Hip Strength in Females and Patellofemoral Pain
Strength Training, running, injury prevention January 20th, 2008If you have read some of my blog posts lately than you have seen that I have been digesting some research articles related to patellofemoral pain and strength training.
One question that could be asked is; Why patellofemoral pain? Here are two answers:
1. If you read my review of the article that discussed the benefits of physical therapy then you would know that patellofemoral pain is also known by many other names, such as, chondromalacia patellae, anterior knee pain, patellar malalignment, and patellofemoral arthralgia. Therefore it may seem that the name is a very narrow issue, but it is not.
2. These issues seem to be very common set backs that runners deal with from my experience. While I used to believe that these knee issues (runner’s knee even) were more prevalent with new runners, I am not sure that I can make that general observation anymore. I feel like I get these questions all the time lately, from all sizes, shapes, gender and experience of runners.
The previous two articles have been a review of: a - suggestions to sports physicians on how to address and manage pfp and b - the role that physical therapy interventions have, especially strength exercises.
The article that I reviewed today discussed the question from another angle, Is there a difference in hip strength in females that have patellofemoral pain versus those that don’t?
Here’s the article source:
Ireland ML, Wilson JD, Ballantyne BT and Davis IM. (2003). Hip strength in females with and without patellofemoral pain. Journal of Orthopaedic and Sports Physical Therapy. Vol. 33, No. 11, Pgs. 671 - 676.
The basics of the study is that they matched 15 females subjects with patellofemoral pain to 15 female subjects without patellofemoral pain. They then tested both hip abduction (moving your leg away from your body) and external rotation (rotating your foot in).
They had some interesting findings:
1. isometric hip abduction was 26% weaker in the females with patellofemoral pain
2. external rotation was 36% weaker in females with patellofemoral pain
They do point out in their discussion that b/c of the study design it is not possible to determine a cause/effect relationship, but they do make some observations that I felt were worth mentioning:
1. the results of this study, along with previous studies show that proximal stabilization programs (this means proximal to the knee… thus the stabilization at the hip) may be beneficial for those with patellofemoral pain.
2. strengthening of the hip abduction and external rotators may benefit those with patellofemoral pain (they mention other studies that have focused on strengthening the gluteus medius)
My thoughts:
This observation is essential to my understanding of the patellofemoral pain issue and helping runners. Why? Because most of the articles that I’ve read and found deal with the issue of patellofemoral pain treatment. Which is not what I would ultimately like to do. The desire is to find characteristics of the problem and correct them before they become an injury that needs treatment.
Again, this article does not show a cause / effect relationship. I could not promise someone that if they increased their strength for hip abduction and external rotation, they would not ever develop knee pain. The injury is multifactoral, therefore that idea is too simplistic in my point-of-view.
But it does point to a possible factor that we can control by including some appropriate strength training exercises.
One of the biggest revelations that I’ve had lately is just how oblivious I have been to this issue in the past. I have always had personal training clients strengthen their hips in the different planes, but I have seen the hip abduction weakness and hip stability (glut med) weakness a lot recently. Even in my own hips, which has created other problems (tight psoas muscle and back pain).
Does this mean that doing a hip strengthening routine is appropriate for everyone? I am not sure I can answer that, but I will say that my belief now is that it can’t hurt (while knee pain can), especially for those who are beginning a running/cycling program or are in a period where they are increasing their activity levels by a large percentage.
Hopefully I can find an article that discusses these weakness issues and interventions related to prevention. If I can, that will be the next patellofemoral pain article I review.
Until then… happy abductions.
January 21st, 2008 at 3:48 pm
I used to think that runners knee was for beginners too. Having never had it happen to me when I started out, I thought I was out of the range of it. Now, having run for 6 years, it has hit me a few times.
Overall, I know I need to strength train my entire leg (hips and all) to help this issue and work on my form. Thanks for posting all of your thoughts on these articles!
January 21st, 2008 at 9:31 pm
kate. I’m not sure if you read the other articles or not but they addressesed the issue of other weakness issues associated with patellofemoral pain. To sum them up, VMO strength (inner quad) is important along with hamstring flexibility. The idea of the abduction weakness has just been very prevelant in my observations lately. And I personally don’t beleive that a set on the adduction/abduction machine is the best method to address that issue in runners. I’m trying to put some things together to share how I feel would be the best way to address it. Hopefully I can share more soon.
January 22nd, 2008 at 3:29 am
Gary,
Here’s some more feedback on this topic. Mid last year I was having knee pain (coincidentally after getting new orthotics), the PT I had been seeing diagnosed it at patellofmoral pain and started looking for classic weakness issues. I have fairly large VMOs and so she didn’t think it was an issue of VMO strength, and although my hamstrings are tight like most runners, she was actually more concerned about my IT band which she felt was particularly tight. She was also concerned that I had potential “relative” weakness in my gluteus medius muscle on my left side, which she felt may have contributed to instability in my hips, upper legs, and knees.
