Patellofemoral Pain Syndrome: Implementing a hip strengthening injury prevention program for adolescent, female athletes

by Leigh Rolandelli Brogdon

Introduction

My history in athletics has been influential in my physical therapy areas of interest. During my 8 years that I played competitive basketball and soccer, I was fortunate to only suffer from relatively minor injuries—a couple ankle and MCL sprains. However, many of my teammates were not so fortunate. Knee injuries were particularly rampant among my teammates, with many suffering from debilitating Patellofemoral Pain Syndrome (PFPS) or ACL injuries.

Given my interests in athletics and working with adolescent athletes,  I chose to focus my capstone project on patellofemoral pain syndrome. More specifically, my research focused on hip strengthening and its role in prevention and treatment of PFPS in adolescent, female athletes. Female adolescents are between 2 and 10 times more likely than their male counterparts to develop PFPS¹.  Sports that subject the athlete to repetitive pounding on the knees place these athletes at an even greater risk; an estimated 26% of adolescent, female basketball players will develop PFPS^2,3.

PFPS can be a difficult condition to treat, since there are so many factors that can contribute to its cause. Anatomical malalignment, the dynamic Q-angle, decreased lower extremity flexibility and excessive pronation can all play a role in decreasing the contact area and increasing the stress at the patellofemoral joint^3-5. Deficits in muscle weakness and the timing of the onset of activation of the quadriceps muscles can also contribute^3,6. However, recent research has emphasized the importance of the hip abductors and external rotators in the treatment of PFPS. Therefore, I chose to research the role of hip strengthening for both the prevention and treatment of PFPS. Ultimately, this led to the creation of a simple hip strengthening prevention program that could be implemented by coaches of young, female basketball teams.

Research

As part of the Evidence Based Practice II class (fall 2013), I completed a preliminary evidence table that aimed to address the PICO question, “For adolescent female athletes ages 8 to 18 participating in amateur athletic sports, is pre-season hip strengthening beneficial in decreasing in-season patellofemoral knee pain compared to no pre-season strengthening at all?” [RolandelliL_Module4_evid table_10.7.13] The literature featured in the table included RCT studies that compared hip strengthening to various controls in females with PFPS. Many of the nonexperimental studies examined the frontal and transverse plane biomechanics of females with PFPS.  My ongoing research during spring 2014 yielded an additional 12 articles that were used to supplement my original evidence table. [Capstone Evidence Table_spring 2014].  As part of my needs assessment, I conducted two preliminary interviews with basketball coaches to gauge their interest in learning more about PFPS and injury prevention.  Both coaches expressed a need for more injury prevention resources, and felt this would be valuable for not only themselves, but also the players and parents.  I also asked for their feedback regarding the best way to disseminate this knowledge to basketball coaches and their players.  This preliminary research is what sparked the idea for my final product—to create a hip strengthening prevention program that coaches could teach to their athletes.

After a review of the literature regarding hip strengthening for PFPS, I summarized my findings in a final paper[PFPS Capstone Paper_Leigh Rolandelli]. The intended audience is for physical therapy students or any other health professional who is interested in learning the basics of PFPS, as well as learning about the most recent research regarding hip strengthening interventions for PFPS.  The paper identifies the need for a PFPS prevention program in the female, adolescent population. Further, it outlines how coaches have the ability to effectively implement prevention programs when given adequate educational resources.

Part one of the paper outlines the anatomy, etiology and biomechanics related to PFPS. A familiarity with these topics will allow the reader and clinician to have a better understanding of the rationale for hip strengthening in this population.  A summary of research trials and hip strengthening interventions, as well as an identification of the trial limitations and the needs of future research, is discussed in part two of the paper.

Final Product

Using the results from my literature search, as well as my summarized findings that were presented in the evidence tables and final paper, I created my final product [PFPS brochure for distribution]. This is an educational brochure that explains the basics of PFPS. It includes written instructions and photos for 3 hip strengthening exercises that can be taught to athletes, with the goal of strengthening the hip abductors and external rotators, and ultimately protecting against PFPS and other lower extremity injuries. The brochure is intended for coaches of youth, female basketball teams, although it has the potential to be distributed to parents and players of other sports as well. At midterm, I completed a health literacy assessment [Rolandelli_Health Lit Assessment] and received feedback on my brochure draft from my adviser and committee members. The feedback was incorporated into the final brochure before it was disseminated to a larger audience of coaches.

