Knee Pain? Ignore it; Fix the Hip!

I have posted on this topic many, many times. Unfortunately, many still revert to antiquated rehabiltiation protocols. Thus, I feel compelled to keep talking about it. If you or a client has knee pain focus on the hip, not the knee. There is so much data out there on linking decreased glute strength to knee pain. A weak or inhibited glute medius is unable to control femoral internal rotation and obligatory knee frontal plane motion. These motions are a primary cause in knee pain – traumatic and acute. Today I discovered two, recently-published, systematic reviews to prove my point.

The first review examined 47 studies which looked at factors causing Patellofemoral Pain Syndrome (PFPS) (1). This review identified decreased muscle strength for hip abduction and hip external rotation as an important factor associated with the cause of PFPS. The pooled data also found increased Q-angle and sulcus angle to be factors – both of which have been linked to muscle imbalance.

The second systematic review was more specific by evaluating gluteal muscle activity – via EMG – and PFPS (2). The authors identified ten studies to be included in their review, with six of these studies considered to be high-quality and eight studies having a score of 8 or higher on the Downs and Black scale. The authors conclude there is moderate to strong evidence linking delayed or short Glute medius muscle activity to PFPS. The authors also state, “If gluteal muscle activation is delayed, frontal and transverse plane hip motion control may be impaired, leading to increased stress on the PFJ and subsequent symptoms associated with PFPS.”

Rehabilitation practitioners should note this when developing rehabilitation programs. Specifically targeting glute weakness and inhibition will limit hip internal rotation and obligatory knee frontal plane motion. Correcting faulty movement patterns will allow for optimal neuromuscular recruitment and joint kinematics, ultimately relieving or preventing pain.

If you are wondering which exercises will target the glute medius look at the study published in the recent JOSPT (3) and my recent blog titled “The Glute vs TFL Muscle Battle: Proper Exercise Selection to Correct Muscle Imbalance”. The data represented in the JOSPT article demonstrate the bilateral bridge, unilateral bridge, side step, clam, squat and two quadruped exercises are best for activating the glute medius.

Are you ready to change your rehabilitation program?

References:

Lankhorst NE, Bierma-Zeinstra, SMA, and van Middelkoop, M. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013;47:193–206. Barton CJ, Lack, S, Malliaras, P, and Morrissey, D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013; 47:207–214. Selkowitz, DM, Beneck, GJ, and Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther. 2013; 43(2):54-64.