluteus medius (GMed), biceps femoris (BF) and vastus lateralis (VL). Differences between groups were calculated using three separate sets of multivariate analysis of variance for kinematics, kinetics, and electromyographic data. Women with PFPS exhibited ipsilateral trunk lean; greater trunk flexion; greater contralateral pelvic drop; greater hip adduction and internal rotation; greater ankle pronation; greater internal hip abductor and ankle supinator moments; lower internal hip, knee and ankle extensor moments; and greater GM, GMed, BL, and VL muscle activity. The results of the present study are related to abnormal movement patterns in women with PFPS. We speculated that these findings constitute strategies to control a deficient dynamic alignment of the trunk and lower limb and to avoid PF pain. However, the greater BF and VL activity and the extensor pattern found for the hip, knee, and ankle of women with PFPS may contribute to increased PF stress.
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NewsBot · May 27, 2014

Evaluation of Postural Stability in Patellofemoral Pain Syndrome Patients
Ibrahim M M, Alayat MS, Shousha T M
Indian Journal of Physiotherapy and Occupational Therapy - An International Journal; Year : 2014, Volume : 8, Issue : 2

Objective
To assess the effect of patellofemoral pain syndrome (PFPS) on the postural stability.

Materials and Method
Two groups, each of 30 subjects participated in this study. The first group consisted of 30 patients who had PFPS with mean age 20.50 (±0.97) years, mean weight 69.3(±3.71) Kg. and mean height 173.8(±4.29) Cm. The second group consisted of 30 normal subjects with mean age 20.90 (± 0.99) years, mean weight 70.0 (± 2.75) Kg. and mean height 173.3 (±5.42) Cm. Both groups were tested by athletes’ single leg test including overall stability (OASI), medio-lateral stability (MLSI), antero-posterior stability (APSI) indexes and the fall risk test (FR) by using the Biodex balance system. Testing was performed for single and double leg stance conditions over a period of 20 seconds, 3 trials were done for each test and the mean value was recorded.

Results
Using the unpaired t - test to compare between the PFPS and control groups; revealed a significant difference between both groups regarding fall risk test (t = 4.548 and p = 0.0001). In addition, there was a significant difference between both groups regarding athletes’ single leg test (OASI, p = 0.0001 and t = 4.653), (APSI, p = 0.0001 and t = 4.723) and (MLSI, p = 0.0001 and t = 4.330).

Conclusion
This study had shown that PFPS causes significant reduction in postural stability that may require further attention during rehabilitation.
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NewsBot · Aug 9, 2014

Correlation between Intrinsic Patellofemoral Pain Syndrome in Young Adults and Lower Extremity Biomechanics
Ohjeoung Kwon, Mijung Yun, Wanhee Lee
Journal of Physical Therapy Science Vol. 26 (2014) No. 7 July p. 961-964

[Purpose] The purpose of this study was to evaluate the correlation between intrinsic patellofemoral pain syndrome (PFPS) in young adults and lower extremity biomechanics. [Subjects] This experiment was carried out with sixty (24 men and 32 women), who are normal university students as subjects.
[Methods] All subjects underwent 3 clinical evaluations. For distinguishing the intrinsic PFPS from controls, we used the Modified Functional Index Questionnaire (MFIQ), Clarke’s test and the Eccentric step test. Based on the results of the tests, subjects who were classified as positive for 2 more tests were allocated to the bilateral or unilateral intrinsic PFPS group (n=14), and the others were allocated to the control group (n=42). These two groups were tested for hamstring tightness, foot overpronation, and static Q-angle and dynamic Q-angle. These are the four lower extremity biomechanic, cited as risk factors of patellofemoral pain syndrome.
[Results] The over pronation, static Q-angle and the dynamic Q-angle were not significantly different between the two groups. However, the hamstring tightness of the PFPS group was significantly greater than that of the controls.
[Conclusion] We examined individuals for intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. We found a strong correlation between intrinsic PFPS and hamstring tightness.
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NewsBot · Aug 20, 2014

PATELLOFEMORAL PAIN SUBJECTS EXHIBIT DECREASED PASSIVE HIP RANGE OF MOTION COMPARED TO CONTROLS
Sean M. Roach et al
Int J Sports Phys Ther. Aug 2014; 9(4): 468–475.

Background:
Patellofemoral pain is a common condition without a clear mechanism for its presentation. Recently significant focus has been placed on the hip and its potential role in patellofemoral pain (PFP). The majority of the research has examined hip strength and neuromuscular control. Less attention has been given to hip mobility and its potential role in subjects with PFP.
Purpose/Aim:
The purpose of this study was to compare passive hip range of motion (ROM) of hip extension and hip internal and external rotation in subjects with PFP and healthy control subjects. The hypothesis was that subjects with PFP would present with less total hip ROM and greater asymmetry than controls.
Design:
Two groups, case controlled.
Setting:
Clinical research laboratory
Participants:
30 healthy subjects without pain, radicular symptoms or history of surgery in the low back or lower extremity joints and 30 subjects with a diagnosis of PFP.
Main Outcome Measures:
Passive hip extension, hip internal rotation (IR) and hip external rotation (ER). A digital inclinometer was used for measurements.
Results:
There was a statistically significant difference (p<0.001) in hip passive extension between the control group and the PFP group bilaterally. Mean hip extension for the control group was 6.8° bilaterally. For the PFP group, the mean hip extension was −4.0° on the left and −4.3° on the right. This corresponds to a difference of means between groups of 10.8° on the left and 11.1° on the right with a standard error of 2.1°. There was no statistically significant difference (p>0.05) in either hip IR or ER ROM or total rotation between or within groups.
Conclusions:
The results of this study indicate that a significant difference in hip extension exists in subjects with PFP compared to controls. These findings suggest that passive hip extension is a variable that should be included within the clinical examination of people with PFP. It may be valuable to consider hip mobility restrictions and their potential impact on assessment of strength and planned intervention in subjects with PFP.
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NewsBot · Aug 21, 2014

Correlation between Intrinsic Patellofemoral Pain Syndrome in Young Adults and Lower Extremity Biomechanics.
Kwon O, Yun M, Lee W.
J Phys Ther Sci. 2014 Jul;26(7):961-4.

