Hip Internal Rotation and Adduction Correlated with Knee Pain

Hip Internal Rotation and Adduction Correlated with Knee Pain

By Jon Snyder DPT, PT, CSCS

Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain . Medicine & Science in Sports & Exercise. 2013;45(6):1120–1124. ABSTRACT

Why is this relevant? Patellofemoral pain syndrome (PFP) is a condition resulting in significant anterior knee pain. This condition presents itself primarily in an athletic population, and is especially common in female endurance athletes. Previous research has found consistent changes in lower leg muscle activation in individuals with this condition, but no prospective studies have been conducted. This research provides evidence that excess femoral adduction and internal rotation correlate with PFP, but fails to make a correlations between rear foot eversion and the development of PFP. This information gives us direction in the treatment and prevention of PFP.

Examples of Dynamic Knee Valgus - http://bretcontreras.com/wp-content/uploads/Capture32.jpg

Study Summary

Review & Commentary:

According to a retrospective case-control analysis by Taunton et al 4, of the 2,002 running-related injuries seen at a primary care sports injury facility, 42.1% (842/2,002) were knee injuries. Of these knee injuries, 39.3% (331/842) were due to patellofemoral pain syndrome (PFPS), which made PFPS far and away the most common diagnosis found in this large-scale study. Additionally, an older study done in 1984 found very similar results. Devereaux and colleagues 5 found that over a five-year period, 137 patients presented with PFPS, which accounted for 25% of all knee injuries seen at this sports injury clinic. Based on the prevalence of this injury, determining the etiology of patellofemoral pain should be a priority - with the goal of refining treatment and possibly prevention.

This has been an area of interest for multiple clinicians and researchers with many conflicting opinions. One of the most common and supported biomechanical influences is the influence of the hip musculature (gluteus medius and gluteus maximus ). In agreement with the reviewed study by Noehren and colleagues, several other authors have found impaired hip biomechanics in runners suffering from PFP. During weight bearing, the femur moves about a fixed patella and therefore excessive femoral internal rotation results in increased contact directed primarily at the lateral facet of the patella (Powers et al 6). In fact, just 10° of IR can lead to a substantial decrease in patellofemoral joint (PFJ) contact area and a 50% increase in joint stress. Additionally, Souza et al 7 found that females with PFPS demonstrated greater peak hip internal rotation compared to the control group during running, drop jumps, and step downs. The PFPS group also demonstrated 14% weaker hip abductor strength and 17% weaker hip extensor strength. Wilson et al 8, Noehren et al 9, and Nakagawa et al 10 found that individuals presenting with PFPS demonstrated increased hip adduction during running, jumping, and single-leg squats. This adduction creates an increased valgus force about the knee joint, which in turn causes increased loading of the lateral PFJ.

Why is this study important?

There is a bounty of research to support the implication that proximal instability on femoral adduction and internal rotation, which has a negative influence on joint loading and the onset of PFP. With this information, clinicians can work on improving gluteal neuromuscular control following injury or as part of a comprehensive injury prevention program.

How does it affect practice?

Our current understanding of proximal lumbopelvic musculature on running and lower extremity biomechanics implies special attention should be given to the hip joint and gluteal musculature for patients presenting with knee pain. Often, during evaluation, clinicians focus their interest solely on local factors (tight musculature, strength deficits, inflammation, etc.), however local deficits are rarely the sole cause of disability. This is true not only of patellofemoral pain syndrome, as excess femoral adduction and internal rotation have been found in individuals suffering from iliotibial band syndrome11 , anterior cruciate ligament rupture12 , and Achilles tendinopathy13 . With this knowledge, clinicians should begin incorporating proximal strengthening and neuromuscular control drills for the GMED and GMAX in addition to local interventions.

How does it relate to Brookbush Institute Content?

This research study, and the additional studies cited in this article support the propensity of the hip to adopt a dysfunctional compensatory pattern that includes excessive hip internal rotation and adduction. This trend is noted in both the Lower Leg Dysfunction (LLD) and Lumbo-Pelvic Hip Complex Dysfunction (LPHCD) models. Although careful assessment should always precede intervention, this study and the models mentioned above highlight additional considerations when treating individuals with knee pain. Further, the research supports the assertion that that LLD and LPHCD may be the cause of, or result from knee pathology. The Brookbush Institute uses an integrated model of treatment, that includes mobility, activation, integration and neuromuscular re-education. Mentioned in this study and several supporting studies is the implication that activation of the gluteus maximus and gluteus medius may improve hip kinematics and aid in rehabilitation of PFPS, and or prevent PFPS in those who are showing signs of increased internal rotation and adduction, but are not yet experiencing pain. Below you will find several videos covering techniques used to activate these commonly under-active muscles.

Related Videos:

Gluteus Maximus Isolated Activation

Gluteus Maximus and TVA Activation Progressions

Gluteus Medius Isolated Activation

Gluteus Medius Activation Progression

Quick Glute Activation Circuit

Gluteus Medius Reactive Activation

Gluteus Maximus Reactive Activation

References:

1. Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain . Medicine & Science in Sports & Exercise. 2013;45(6):1120–1124.
2. Ferber R, Davis IM, Williams DS, Laughton C. A comparison of within- and between-day reliability of discrete 3D lower extremity variables in runners . J Orthop Res. 2002;20(6):1139–45.
3. Noehren B, Manal K, Davis I. Improving between-day kinematic reliability using a marker placement device . J Orthop Res. 2010;28: 1405–10.
4. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36: 95–101.
5. Devereaux MD, Lachmann SM. PATELLO-FEMORAL ARTHRALGIA INATHLETES ATTENDING A SPORTS INJURY CLINIC . Br J Sports Med. 1984; 18(1): 18-21
6. Powers CM. The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective . Journal of Orthopaedic & Sports Physical Therapy. 2010;40(2):42–51. doi:10.2519/jospt.2010.3337.
7. Powers CM, Ho K-Y, CHEN Y-J, Souza RB, Farrokhi S. Patellofemoral Joint Stress During Weight-Bearing and Non—Weight-Bearing Quadriceps Exercises . Journal of Orthopaedic & Sports Physical Therapy. 2014;44(5):320–327. doi:10.2519/jospt.2014.4936.
8. Willson JD, Davis IS. Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands . Clin Biomech. 2008; 23(2): 203-11.
9. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome . Br J Sports Med. 2011; 45(9): 691-6.
10. Nakagawa TH, et al. Frontal Plane Biomechanics in Males and Females with and without Patellofemoral Pain . Medicine & Science in Sports & Exercise. 2012; 44(9): 1747-1755.
11. Qi W. Effect of Increased Iliotibial Band Load on Tibiofemoral Kinematics and Force Distributions: A Direct Measurement in Cadaveric Knees . Journal of Orthopaedic & Sports Physical Therapy. 2013;43(7):478–485.
12. Hewett TE, et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study . American Journal of Sports Medicine. 2005;33(4):492–501.
13. Franettovich, SM, Honeywill, C, Wyndow N, Crossley KM, Creaby MW. Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Medicine and science in sports and exercise. 2014; 46(3): 594-599.

© 2015 Brent Brookbush

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