Presented by: Marilyn Abel, Alyssa Hamm, Yves Leduc, Silas Wiefelspuett, Pantea Zarrinkamar Supervisor: Dr. Donna MacIntyre.

Presented by:Marilyn Abel, Alyssa Hamm, Yves Leduc, Silas Wiefelspuett, Pantea Zarrinkamar

Supervisor: Dr. Donna MacIntyre

INTRODUCTION PFPS Overview PFPS Theory Systematic Review Purpose

METHODS Search Strategy Screening Strategy Quality Assessment Data Analysis

RESULTS Search Strategy Quality Assessment Data Extraction Outcomes

DISCUSSION CONCLUSION

No universally accepted definition

Retropatellar or peripatellar pain of insidious onset in the absence of other diagnosed pathological conditions

Describes a spectrum of orthopedic abnormalities

Most common diagnosis of knee pain in active adults and adolescents

1 in 4 of total population; females > men

Exacerbated by prolonged sitting & repetitive weight-bearing activities

↓ Quality Of Life ↓ Participation in exercises or sports

↑ Economic burden (medical cost, days off work, etc)

Difficult to determine

Considered multi-factorial

Main Current Theory: Patellar maltracking within femoral trochlear notch

caused by abnormal muscular and biomechanical forces

Contributing Factors:

↑ Q angle Hypermobile patella Patella alta Pes planus Weak quads

↓ Flexibility of: Quadriceps Hamstrings Gastrocnemius Iliotibial band (ITB)

Potential mechanisms of patellar maltracking:

1. VL tends to be stronger and/or activates prior to the VMO Patella tracks laterally in the trochlear groove of the femur

2. Weak hip abductors Excessive femoral internal rotation and adduction under patella Relative lateral distraction of patella Increase patellofemoral joint stress

Wear on articular cartilage and altered lower extremity kinematics

Prins & Wurff, 2009 Females with patellofemoral pain syndrome have weak

hip muscles: a systematic review

Review of 5 studies that measured hip strength in females with PFPS

Concluded that females with PFPS show decreased strength in hip abduction, external rotation and extension when compared to healthy controls

2. Femoral Internal Rotation/Adduction

3. Relative Lateral Patellar Movement

1. Weak Hip Musculature

4. Knee Pain

Increased femoral internal rotation in PFPS with functional movements

Increased hip adduction angle in a prolonged run

Current rehabilitation of PFPS focuses mainly on knee musculature

Use of hip abductor strengthening as a treatment option needs to be investigated





Patellofemoral Pain Syndrome: anterior or retropatellar pain not associated with other identifiable pathological conditions

MEDLINE search1. Patellofemoral Pain Syndrome/2. patellofemoral pain.ti,ab.3. knee pain.mp.4. runner's knee.mp.5. pfps.mp. 6. anterior knee pain.mp7. peripatellar pain.mp8. retropatellar pain.mp. 9. chondromalacia patella.mp10. patellofemoral.mp11. patellofemoral arthralgia.mp. 12. patellar pain.mp13. patellar pain syndrome.mp14. patellofemoral syndrome.mp15. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or

9 or 10 or 11 or 12 or 13 or 1416. physical therapy.mp17. Rehabilitation/

18. rehabilitation.mp. 19. physiotherapy.mp.20. exp Exercise Therapy/ or exp

Exercise/21. Muscle Strength/22. strength*.mp23. resistance training.mp24. "Physical Therapy (Specialty)"/ or

exp Physical Therapy Modalities/25. exp weight lifting/26. 16 or 17 or 18 or 19 or 20 or 21 or

22 or 23 or 24 or 2527. hip abduct*.mp.28. hip muscle*.mp29. 27 or 2830. Hip Joint/31. Hip/32. 30 or 3133. 26 and 29 and 3234. 15 and 33

Additional databases searched: CINAHL, EMBASE, PEDro, SPORTDiscus

Grey literature searched Google, Google Scholar, Papers First, ProQuest

Dissertation and Thesis

References of selected articles were scanned

Authors in the field were contacted for additional information on unpublished data and studies