[Purpose] The purpose of this study was to evaluate the correlation between intrinsic patellofemoral pain syndrome (PFPS) in young adults and lower extremity biomechanics.

[Subjects] This experiment was carried out with sixty (24 men and 32 women), who are normal university students as subjects.

[Methods] All subjects underwent 3 clinical evaluations. For distinguishing the intrinsic PFPS from controls, we used the Modified Functional Index Questionnaire (MFIQ), Clarke's test and the Eccentric step test. Based on the results of the tests, subjects who were classified as positive for 2 more tests were allocated to the bilateral or unilateral intrinsic PFPS group (n=14), and the others were allocated to the control group (n=42). These two groups were tested for hamstring tightness, foot overpronation, and static Q-angle and dynamic Q-angle. These are the four lower extremity biomechanic, cited as risk factors of patellofemoral pain syndrome.

[Results] The over pronation, static Q-angle and the dynamic Q-angle were not significantly different between the two groups. However, the hamstring tightness of the PFPS group was significantly greater than that of the controls.

[Conclusion] We examined individuals for intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. We found a strong correlation between intrinsic PFPS and hamstring tightness.
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NewsBot · Sep 10, 2014

Trunk biomechanics and its association with hip and knee kinematics in patients with and without patellofemoral pain
Theresa Helissa Nakagawa, PT, PhD, Carlos Dias Maciel, PhD, Fábio Viadanna Serrão, PT, PhD
Manual Therapy; Articles in Press

Patellofemoral pain (PFP) is a common lower extremity condition observed in sports clinics. Recently, it has been suggested that trunk motion could affect hip and knee biomechanics in the frontal plane. Thus, the purpose of the study was compare trunk kinematics, strength and muscle activation between people with PFP and healthy participants. In addition, the associations among trunk biomechanics, hip and knee kinematics were analysed. Thirty people with PFP and thirty pain-free individuals participated. The peak ipsilateral trunk lean, hip adduction, and knee abduction were evaluated with an electromagnetic tracking system, and the surface electromyographic signals of the iliocostalis and external oblique muscle were recorded during single-leg squats. Trunk extension and trunk flexion with rotation isometric strength and side bridge tests were quantified using a handheld dynamometer. Compared with the control group, the PFP group demonstrated increased ipsilateral trunk lean, hip adduction and knee abduction (p = 0.02 - 0.04) during single-leg squat accompanied with decreased trunk isometric strength (p = < 0.001 - 0.009). There was no between-group difference in trunk muscle activation. Only in the control group, ipsilateral trunk lean was significantly correlated with hip adduction (r = -0.66) and knee abduction (r = 0.49); also, the side bridge test correlated with knee abduction (r = -0.51). Differences in trunk, hip and knee biomechanics were found in people with PFP. No relationship among trunk, hip and knee biomechanics was found in the PFP group, suggesting that people with PFP show different movement patterns compared to the control group.
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NewsBot · Sep 16, 2014

Trunk biomechanics and its association with hip and knee kinematics in patients with and without patellofemoral pain
Theresa Helissa Nakagawa, PT, PhD, Carlos Dias Maciel, PhD, Fábio Viadanna Serrão, PT, PhD
Manual Therapy; Articles in Press

Patellofemoral pain (PFP) is a common lower extremity condition observed in sports clinics. Recently, it has been suggested that trunk motion could affect hip and knee biomechanics in the frontal plane. Thus, the purpose of the study was compare trunk kinematics, strength and muscle activation between people with PFP and healthy participants. In addition, the associations among trunk biomechanics, hip and knee kinematics were analysed. Thirty people with PFP and thirty pain-free individuals participated. The peak ipsilateral trunk lean, hip adduction, and knee abduction were evaluated with an electromagnetic tracking system, and the surface electromyographic signals of the iliocostalis and external oblique muscle were recorded during single-leg squats. Trunk extension and trunk flexion with rotation isometric strength and side bridge tests were quantified using a handheld dynamometer. Compared with the control group, the PFP group demonstrated increased ipsilateral trunk lean, hip adduction and knee abduction (p = 0.02 - 0.04) during single-leg squat accompanied with decreased trunk isometric strength (p = < 0.001 - 0.009). There was no between-group difference in trunk muscle activation. Only in the control group, ipsilateral trunk lean was significantly correlated with hip adduction (r = -0.66) and knee abduction (r = 0.49); also, the side bridge test correlated with knee abduction (r = -0.51). Differences in trunk, hip and knee biomechanics were found in people with PFP. No relationship among trunk, hip and knee biomechanics was found in the PFP group, suggesting that people with PFP show different movement patterns compared to the control group.
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NewsBot · Sep 18, 2014

Evaluation of risk factors associated with Patellofemoral Pain Syndrome
Larson, Michael, M.S.,
BOSTON UNIVERSITY, 2014, 68 pages; 1559876

Objective: Patellofemoral Pain Syndrome (PFPS) is the most common diagnosis in patients presenting knee pain (~25%), and one of the most common diagnosis in sports medicine centers. Here we examine believed risk factors in Patellofemoral Pain Syndrome (PFPS) and assess their relationship to PFPS.