After a couple months of working on loosening my IT band with rollers and better stretches, and strengthening my glutes with sideways band walking, etc… the pain never really went away.
I finally decided to switch to a new PT, who did a detailed running gait analysis. Including slow motion video frame by frame analysis. After doing a battery of functional tests, and watching my video several times in slow motion the new PT announced “You’re sagittal plane is picture/textbook perfect, I’ve never seen such perfectly tracking ankles, knees, and hips.”
Wow! Great News… so why the pain!
Upon examining the side view of my running gait, we saw an immediate and glaring problem. I was over striding and landing full force with a straight leg on my heels. He felt this basic (and fundamental) problem explained almost all of my running injuries: calcaneal stress fractures (or possibly just deep bone bruises), knee pain, and hip pain.
Since I was only 5 weeks away from my last marathon when we did this analysis, he didn’t want to radically alter my running style. We worked on increasing my cadence to 180+ where my current cadence was more like 155.
Anyway, my observation would be that knee pain would seem to be a classic indicator of some problem elsewhere in the “running system”, and that unfortunately many practitioners are quick to attribute the pain to the most common cause, when more detailed analysis my identify the real source and prevent further needless injury and incorrect and useless rehabilitation.
January 22nd, 2008 at 12:28 pm
Thanks Brad for your insight.
I think that my final outcome (as mentioned) is to help people find interventions to help prevent injury and enable them to run more (which is really the best way to get faster).
Once there is pain or worse injury, seeking the help of an Sports Med MD or rehab professional must be done (of which I am not). Because there can be one of many reasons for the injury.
When we look at prevention it becomes more broad in prescription; therefore I look at “what causes the majority of x issue?” Sort of like telling people with high blood pressure to not eat salt. Most people are not affected by salt intake (I think it’s around 15% that are impacted), but we give that general guideline to follow, b/c who knows how to separate out the 15%?
It’s interesting that you talk about the running form/gait as the issue for your knee pain.
I’ve focused my thoughts around strength training b/c I’m trying to solidify my thoughts around the benefits of using strength training for improving performance (b/c I still believe that swimming more, biking more and running more is the best way)…..
And the idea that improving your gait improved your knee issues backs up my idea of running more. We become more efficient / economical (depending on interpretation) as we run more.
So as strange as it seems, many people need to learn how to run still! Strength training maybe necessary for some (more and more, I believe) to obtain the durability to run lots of miles… but just as many need to learn to run correctly.
I’ve had a really hard time with my legs as I’ve changed my running gait to run with the Team in Training groups. I picked up some bad habits! (not that I needed more).
January 23rd, 2008 at 2:03 am
Actually, the idea that people need to “learn how to run” is a good one. My current PT basically summed it up like this… “we all assume we know how to run… since we’ve been doing it since we were little kids… but it turns out that there are many more ways to run incorrectly, that can hurt you, then there are ways to run ‘correctly’ that will allow you to run efficiently and injury free.”
January 23rd, 2008 at 4:27 pm
I say it over and over again, how you run will cause most of your problems and if that is not address all the strengthening in the world will not cure the problem.
For instance, the knee should tilt or rotate inward as it comes forward, that is a very natural motion, but a lot of people will tell you not to do it. Just as it tilts inward it will rotate outward as the foot comes back to the ground.
Arms should cross the body as long as the shoulders are not rotating. What one side of the body does doesn’t mean the other side should follow. So if one hand crosses in front and the other doesn’t, no big deal.
Most people run well at a certain pace, but beyond that is where some issue could crop up. Once again don’t think technique, think actions.
Actions like are my hands leading the running action, like are my feet coming back towards before contacting the ground, actions like am I working the elbow joint.
Attempt to command a certain technique will bring more pain and misery.
“Upon examining the side view of my running gait, we saw an immediate and glaring problem. I was over striding and landing full force with a straight leg on my heels. He felt this basic (and fundamental) problem explained almost all of my running injuries: calcaneal stress fractures (or possibly just deep bone bruises), knee pain, and hip pain.” This is easy to correct. I could show you in two minutes how to correct this issue.
I bet that if you look at the video again, pay attention to your hands. You will find that when the hand stops moving forward so does the foot. And if the hand does not start moving backwards so will the foot stay in front of your body and viola your heel is the landing point, with the full force of your bodyweight coming down with gravity and speed, get the picture. Also this could be a problem if your run by lifting or pulling your knees forward.
If you arms are moving it does not mean your hands are moving.
In moving your hands you have to work the elbow joint. Running with fixed arms bent will cause many problems also. Once again this is not a technique but an action.
Just my thoughts