Articles were screened by 2 reviewers

In the case of a disagreement, consensus was met through a meeting of the reviewers

Third party mediation was not needed

Screening Strategy

Hip abductor strength as a component of Patellofemoral Pain Syndrome treatment

Article Screening Form (Adapted from Westby, MD) RefWorks ID: _________________ Screening date: ________________ Reviewer: AH, YL Citation:_______________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________

Level of Review:Title - Appropriate? YES _____ NO _____ (reason) __________________Abstract - Appropriate? YES _____ NO _____ (reason) __________________Included for full text review? YES _____ NO _____ (reason) __________________ Full TextArticle Review:Study Design: RCT _____ CCT or Quasi-RCT _____ Crossover _____ Review _____

Case-Control _____ Cohort _____ Case Series _____Single Subject_____ Pre-Post (no control) ____

Selection Criteria: (all 6 of the selection criteria must be met for inclusion to the systematic review) 1. Subjects clinically diagnosed with Patellofemoral Pain Syndrome _____2. Intervention includes specific hip abductor strengthening _____3. Intervention is at least 4wks in duration, minimum 2-3 days/wk _____4. Comparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatment_____5. Study uses pain and hip abductor strength as a primary outcome _____6. Study is published in English, French, or German _____

Subjects clinically diagnosed with PFPS

Specific hip abductor strengthening as part or whole of intervention

Intervention duration minimum 4wks, 2-3 days/wk

Uses pain and hip abductor strength as outcome measures

Comparisons are able to be drawn regarding the use of hip abductor strengthening as an effective component of treatment

Studies published in English, French or German

Subjects with recent knee injuries in addition to PFPS

Subjects with additional knee pathologies

PEDro Scale was used to assess quality of included studies

Process similar to that of Screening process

Data extraction tool used to collate relevant data

Independently extracted by 2 reviewers and compared for consistency

It was not necessary to contact authors for missing data





Search Strategy Of 182 articles screened, 3 were eligible

Articles were excluded based on: Lack of intervention Type of intervention Focus on other knee pathologies (i.e. ITBS, OA, TKA, etc)

Auto alerts set up in MEDLINE, SPORTDiscus, Embase, and CINAHL 1 article was retrieved from Embase went to full text

included in the review

Mascal et al. 2003, Management of Patellofemoral Pain Targeting Hip, Pelvis and Trunk Muscle Function: 2 Case Reports

Tyler et al. 2006, The Role of Hip Muscle Function in the Treatment of Patellofemoral Pain Syndrome

Nakagawa et al. 2008, The Effect of Additional Strengthening of Hip Abductor and Lateral Rotator Muscles in Patellofemoral Pain Syndrome: a Randomized Controlled Pilot Study

First study to assess the role of hip musculature in PFPS treatment

Progressive hip muscle strengthening (glut max and med, hip abd, and ER): Pain relief and improved biomechanical kinematics in a

step-down exercise (decreased hip adduction and femoral internal rotation)

Strengthened hip flexors, abductors, adductors & stretched hip flexors and ITB

↑ Hip abductor strength: not significant for pain relief

Combined iliopsoas strengthening & lengthening with ITB lengthening

Quad strengthening with hip abductor and external rotation strengthening (intervention group): ↓ Pain during functional activities Did not identify which muscle group had greater

contribution

↑ hip eccentric ER and hip abd torque: not statistically significant but clinically significant Small n & short Tx time → statistically insignificant

↑ Hip motor control → clinically significant

Common PEDro trends amongst 3 included studies:

Similar baseline groups

Measured at least one key outcome in >85% of the subjects

Provided either treatment or control condition to all of their subjects

None of the three studies blinded their therapists providing the treatment

Studies were not similar enough to compare quantitatively

Data from studies was extracted and qualitatively compared based on PICO headings (Population, Intervention, Comparison, Outcomes)

Study Participants Intervention Comparison Outcomes

Mascal et al. (2003)

2 ♀ 14 wksClinic: 1-2/wk & HEP: 2/day- Glut max/med, ext rotators, core, pelvic floor