Methods: The study was a retrospective study completed at Johns Hopkins Department of Orthpaedic Surgery. All patients, who were referred to physical therapy at Johns Hopkins Rehabilitation Therapy Services Clinic, were diagnosed with PFPS for the first time and were mostly recreational runners. Body mass indexes (BMI) were calculated from weight and height. Pain scores were taken using the visual analog scale. Strength measurements were taken from the left and right leg for the following measurements: hip abduction external rotation, hip abduction, knee extension, and hip extension. Balance measurements were also taken on the left and right sides measuring the postural sway with eyes open and eyes closed. Statistical analysis were accomplished using excel.

Results: A total of 23 patients were included in the present study, 9 females and 14 males. BMI's (lb/in

2) for the population was 25.1(±4.2), males were 26.4 (±3.6) and females were 23.2 (±4.2). Pain scores were 6 (±1.9) out of 10 for the total population, males, and females. The total population had composite hip scores 35.0% and 22.9% for the right and left sides, while the knee extension was 50.7% and 51.7%. All hip scores were below 40 except for right hip ABD/ER in females and lower than knee extension scores in males, females, and total population. The ratio for right eyes closed to open was 34.2 (±62.7) and left eye closed to open was 24.7 (±44.3) for the total population

Conclusion: This study demonstrated that age and BMI may have an effect on the development of PFPS but no statistical significance was confirmed. Results suggest that hip strength is a better indicator than knee strength in risk associated with PFPS. Balance appears to be more of an indicator of poor hip strength than as a measurement or potential risk factor for PFPS.
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NewsBot · Oct 21, 2014

HIP MUSCLE STRENGTH AND ENDURANCE IN FEMALES WITH PATELLOFEMORAL PAIN: A SYSTEMATIC REVIEW WITH META‐ANALYSIS
Joachim Van Cant, PT, Catherine Pineux, PT, Laurent Pitance, PT, PhD and Véronique Feipel, PT, PhD
Int J Sports Phys Ther. Oct 2014; 9(5): 564–582.

Purpose/Background:
Patellofemoral pain (PFP) is a common knee conditions experienced by adolescents and young adults, seen particularly in women. Clinicians and researchers need to understand how proximal, local, or distal factors may influence the development of PFP and affect individuals once they have developed PFP. Proximal factors are the focus of recent studies and the purpose of this systematic review was to determine if females with PFP have hip muscle strength or endurance deficits when compared to their unaffected leg and to comparison groups.

Methods:
A systematic review was conducted to identify relevant studies in the databases PubMed, PEDro, ScienceDirect and EBSCOhost up to June 2013. Data including study design, participants demographic data, and assessments of hip muscle strength or endurance were extracted from individual trials. The mean differences of hip muscles strength or endurance between females with PFP and healthy controls or unaffected side were extracted or calculated from individual trials and, when possible, a meta‐analysis was performed.

Results:
Ten cross‐sectional studies were included in this review. Concerning isometric strength, pooled data reported deficit in hip abduction, extension, external rotation and flexion but no deficit in adduction and internal rotation when compared with healthy controls. When compared with the unaffected side, deficit in hip abduction was reported in two studies and deficit in extension and external rotation in one study. Studies with isokinetic strength evaluation reported deficit in abduction but contradictory results for extensors and rotators in females with PFPS. Finally, one study reported hip endurance deficit in extension and one found no significant differences in hip endurance compared to control subjects.

Conclusion:
The results of this systematic review confirm that females with PFPS have deficit in hip muscle strength compared with healthy controls and the unaffected side but are contradictory concerning endurance.
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NewsBot · Nov 6, 2014

Strengthening of the Hip and Core Versus Knee Muscles for the Treatment of Patellofemoral Pain: A Multicenter, Randomized Controlled Trial
Reed Ferber, Lori Bolgla, Jennifer E Earl-Boehm, Carolyn Emery and Karrie Hamstra-Wright
Journal of Athletic Training In-Press.

Context: Patellofemoral pain (PFP) is the most common injury in running and jumping athletes. Randomized controlled trials suggest that incorporating hip and core strengthening (HIP) with knee-focused rehabilitation (KNEE) improves PFP outcomes. However, no randomized controlled trials have, to our knowledge, directly compared HIP and KNEE programs.

Objective: To compare PFP pain, function, hip- and knee-muscle strength, and core endurance between KNEE and HIP protocols after 6 weeks of rehabilitation. We hypothesized greater improvements in (1) pain and function, (2) hip strength and core endurance for patients with PFP involved in the HIP protocol, and (3) knee strength for patients involved in the KNEE protocol.

Design: Randomized controlled clinical trial.

Setting: Four clinical research laboratories in Calgary, Alberta; Chicago, Illinois; Milwaukee, Wisconsin; and Augusta, Georgia.

Patients or Other Participants: Of 721 patients with PFP screened, 199 (27.6%) met the inclusion criteria (66 men [31.2%], 133 women [66.8%], age = 29.0 ± 7.1 years, height = 170.4 ± 9.4 cm, weight = 67.6 ± 13.5 kg).

Intervention(s): Patients with PFP were randomly assigned to a 6-week KNEE or HIP protocol.

Main Outcome Measure(s): Primary variables were self-reported visual analog scale and Anterior Knee Pain Scale measures, which were conducted weekly. Secondary variables were muscle strength and core endurance measured at baseline and at 6 weeks.

