Hip vs Quad Strengthening for Knee Cap Pain
Patellofemoral Pain (PFP) is a condition that I often see hobbling into the clinic. This is characterized by pain at the patella (aka knee cap) and can afflict the active and sedentary. I most often have patients report pain or stiffness after prolonged sitting, walking up or down stairs, and the pain is noticeable during or after activity. There was a time when quadricep strengthening was the predominant exercise management strategy. The thinking was that since the patella is attached to the quad, by strengthening the quad you improve its tracking. However, more recent literature has suggested that improving strength at the hip would improve PFP symptoms because by strengthening the hips you can better control the lower limb, which means there would be less stress at the patella. If we had to compare the two, which would be the better bang for your buck?
An article in the British Journal of Sports Medicine studied the efficacy of a quad-based exercise protocol (QE) vs a hip-based exercise protocol (HE) in those with PFP over the course of a 12-week period with a follow up at 26 weeks. As an aside - note the TWELEVE WEEK INTERVENTION PERIOD. That is 3 months! Rehab takes consistency and time, so don’t expect changes immediately!
What exercises did the groups do?
QE: knee extensions, squats, lunges
HE: clamshells, side lying or standing hip abduction (swing leg out to the side), hip extension
The dosage was 8-12 reps/3 sets, 3x/week. They were also given criteria for how and when to add resistance. Progress was tracked using pain questionnaires specifically for anterior knee pain.
So who did better?
Both groups showed similar improvements in pain scores at the 12- and 26-week marks. Both QE and HE can help with the management of PFP. However, the change from baseline to 12-weeks did not hit the minimum requirement for it to be considered a clinically important change. Why? The researchers hypothesised that it was due to the fact that most of the study participants had had chronic PFP, and the longer you have been dealing with anterior knee pain, the worse your outcomes regardless of intervention. Also, these exercises were done at home, in an unsupervised environment, so there was no way of knowing how they were executing the exercises, and if they were pushing themselves appropriately.
The takeaway? You can’t go wrong with general strengthening, as it appears there is no protocol that is superior to another when it comes to the management of PFP. The best treatment is the one that is tailored to the needs and preferences of the patient you are working with. Does it hurt like crazy if you do a bunch of knee extensions? Then maybe it isn’t appropriate for you at this time. This is why when I see someone with knee pain, I go through a thorough assessment of their strength and so that we can give exercises that meet you where you are at.
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