The brochure, along with a survey, was distributed to various basketball coaches in the Greensboro, NC area [Coaches Survey].  Coaches were asked to fill out a survey both before and after reading through the educational brochure. The survey aimed to assess the coaches’ knowledge of PFPS and their knowledge and implementation of injury prevention strategies. Further, it asked for feedback regarding the feasibility, pros/cons, and barriers to implementing the suggested strengthening program, as well as feedback regarding the readability, relativity, and presentation of the brochure.

Evaluation

I received feedback from 8 coaches; overall, their players ranged in age from 10 to 18 years old. An evaluation and summary of comments from the coaches, as well as an Excel data analysis of the survey scores, are provided [Evaluation]  [Coaches Survey Feedback Analysis]. Overall, the coaches responded favorably to the brochure and the PFPS material.  The educational  information resulted in a positive increase in their knowledge of the symptoms, risk factors, and a prevention strategy for PFPS.  The coaches globally agreed that they felt confident in teaching the exercises to their athletes after reviewing the brochure, and were likely to implement the exercises with their teams.

After reviewing the feedback, it seems the biggest barrier to implementing the suggested strengthening program is time. Especially for those teams who only have practices 2 times per week, some coaches were concerned about when they could fit these exercises in. Several suggested that the exercises could initially be taught in practice, but then carried out at home.  On the other hand, some coaches thought they could find time in practice, while one coach suggested having the athletes arrive to practice 5-10 minutes early to complete the exercises.

The feedback suggests that a combined approach could most benefit the coaches and athletes. The exercises can be initially taught at practice, to ensure athletes know how to perform the exercises. Then, the exercises can be continued at home, possibly with the edition of a participation log in order to increase adherence.  In the future, I would revise the brochure to emphasize this combined structuring of the exercises.

Overall, this capstone project allowed me to gain knowledgeable insight into PFPS and specific hip strengthening interventions that can have a profound impact on the prevention and management of PFPS. Further, my research resulted in a comprehensive yet concise educational brochure that effectively educated coaches on PFPS and a strengthening program to prevent PFPS. I hope this brochure can be used in the future to further educate coaches—and even parents and players—on this common, yet often overlooked, knee condition. Further, I hope they will use this brochure as a tool to not only help prevent PFPS and lower extremity injuries, but as a way to play an active role in their health and well-being.

A Special Thanks:

Thank you for taking the time to visit my capstone page. Thank you to my adviser, Mike Gross, and to my committee members, Shubhra Tyagi and Kristin Shelton, for your valuable insight and time, and for helping me to turn my passions and interests into a valuable tool to share with others.

References:

1. Quatman-Yates CC, Myer GD, Ford KR, Hewett TE. A longitudinal evaluation of maturational effects on lower extremity strength in female adolescent athletes. Pediatr Phys Ther. 2013. Accessed 6/4/2013 7:58:45 PM; 6/4/2013 7:58:45 PM. doi: 10.1097/PEP.0b013e31828e1e9d.
2. Barber Foss KD, Myer GD, Chen SS, Hewett TE. Expected prevalence from the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening. J Athl Train. 2012;47(5):519-524. doi: 10.4085/1062-6050-47.5.01; 10.4085/1062-6050-47.5.01.
3. Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Factors associated with patellofemoral pain syndrome: A systematic review. Br J Sports Med. 2013;47(4):193-206. doi: 10.1136/bjsports-2011-090369; 10.1136/bjsports-2011-090369.
4. Powers CM, Bolgla LA, Callaghan MJ, Collins N, Sheehan FT. Patellofemoral pain: Proximal, distal, and local factors, 2nd international research retreat. J Orthop Sports Phys Ther. 2012;42(6):A1-54. doi: 10.2519/jospt.2012.0301; 10.2519/jospt.2012.0301.
5. Waryasz GR, McDermott AY. Patellofemoral pain syndrome (PFPS): A systematic review of anatomy and potential risk factors. Dyn Med. 2008;7:9-5918-7-9. doi: 10.1186/1476-5918-7-9; 10.1186/1476-5918-7-9.
6. Khayambashi K, Fallah A, Movahedi A, Bagwell J, Powers C. Posterolateral hip muscle strengthening verses quadriceps strengthening for patellofemoral pain: A comparative control trial. Arch Phys Med Rehabil. 2014. doi: 10.1016/j.apmr.2013.12.022; 10.1016/j.apmr.2013.12.022.