Results: Compared with baseline, both the visual analog scale and the Anterior Knee Pain Scale improved for patients with PFP in both the HIP and KNEE protocols (P < .001), but the visual analog scale scores for those in the HIP protocol were reduced 1 week earlier than in the KNEE group. Both groups increased in strength (P < .001), but those in the HIP protocol exhibited gained more in hip-abductor (P = .01) and -extensor (P = .01) strength and posterior core endurance (P = .05) compared with the KNEE group.

Conclusions: Both the HIP and KNEE rehabilitation protocols produced improvements in PFP, function, and strength over 6 weeks. Although outcomes were similar, the HIP protocol resulted in earlier resolution of pain and greater overall gains in strength compared with the KNEE protocol.
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NewsBot · Nov 8, 2014

EFFECT OF PAIN ON HIP AND KNEE KINEMATICS DURING A PROLONGED RUN IN FEMALE RUNNERS WITH PATELLOFEMORAL PAIN SYNDROME
Tiffany Berry, Andrew Barnes, Peter Hanley, Jonathan Wheat
International Conference of Biomechanics in Sports (2014)

The purpose of this study was to investigate hip and knee mechanics during a prolonged run in individuals with patellofemoral pain syndrome. Kinematic data was collected from 8 female recreational runners currently suffering from the condition and 7 controls during a prolonged treadmill run. Runners with patellofemoral pain syndrome did not appear to display altered running mechanics in the presence of significant pain or exertion, but did display differences in mechanics compared with controls, with two distinct subgroups identified. This finding might suggest two distinct mechanisms of injury for patellofemoral pain syndrome. This knowledge is important for establishing clear links between running mechanics and injury mechanisms and can be used to inform injury prevention and rehabilitation techniques.
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NewsBot · Nov 20, 2014

Comparison of hip and knee strength in males with and without patellofemoral pain
Lori A. Bolgla, PT, PhD, MAcc, ATC, Jennifer Earl-Boehm, PhD, ATC/L, Carolyn Emery, PhD, PT, Karrie Hamstra-Wright, PhD, ATC, Reed Ferber, PhD, ATC
Physical Therapy in Sport; Articles in Press

Highlights
•Unlike females, males with patellofemoral pain (PFP) did not exhibit hip weakness.
•Males with PFP demonstrated less knee extensor strength than controls.
•Males with PFP may benefit more from a knee-based strengthening protocol.
•Clinicians should consider implementing sex-specific interventions for managing PFP.
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Objectives
The primary purpose of this study was to compare hip strength in males with and without patellofemoral pain (PFP). The secondary purpose was to compare knee strength in males with and without PFP.

Design
Secondary analysis of cross-sectional data for males with and without PFP from a larger randomized controlled trial examining hip and core versus knee-muscle strengthening for the treatment of PFP.

Setting
Laboratory setting.

Participants
Sixty-six males with PFP and 36 controls.

Main Outcome Measures
Peak isometric force for the hip abductors, external rotators, internal rotators, extensors, and knee extensors expressed as a percentage of body mass (%BM)

Results
No differences existed with respect to any of the hip strength measures (P > .05). Males with PFP demonstrated almost 17% less knee extensor strength than controls (mean difference = 7.3 %BM; 95% confidence interval, 1.3-13.4 %BM; t = 2.41; P = .02).

Conclusions
Unlike females, males with PFP did not demonstrate hip muscle weakness. However, differences did exist with knee extensor strength. These data provide preliminary evidence for the potential need for sex-specific interventions for individuals with PFP.
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HansMassage · Nov 24, 2014

I will offer my observational opinion based on 20 years experience. patellofemoral pain syndrome (PFPS) is a symptom rather than a problem.

It may be unilateral but if bilateral usually my palpation findings are hypertonic vastus lateralus on one side and vastus medialus on the other.

The association I find with full body analysis is usually fixed spinal rotation or uneven arm swing. There can be pelvic rotation involved but that is often associated with the above. It can be associated with old foot and ankle injuries.

By working from the abnormal motion that I suspect is the cause toward the knee resolving problems found, if the patellofemoral pain syndrome (PFPS) disappears then it is a symptom not the problem.

NewsBot · Dec 10, 2014

From LER:
The role of hip mobility in patellofemoral pain

NewsBot · Dec 27, 2014

Hip rotation angle is associated with frontal plane knee joint mechanics during running
Masanori Sakaguchi, Norifumi Shimizu, Toshimasa Yanai, Darren J. Stefanyshyn, Yasuo Kawakami
Gait and Posture; Article in Press

Highlights
•We explore how hip rotation angles are related to frontal plane knee joint mechanics.
•Greater hip external rotation angles resulted in smaller knee abduction impulses.
•Knee abduction impulse was negatively correlated with peak knee abduction angle.
•The kinematic and kinetic risk factors for PFP are not corresponding.
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Inability to control lower extremity segments in the frontal and transverse planes resulting in large knee abduction angle and increased internal knee abduction impulse has been associated with patellofemoral pain (PFP). However, the influence of hip rotation angles on frontal plane knee joint kinematics and kinetics remains unclear. The purpose of this study was to explore how hip rotation angles are related to frontal plane knee joint kinematics and kinetics during running. Seventy runners participated in this study. Three-dimensional marker positions and ground reaction forces were recorded with an 8-camera motion analysis system and a force plate while subjects ran along a 25-m runway at a speed of 4 m/s. Knee abduction, hip rotation and toe-out angles, frontal plane lever arm at the knee, internal knee abduction moment and impulse, ground reaction forces and the medio-lateral distance from the ankle joint center to the center of pressure (AJC-CoP) were quantified. The findings of this study indicate that greater hip external rotation angles were associated with greater toe-out angles, longer AJC-CoP distances, smaller internal knee abduction impulses with shorter frontal plane lever arms and greater knee abduction angles. Thus, there appears to exist a conflict between kinematic and kinetic risk factors of PFP, and hip external rotation angle may be a key factor to control frontal plane knee joint kinematics and kinetics. These results may help provide an appropriate manipulation and/or intervention on running style to reduce the risk of PFP.
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NewsBot · Jan 3, 2015

Hip Strengthening Compared With Quadriceps Strengthening in Conservative Treatment of Patients With Patellofemoral Pain: A Critically Appraised Topic
IJATT Volume 20, Issue 1, January 2015, 20, 4 – 12

Clinical Scenario: Patellofemoral pain is a common injury that affects both athletic and sedentary populations. Clinicians may treat patellofemoral pain more effectively through a comprehensive understanding of the most effective exercise protocols.

