The effectiveness of hip strengthening exercises in the management of patellofemoral pain syndrome (PFPS) in females.

Purpose

Patellofemoral pain syndrome (PFPS) is a common and often chronic knee condition with a high prevalence in females of working age. The regular presence of hip weakness in female patients with PFPS, has led to research emerging on hip strengthening exercises.

The aim of the systematic review was to examine the effectiveness of hip specific strengthening exercises on the management of patellofemoral pain syndrome (PFPS) specifically in females.

Secondly, to evaluate whether hip strengthening exercises should be identified as a primary treatment choice for managing PFPS in females.

Combined hip and knee strengthening exercise
is effective and appropriate in the management of female patients with PFPS.
There is good quality evidence to suggest
that a combined approach is more effective than knee exercises alone.

Approach

A systematic review of randomised control trials (RCTs) was conducted using the PICO framework to define the parameters to be included in the study. The review was conducted following PRISMA guidelines. Medline, EMBASE, PEDro, CINAHL, Web of Science, Scopus and AMED databases were searched between 12th June 2018 and 20th June 2018.

Two independent reviewers assessed each RCT for inclusion and methodological quality using the PEDro scoring system focusing on key features such as randomisation, allocation concealment and blinding. The Joanna Briggs Institute data extraction tool was used

Outcomes

1789 studies were identified through database searching, 33 full text papers were assessed; 26 were excluded leaving seven moderate to high quality RCTs, involving a total of 402 participants to be included in the review.

All seven studies demonstrated statistically significant  improvements in pain levels and functional outcomes pre-post intervention across hip strengthening interventions (p< 0.05). Combined hip and knee exercises were shown to be significantly more effective than knee exercises alone for both function and pain (p< 0.05).

However, there were no statistically significant differences reported between hip only/hip focused exercises with no standardised comparison, when compared to knee only exercises.

A systematic review of randomised control trials (RCTs) was conducted using the PICO framework to define the parameters to be included in the study. The review was conducted following PRISMA guidelines. Medline, EMBASE, PEDro, CINAHL, Web of Science, Scopus and AMED databases were searched between 12th June 2018 and 20th June 2018.

Two independent reviewers assessed each RCT for inclusion and methodological quality using the PEDro scoring system focussing on key features such as randomisation, allocation concealment and blinding. The Joanna Briggs Institute data extraction tool was used. There were insufficient common data points on outcome measures to perform a statistical meta analysis.

There is consistent moderate to high quality evidence to support the use of hip strengthening exercises in the management of female patients with PFPS. There is also some good quality evidence to suggest that a combined hip and knee approach is more effective in reducing pain than knee exercises alone. However, at present, there is insufficient evidence to suggest that hip strengthening exercises should be introduced as an alternative to knee strengthening exercise regimes.

Cost and savings

No cost as this was research performed as part of a masters degree. 

Implications

Combined hip and knee strengthening exercise is effective and appropriate in the management of female patients with PFPS. There is good quality evidence to suggest that a combined approach is more effective than knee exercises alone.

If practitioners are not already doing so, in line with current guidance from consensus statements on the management of PFPS, we would recommend that a combined hip and knee exercise approach is used in the management of females with patellofemoral pain.

However, further research is needed with established standardisation of the methodology and adequate control group comparison before it can be concluded that hip exercises are more effective than traditional knee strengthening regimes.

Top three learning points

  1. This research study helped me understand the usefulness of including additional proximal strengthening in the management of knee conditions, on both improving function and pain in females with patellofemoral pain. 
  2. The importance of considering the methodological quality of included studies in the overall findings of a good systematic review.
  3. The difficulty of producing reliably reproducible studies in Physiotherapy exercise intervention studies and also the huge variation in what researchers consider to be ‘hip strengthening exercises’ and ‘knee strengthening exercises’.

Additional notes

This work was presented at Physiotherapy UK 2019

 

For further information about this work please contact Claire Gilson

 

Reference(s):

Baldon, R. D. et al. 2014. Effects of Functional Stabilization Training on Pain, Function, and Lower Extremity Biomechanics in Women With Patellofemoral Pain: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy 44(4), pp. 240-251. doi: 10.2519/jospt.2014.4940

Bolgla, L. A. et al. 2016. Pain, function and strength outcomes for males and females with patellofemoral pain who participate in either a hip/core- or knee-based rehabilitation programme. International Journal of Sports Physical Therapy 11(6), pp. 926-935.

Fukuda, T. Y. et al. 2012. Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: A randomized controlled clinical trial with 1-year follow-up. Journal of Orthopaedic and Sports Physical Therapy 42(10), pp. 823-830. doi: http://dx.doi.org/10.2519/jospt.2012.4184 

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Saad, M. C. et al. 2018. Is hip strengthening the best treatment option for females with patellofemoral pain? A randomized controlled trial of three different types of exercises. Brazilian Journal of Physical Therapy 22(5), pp. 408-416. doi: 10.1016/j.bjpt.2018.03.009

Şahin, M. et al. 2016. The effect of hip and knee exercises on pain, function, and strength in patients with patellofemoral pain syndrome: A randomized controlled trial. Turkish Journal of Medical Sciences 46(2), pp. 265-277. doi: 10.3906/sag-1409-66

Van Cant, J. et al. 2014. Hip muscle strength and endurance in females with patellofemoral pain: A systematic review with meta-analysis. International Journal of Sports Physical Therapy 9(5), pp. 564 -582.