Pre/Post measures, no control group

Muscle strength, Pain, Fxn’l status, P-F jt exam, Dynamic Ax, Biomech Ax

Tyler et al. (2006)

29 ♀ 6 ♂(8 bilat, total 43 knees)

6 wksClinic: ~2/wk & HEP: 1/day - Hip flexors, abductors, adductors

Pre/Post measures, no control group

Muscle strength, Pain,Flexibility, Physical Exam

Nakagawa et al. (2008)

10 ♀ 4 ♂

6 wksClinic: 1/wk and HEP: 4/wk - All: quads- Intervention group: TA, hip abductors, ext rotators

Control group vs. Intervention group

Muscle strength, Pain,EMG

All 3 studies used the Visual Analog Scale (VAS): Nakagawa et al. (2008): squatting and prolonged sitting Mascal et al. (2003): walking Tyler et al. (2006): ADLs and exercise

All 3 looked at the presence of pain with completion of stairs Tyler et al. (2006): climbing stairs (Y/N questionnaire) Nakagawa et al. (2008): ascending & descending stairs (VAS) Mascal et al. (2003): stairs in general (VAS)

Large ↓ in pain in participants in the Mascal et al. and Nakagawa et al. studies

Tyler et al. had a ↓ in their participant’s pain but at a smaller reduction





Aim: investigate whether patients with PFPS could benefit from hip abductor strengthening to reduce their symptoms

Conclusion: limited amount of clinical research supporting this theory presently Further research required to clarify role of hip muscle

strengthening for certain PFPS patients

Similar PFPS theoretical framework: Lack of hip control and/or weak hip musculature

Excessive femoral internal rotation and adduction under patella

Relative lateral distraction of patella Increase patellofemoral joint stress

Wear on articular cartilage and altered lower extremity kinematics

Treatment Approach: focus on hip musculature control of femoral movement

Chronological progressive improvement in quality of study design

1. Mascal et al. (2003) – case study2. Tyler et al. (2006) – cohort study3. Nakagawa et al. (2008) – RCT

Comparable outcome measures in all three studies:

1. ∆ hip abductor strength

2. ∆ pain

Hip abductor strength ↑ as a result of each treatment protocol

Mascal et al. & Nakagawa et al. Combination of ↑ hip muscle strength (abd & ER) &

motor control → improvement of L.E. kinematics

Tyler et al. Hip abductor strengthening not clinically significant Suggests other hip musculature reduces femoral internal

rotation

Mascal et al. & Nakagawa et al. Hip abductor & external rotator strength improvements

explain change in hip kinematics recorded pain reduction

Tyler et al. Implicates different sets of musculature changes

responsible for arriving at the same conclusion of pain reduction

These variables were not specifically evaluated and tabulated in any of the included articles

Possible increases in core and hip motor control may contribute to the decrease of PFPS symptoms

Small number of studies available

Total of 51 participants were studied: → limits the conclusions that can be made from the

resulting data

Heterogeneity between the included articles: → analysis and comparison more difficult → may result in themes being overlooked and not identified for discussion

RCTs

Increase sample size

Longitudinal studies with short, medium and long-term follow-up periods

Exercise protocols with core strengthening and hip motor control exercise

Differentiation for hip external rotation, extension and abduction musculature





Physiotherapy Canada Distributed to a large population of our peers Reach PTs across different domains

Present research does not conclusively identify the benefits of hip abductor strengthening for PFPS treatment

PFPS patients present with unique biomechanical dysfunctions

Excessive femoral internal rotation and adduction pathology Multiple hip muscles may be involved

Patients with insidious knee pain require thorough assessment of the hip, as well as the knee, to determine cause of pain and best course of treatment

Dr. Donna MacIntyre

Charlotte Beck

Dr. Darlene Reid

Dr. Elizabeth Dean

Presented by: Marilyn Abel, Alyssa Hamm, Yves Leduc, Silas Wiefelspuett, Pantea Zarrinkamar Supervisor: Dr. Donna MacIntyre.

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