Clinical Question: In patients with patellofemoral pain, are hip abductor and external rotator muscle strengthening exercises more effective in reducing pain and improving patient-reported function compared with isolated quadriceps strengthening?

Summary of Key Findings: A comprehensive and systematic database search was conducted for studies of level 2 evidence or higher. The search yielded 253 studies; of these studies, four randomized control trials and one comparative control trial fit the inclusion and exclusion criteria. A combination of quadriceps and hip strengthening exercises or hip strengthening exercises alone reduced pain and improved patient-reported function compared with quadriceps strengthening alone.

Clinical Bottom Line: There is strong evidence to support the use of hip strengthening or hip strengthening combined with quadriceps strengthening in the treatment of patellofemoral pain to decrease pain and improve patient reported function.

Strength of Recommendation: The Strength of Recommendation Taxonomy recommends a grade of A for level 1 evidence with consistent patient-oriented findings.
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HansMassage · Jan 3, 2015

I do not like the use of strengthening as the descriptive phrase of intervention. In most cases muscle strength is not a problem. Balancing is the more appropriate term. The muscles are either hypertonic or hypotonic or to put it another way their enervation is hypervigilant or inhibited.

My clinical experience is that the knee pain is the symptom, posture distortion and dysfunctional movement are the problem. Strength training machines may be more valuable for holding the joints in functional alignment than strengthening.

NewsBot · Jan 27, 2015

Does Anterior Knee Pain Severity and Function Relate to the Frontal Plane Projection Angle and Trunk and Hip Strength in Women with Patellofemoral Pain?
Gabriel Peixoto Leão Almeida, PT, MSc, Ana Paula de Moura Campos Carvalho e Silva, PT, MSc, Fábio Jorge Renovato França, PT, PhD, Maurício Oliveira Magalhães, PT (PhD candidate), Thomaz Nogueira Burke, PT, PhD, Amélia Pasqual Marques, PT, PhD
Journal of Bodywork and Movement Therapies; Article in Press

The aim of the present study was to determine the relationship between knee pain severity and function with the frontal plane projection angle (FPPA) and trunk and hip peak torque (PT) in women with patellofemoral pain (PFPS). Twenty-two women with PFPS were assessed. Knee pain severity (KPS) was assessed with an 11-point visual analog scale and function with an Anterior Knee Pain Scale. The FPPA was recorded with a digital camera. PT of extensors, abductors, and the lateral rotators of hip and lateral core stability were measured with a handheld dynamometer. FPPA was the only predictor for the KPS. Regarding predictors of function, PT of lateral core stability and the extensor and abductor of the hip explained 41.4% of the function. Increase in FPPA was associated with greater KPS, and the lowest PT of lateral core stability, hip abductors, and extensors was associated with lower function in women with PFPS.
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NewsBot · Jan 28, 2015

High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study
Daniel Ramskov, PT, MHSc, Christian Barton, PT, PhD, Rasmus O. Nielsen, PT, MHSc, Sten Rasmussen, MD
Journal of Orthopaedic & Sports Physical Therapy > Ahead of Print

Study Design
Observational prospective cohort study with 1-year follow-up.

Objectives
To investigate the relationship between eccentric hip abduction strength and the development of patellofemoral pain (PFP) in novice runners, during a self-structured running regime.

Background
Recent research indicates gluteal muscle weakness in individuals with PFP. However, current prospective research is limited to evaluation of isometric strength, producing inconsistent findings. Considering hip muscles including gluteus maximus and medius activate eccentrically to control hip and pelvic motion during weight-bearing activities such as running, evaluating the potential link between eccentric strength and PFP risk is needed.

Methods
832 novice runners were included at baseline and 629 participants were included in the final analysis. Maximal eccentric hip abduction strength was measured using a handheld dynamometer prior to initiating a self-structured running program. The diagnostic criteria to classify knee pain as PFP were based on a thorough clinical examination. Participants were followed for 12 months and training characteristics was gathered with a Global Positioning System (GPS).

Results
Results from the unadjusted generalized linear regression model for the cumulative risk at 25 and 50 kilometres indicated differences in cumulative risk of PFP between high strength, normal strength, and low strength (P< 05), with higher strength associated with reduced risk.

