It's The Hip Not The Knee

My patient came with anterior (or front) knee pain yesterday. She had been to see another physiotherapist who said she needed to strengthen her quadriceps muscle. Who says physios can't prescribe exercises compared to strength and conditioning coaches? 

Pardon the link - it seems that almost every single patient that comes to our clinic (after seeing another physiotherapist) had been given exercises to do during the treatment session itself. Maybe that's why the general public thinks all a physiotherapist does is teach exercises.

In our clinics, we may give an exercise or two to our patients near the end of the session, for them to do at home. However, we do not make our patients do any exercises DURING the treatment session. We treat them, mostly using our hands. We do treatment that the patients cannot do themselves, while they are in the clinic. 

Anyway back to my patient with knee pain who was asked to strengthen her quads. I've written a few times since 2009 that treating (or strengthening the hip) is much more important than strengthening the knee (quadriceps). Well, here is further proof.

In this systematic review referenced below, researchers studied data from 14 suitable studies (out of 119) that were found between 1994 and September 2019. Results from all 14 studies demonstrated that strengthening the hip 2-4 times a week (for 3-8 weeks) effectively relieved pain and improved knee function compared to quadriceps stengthening and no exercise. This lasted for up to 12 months post intervention.

The researchers recommended that hip muscle strengthening be a standard clinical practice while treating patients with anterior knee pain. So if the physiotherapist that you're seeing gets you to do quadriceps strengthening for your anterior knee pain, you need to tell them that hip strengthening is superior to quadriceps exercise. Please note that hip strengthening does not mean clam shell exercises.

Please also note that this present review included  randomized clinical trials that also got their subjects to do both hip plus quadriceps strengthening exercises over just the quadriceps alone. All except one study showed that hip and quadriceps strengthening exercises over just quadriceps alone. There were no no hip plus quadriceps strengthening versus hip exercises alone study done.

Perhaps a combination of hip-quadriceps strengthening may be a more effective strategy in the treatment of anterior knee pain? We can certainly try that in our clinic before more studies are done. It would depend on what we find to be weak at your objective examination ;)

Reference

Alammari A, Spence N, Narayan A et al (2022). Effect Of Hip Abductors And Lateral Rotators' Muscle Strengthening On Pain And Functional Outcome In Adult Patients With Patellofemoral Pain : A Systematic Review And Meta-analysis. J baxk Muscl Rehab. Pre-press. pp 1-26. DOI: 10.3233/BMR-220.

** For those of you wondering, there were no standardized protocol for hip and knee exercises in the various studies. The common hip exercise protocol included hip abduction against an elastic band while standing and with weights in a side-lying position coupled with hip lateral rotation against an elastic band while seated and hip extension (3 sets of 10 repetitions). 

Conversely, quadriceps strenthening in all studies generally involved weight bearing and non weight bearing exercises such as closed kinetic chain exercises, seated knee extension, leg press, squatting and stretching of hamstrings and quadriceps (3 sets of 10 repetitions).