Conclusion
Findings from this study indicate that among novice runners a level of peak eccentric hip abduction strength higher than normal reduces the risk of PFP during the first 50 kilometres of a self-structured running program.
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NewsBot · Mar 11, 2015

Lower limb control and strength in runners with and without patellofemoral pain syndrome
Jean-Francois Esculier, Jean-Sébastien Roy, Laurent Julien Bouyer
Gait and Posture; Article in Press

Highlights
•Runners with and without PFPS were assessed during treadmill running.
•Overall, no differences in previously identified risk factors for PFPS were found.
•Sub-analyses were performed for females and rearfoot strikers.
•Increased HADD was found at toe-off in females and RFS with PFPS.
•RFS with PFPS had lower GMed EMG activity and vertical ground reaction forces.
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Recreational runners with patellofemoral pain syndrome (PFPS) have been shown to present altered movement kinematics, muscle activations, and ground reaction forces (GRF) during running as well as decreased lower limb strength. However, these variables have never been concurrently evaluated in a specific cohort. Therefore, the aim of this study was to compare lower limb control variables during running in recreational runners with and without PFPS. Lower limb control during treadmill running under typical training conditions (usual shoes, foot strike pattern, and speed) was compared between runners with (n = 21) and without (n = 20) PFPS using lower limb kinematics, electromyographic (EMG) recordings from representative muscles (gluteus medius/maximus, quadriceps and soleus), and vertical GRF. Isometric muscle strength was also evaluated. When comparing all runners from both groups, no between-group differences were found in variables commonly associated with PFPS such as peak hip adduction, hip internal rotation, contralateral pelvic drop, EMG of gluteal and quadriceps muscles, vertical loading rate, or lower limb strength. However, runners with PFPS showed significantly higher hip adduction at toe-off, lower excursion in hip adduction during late-stance, and longer duration of soleus activation. Sub-analyses were performed for females and for rearfoot strikers (RFS), and revealed that these subgroups accounted for most of between-group differences in hip adduction kinematics. Specifically for RFS with PFPS, lower activation of gluteus medius as well as lower GRF were observed. Our results suggest that deficits reported in runners with PFPS may vary depending on gender and on foot strike pattern.
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NewsBot · Apr 21, 2015

Addition of hip exercises to treatment of patellofemoral pain syndrome: A meta-analysis
Kimberly M Morelli, Maria Carrelli, Maria A Nunez, Caroline A Smith, Gordon L Warren
World J Meta-Anal 2015; 3(2): 118-124

AIM: To determine if the addition of hip-strengthening exercises decreases pain and improves function in patients with patellofemoral pain syndrome.

METHODS: The authors completed a systematic review searching eight databases (i.e., PubMed, Cochrane, CINHAL, MEDLINE, SportsDiscus, EMBASE, APTA Hooked on Evidence, and PEDro). Two independent reviewers screened and excluded studies if they did not meet the following inclusion criteria: subjects had a primary diagnosis of patellofemoral pain syndrome (PFPS), intervention group included hip-strengthening exercises, control group included a traditional physical therapy intervention, study included outcome measures of pain and/or function, study used a randomized controlled trial design, PEDro score was ≥ 7, and study was published in a peer-reviewed journal. Primary outcome measures were subjective scales of pain and function. These measures were converted to standardized mean difference [effect size (ES)], and a random-effects model was used to calculate the overall ES.

RESULTS: Two hundred eighty-three studies were screened for inclusion in our meta-analysis. Nine studies were deemed suitable for data extraction and analysis. A total of 426 subjects were used in the nine studies. Overall, there was a significant positive effect of hip-strengthening exercises on measures of pain and function in subjects with PFPS (ES = 0.94, P = 0.00004). None of the individual studies had a negative ES, with study ES ranging from 0.35 to 2.59. Because of the high degree of between-study variance (I2 = 76%; Q = 34.0, P < 0.001), subgroup meta-analyses and meta-regressions were performed. None of the potential moderator variables that were investigated (e.g., outcome type, hip region targeted, duration of treatment) could explain a significant amount of the between-study variance in ES (P ≥ 0.23).

CONCLUSION: Overall, the addition of hip-strengthening exercises to traditional physical therapy produced greater improvements in measures of pain and function.
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NewsBot · May 5, 2015

Lower extremity rotational deformities and patellofemoral alignment parameters in patients with anterior knee pain
Omer Faruk Erkocak, Egemen Altan, Murat Altintas, Faik Turkmen, Bahattin Kerem Aydin, Ahmet Bayar
Knee Surgery, Sports Traumatology, Arthroscopy; May 2015

Purpose
Anterior knee pain is a common musculoskeletal condition amongst young adult population. Lower extremity structural factors, such as increased femoral anteversion and lateral tibial torsion, may contribute to patellofemoral malalignment and anterior knee pain. The aim of this study was to evaluate the lower extremity structural factors and related patellofemoral alignment parameters that play a role in the aetiology of anterior knee pain.
Methods
This study involved three groups: patients with unilateral symptomatic knees (n = 35), asymptomatic contralateral knees in the same patients and a control group (n = 40). All subjects were physically examined, and Q-angles were measured. The lower extremities of all subjects were imaged by a very low-dose CT scan, and the symptomatic knees of patients were compared with their asymptomatic contralateral knees and with the healthy knees of controls regarding femoral anteversion, tibial torsion, sulcus angle, patellar tilt angle and lateral patellar displacement.
Results
Regarding the Q-angle, femoral anteversion and lateral tibial torsion, no significant differences were found between the symptomatic and asymptomatic knees, whereas significant differences were found between the symptomatic knees and controls. The symptomatic group demonstrated significantly greater sulcus angle only in 30° of knee flexion than did the controls.
Conclusion
Patients with unilateral anterior knee pain may have similar morphology at their contralateral asymptomatic lower extremity, and different morphology compared with healthy controls. Lower extremity rotational deformities may increase the risk of anterior knee pain; however, these deformities alone are not sufficient to cause knee pain, and may be predisposing factor rather than a direct aetiology.
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NewsBot · May 5, 2015

Strengthening the hip muscles in individuals with patellofemoral pain: what can be learned from the literature?
Christopher Dorey; Jonathan Mark Williams
Physical Therapy Reviews Volume 20, Issue 2 (April 2015), pp. 63-72

Background:
The precise aetiology of Patellofemoral Pain Syndrome (PFPS) remains unclear; however, the efficacy of employing hip abductor and lateral rotator muscle strengthening interventions in the rehabilitation of patients with PFPS has been previously documented. Despite this it remains unclear as to the most efficacious protocol to optimise outcome.
Objectives:
To synthesise the literature regarding different hip strengthening protocols and their effect on decreasing pain and increasing hip strength in individuals with PFPS.
Methods:
A systematic search of Medline, Google Scholar, SPORTDiscuss, Science Citation Index, OAIster, CINAHL, Academic Search Complete, Science Direct, Scopus was completed in October 2013. Critical appraisal was completed using multiple tools depending on study design.
Results:
Five articles satisfied the inclusion criteria. Overall articles scored highly on critical appraisal and positive effects of proximal strengthening were identified as was a reduction in pain in individuals with PFPS. No correlation was established between change in strength of hip lateral rotators or hip abductors and change in pain ( = 0.003; = 0.010). A programme incorporating open and closed chain exercises was more effective than open chain alone for decreasing pain. Higher frequency and longer duration of exercise was identified as resulting in greater reduction of pain. The frequency required may be linked to participant's strength before intervention.
Conclusions:
Hip strengthening results in significant gains in strength and reductions in pain in individuals with PFPS. Exercise protocols incorporating open and closed kinetic chain, with high frequency and long duration seem to be important in optimising their effect on pain and strength
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NewsBot · May 5, 2015

A randomised trial into the effect of an isolated hip abductor strengthening programme and a functional motor control programme on knee kinematics and hip muscle strength
Kathryn Palmer, Clair Hebron and Jonathan M Williams
BMC Musculoskeletal Disorders 2015, 16:105 doi:10.1186/s12891-015-0563-9

Background Dynamic knee valgus and internal femoral rotation are proposed to be contributory risk factors for patellofemoral pain and anterior cruciate ligament injuries. Multimodal interventions including hip abductor strengthening or functional motor control programmes have a positive impact of pain, however their effect on knee kinematics and muscle strength is less clear. The aim of this study was to examine the effect of isolated hip abductor strengthening and a functional motor control exercise on knee kinematics and hip abductor strength.

Methods This prospective, randomised, repeated measures design included 29 asymptomatic volunteers presenting with increase knee valgus and femoral internal rotation. Participants completed either isolated hip abductor strengthening or a functional motor control exercise for 5 weeks. Knee kinematics were measured using inertial sensors during 2 functional activities and hip abductor strength measured using a load cell during isometric hip abduction.

Results There were no significant differences in dynamic knee valgus and internal rotation following the isolated hip abductor or functional motor control intervention, and no significant differences between the groups for knee angles. Despite this, the actual magnitude of reduction in valgus was 10° and 5° for the functional motor control group and strengthening group respectively. The actual magnitude of reduction in internal rotation was 9° and 18° for the functional motor control group and strengthening group respectively. Therefore there was a tendency towards clinically significant improvements in knee kinematics in both exercise groups. A statistically significant improvement in hip abductor strength was evident for the functional motor control group (27% increase; p = 0.008) and strengthening group (35% increase; p = 0.009) with no significant difference between the groups being identified (p = 0.475).

Conclusions Isolated hip strengthening and functional motor control exercises resulted in non-statistically significant changes in knee kinematics, however there was a clear trend towards clinically meaningful reductions in valgus and internal rotation. Both groups demonstrated similar significant gains in hip abductor strength suggesting either approach could be used to strengthen the hip abductors.
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NewsBot · Jun 10, 2015

Effectiveness of hip muscle strengthening in patellofemoral pain syndrome patients: a systematic review.
Santos TR, Oliveira BA, Ocarino JM, Holt KG, Fonseca ST
Brazilian Journal of Physical Therapy [2015:0]

INTRODUCTION: Patellofemoral pain syndrome (PFPS) is characterized by anterior knee pain, which may limit the performance of functional activities. The influence of hip joint motion on the development of this syndrome has already been documented in the literature. In this regard, studies have investigated the effectiveness of hip muscle strengthening in patients with PFPS. OBJECTIVES: The aims of this systematic review were (1) to summarize the literature related to the effects of hip muscle strengthening on pain intensity, muscle strength, and function in individuals with PFPS and (2) to evaluate the methodological quality of the selected studies.

METHOD: A search for randomized controlled clinical trials was conducted using the following databases: Google Scholar, MEDLINE, PEDro, LILACS, and SciELO. The selected studies had to distinguish the effects of hip muscle strengthening in a group of patients with PFPS, as compared to non-intervention or other kinds of intervention, and had to investigate the following outcomes: pain, muscle strength, and function. The methodological quality of the selected studies was analyzed by means of the PEDro scale.

RESULTS: Seven studies were selected. These studies demonstrated that hip muscle strengthening was effective in reducing pain. However, the studies disagreed regarding the treatments' ability to improve muscle strength. Improvement in functional capabilities after hip muscle strengthening was found in five studies.

CONCLUSION: Hip muscle strengthening is effective in reducing the intensity of pain and improving functional capabilities in patients with PFPS, despite the lack of evidence for its ability to increase muscle strength.
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HansMassage · Jun 11, 2015

In my opinion based on clinical experience, it is not the strength of the muscles but but he sequence of contraction and relaxation along with orientation that makes the difference. If the exercise is well designed these are improved even if the strength is not increased.

NewsBot · Jul 15, 2015

Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis
Simon Lack, Christian Barton, Oliver Sohan, Kay Crossley, Dylan Morrissey
Br J Sports Med doi:10.1136/bjsports-2015-094723

Background Proximal muscle rehabilitation is commonly prescribed to address muscle strength and function deficits in individuals with patellofemoral pain (PFP). This review (1) evaluates the efficacy of proximal musculature rehabilitation for patients with PFP; (2) compares the efficacy of various rehabilitation protocols; and (3) identifies potential biomechanical mechanisms of effect in order to optimise outcomes from proximal rehabilitation in this problematic patient group.

Methods Web of Knowledge, CINAHL, EMBASE and Medline databases were searched in December 2014 for randomised clinical trials and cohort studies evaluating proximal rehabilitation for PFP. Quality assessment was performed by two independent reviewers. Effect size calculations using standard mean differences and 95% CIs were calculated for each comparison.

Results 14 studies were identified, seven of high quality. Strong evidence indicated proximal combined with quadriceps rehabilitation decreased pain and improved function in the short term, with moderate evidence for medium-term outcomes. Moderate evidence indicated that proximal when compared with quadriceps rehabilitation decreased pain in the short-term and medium-term, and improved function in the medium term. Limited evidence indicated proximal combined with quadriceps rehabilitation decreased pain more than quadriceps rehabilitation in the long term. Very limited short-term mechanistic evidence indicated proximal rehabilitation compared with no intervention decreased pain, improved function, increased isometric hip strength and decreased knee valgum variability while running.

Conclusions A robust body of work shows proximal rehabilitation for PFP should be included in conservative management. Importantly, greater pain reduction and improved function at 1 year highlight the long-term value of proximal combined with quadriceps rehabilitation for PFP.
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Craig Payne · Jul 27, 2015

I missed this from October 2014:
Despite its popularity, “weak hips” is a weak theory, and there is no compelling evidence that hip strengthening can treat or prevent running overuse injuries of leg

Its pretty scathing on those who claim "weak hips" is an issue in runners!

NewsBot · Jul 29, 2015

Prevalence of Myofascial Trigger Points in the Hip in Patellofemoral Pain
Sean Roach, PhD, DPT, ATC Eric Sorenson, PhD, ATC, Barbara Headley, MS, PT, Jun G. San Juan, PhD, ATC
Archives of Physical Medicine and Rehabilitation
Volume 94, Issue 3, March 2013, Pages 522?526

Objectives
To determine the prevalence of myofascial trigger points (MTrPs) in the gluteus medius (GMe) and quadratus lumborum (QL) for subjects with patellofemoral pain (PFP), and to examine the relationship between MTrPs and force production of the GMe after treatment.

Design
Randomized controlled trial.

Setting
A physical therapy clinic.

Participants
Subjects (N=52; mean age ? SD, 30?12y; mean height ? SD, 172?10cm; mean mass ? SD, 69?14kg) volunteered and were divided into 2 groups: a PFP group (n=26) consisting of subjects with PFP, and a control group (n=26) with no history of PFP.

Interventions
Patients with PFP received trigger point pressure release therapy (TPPRT).

Main Outcome Measures
Hip abduction isometric strength and the presence of MTrPs.

Results
Prevalence of bilateral GMe and QL MTrPs for the PFP group was significantly higher compared with controls (P=.001). Subjects in the PFP group displayed significantly less hip abduction strength compared with the control group (P=.007). However, TPPRT did not result in increased force production.

Conclusions
Subjects with PFP have a higher prevalence of MTrPs in bilateral GMe and QL muscles. They demonstrate less hip abduction strength compared with controls, but the TPPRT did not result in an increase in hip abduction strength
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NewsBot · Aug 6, 2015

Predictors of treatment response to strengthening and stretching exercises for patellofemoral pain: An examination of patellar alignment
Hsien-Te Peng, Chen-Yi Song
The knee; Article in Press

Highlights
?Patellar tilt is a predictor of exercise treatment outcome in patients with patellofemoral pain syndrome (PFPS).
?Leg press (LP) and stretching exercise are beneficial for patients whose patella realigns after quadriceps contraction.
?Patient classification based on patellar tilt could aid in clinical decision making and therefore increase the efficacy of exercise intervention.
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Background
Closed kinetic chain and quadriceps strengthening, combined with flexibility exercises of the lower limb musculature, is a common treatment for patellofemoral pain syndrome (PFPS). The effectiveness has been well documented; however, very little is known about which factors predict treatment success.

Methods
A total of 43 female subjects with PFPS participated in an eight-week progressive leg press (LP) strengthening and stretching exercise program. A decrease of 1.5 cm on a 10 cm visual analog scale (VAS) score was used as an indicator for treatment success. The baseline patellar tilt angle difference (PTA-d) due to quadriceps contraction prior to treatment was evaluated as a predictor of treatment success. The logistic regression and receiver operating characteristics (ROC) curve analysis were performed to investigate the predictive value of PTA-d.

Results
PTA-d could significantly predict the treatment success of LP strengthening and stretching exercises. The odds ratio (OR) for having an unsuccessful outcome was 1.19 (95% confidence interval (CI), 1.03−1.39, P < 0.021) per degree increment of PTA-d. The most optimal cut-off value for the clinical discrimination of treatment success after LP strengthening and stretching exercise was −1.5? of PTA-d (sensitivity = 0.74, specificity = 0.71). The area under the ROC curve was 0.73 (standard error = 0.08).

Conclusions
Female patients with PFPS whose quadriceps contraction reduced the lateral patellar tilt prior to LP strengthening and stretching exercise treatment are more likely to experience pain relief. It seems clinically important to check dynamic patellar tilt characteristics before treatment to aid in clinical decision making.
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Patellofemoral pain and asymmetrical hip rotation

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