RESEARCH ARTICLE http://dx.doi.org/10.17784/mtprehabjournal.2016.14.408
Correlation between anterior knee pain with flexibility muscles hip Natália Faria Borges1, Beatriz Santana Borges2, Eliane Gouveia de Morais Sanchez3, Hugo Machado Sanchez3
Introduction: The patellofemoral pain syndrome (PFPS) is one of the most common affections of the knee joints that has as one of its main functions the human locomotion, while the hip is the largest spherical joint of the human body. Objective: To know the correlation of anterior knee pain with hip flexibility and range of motion (ROM) in female academics. Method: A cross-sectional descriptive study was carried out with a population composed by 40 academics, divided into 2 groups of equal size, one composed by volunteers with PFPS and the other without the syndrome. The volunteers were aged between 18 and 30 years. For flexibility and ROM evaluation was used a fleximeter and a universal goniometer, respectively. Results: After statistical analysis, it was verified that the ROM of the hip abduction was decreased in the PFPS group, probably due to the retraction of the adductor muscles of the hip, or even by the loss of the muscular strength of them. With regard to flexibility, hip flexor muscles were retracted, with a significant difference comparing the group with pain and the group without anterior knee pain. Conclusion: It was shown that there are muscle changes related to flexibility and ROM in the flexor and hip abductor groups, respectively, in the volunteers with presence of Patellofemoral Pain Syndrome. Keywords: Femoropatellar pain; Hip; Knee; Flexibility; Range of motion.
INTRODUCTION The knee is a loading joint with a large range of motion, located in the central portion of the lower limb, and is subject to a large number of pathologies, mainly mechanical, despite its static stabilizers (meniscus, ligaments and capsule) and dynamic stabilizers (muscles and tendons).(1) Because it is an intermediate joint of the lower limb, changes in the hip muscles can generate imbalances in the knee, since these are inserted close to this joint, and perform important functions related to both movement and stabilization.(2) The hip is the largest spherical joint of the human body. The head of the femur, the end of the long bone of the thigh, fits into the acetabular cavity of the pelvic bone. It is, therefore, a large joint adapted to support the weight of the body, distribute the efforts and allow the movements of flexion, extension and rotations of the lower limbs. Thus, when all these structures function correctly, the movement in the hip is made, without being noticed, and mainly, without pain. This occurs because the contact is made in the cartilage, which does not present innervation.(3) The anterior knee pain, also known as Patellofemoral Pain Syndrome (PFPS), is characterized by a general non-specific pain present diffusely, with possibility of irradiation to the popliteal region.(5) Its onset is usually insidious, and may increase when walking up and down stairs, during physical
activity, maintenance for prolonged period of knee flexion and a squat position, and may be accompanied by pseudoblocks and increased of the Q angle.(6) The SDPF Affects mainly young adults and female athletes, being these more susceptible when compared to male athletes practicing the same sports modalities. The most common symptoms are pain, crepitation, fissures and joint blockages.(7) The patellofemoral pain syndrome, which accounts for 25% of all sports-related knee injuries, is of multifactorial origin, resulting from a combination of variables that include abnormal biomechanics of the lower limbs, soft tissue tightness, muscle weakness and excessive exercise.(8) Among the factors predisposing to PFPS, can be mentioned: femoral anteversion, weakness or atrophy of the vastus medialis oblique muscle, increased Q angle, valgus knee, external tibial torsion, subtalar hyperpronation, trochlear dysplasia, the high patella, the rigidity of the iliotibial tract and the weakness of the abductor muscles and lateral rotators of the hip.(9) The adduction and medial rotation of the femur during functional activities produce an increase in the angle Q, which generates an overpressure in the lateral aspect of the patellofemoral joint, leading to patellofemoral pain.(10)
Corresponding Author: Name: Hugo Machado Sanchez. Address: Rua Um, Q. 2, Lt9. E-mail: [email protected]
Telephone: +55 (62) 81228136 3
Professor, Universidade de Rio Verde (UNIRV), Rio Verde (GO), Brazil.
Full list of author information is available at the end of the article.
Financial support: The authors declare that there was no financial support. Submission date 9 October 2016; Acceptance date 15 December 2016; Publication date 27 December 2016 Manual Therapy, Posturology & Rehabilitation Journal. ISSN 2236-5435. Copyright © 2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted noncommercial use, distribution, and reproduction in any medium provided article is properly cited.
Anterior knee pain and flexibility muscles hip
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The diagnosis of a patient with patellofemoral pain requires a thorough physical examination based on a complete history. The nature of the injury and specific physical findings, including a detailed examination of the retinacular structure around the patella, identified more accurately the specific source of anterior knee pain or instability. Radiographs should include a standard 30 degree to 45 degree axial view of the patella and a precise lateral radiograph.(11) Conservative treatment leads to relief of symptoms in most patients and generally includes strengthening exercises (with emphasis on the vastus medialis oblique muscle, one of the vastus medialis portions), muscle stretching, motor control, therapeutic modalities, and anti-inflammatory use(12); however, there is no objective data to determine the best conservative approach to this syndrome, since the quadriceps femoral muscle strengthening performed on an open and a closed kinetic chain are considerably different.(13) Therefore, the current study aimed to correlate anterior knee pain with flexibility and range of motion of the hip in female academics.
or hip surgeries, pregnant women, and persons with a body mass index above 40. The data collection was done only after acceptance and signing of the Informed Consent Term clarifying doubts that may arise about the evaluation to be applied. Data collection was performed by the researchers, after training, through the goniometer, which is an instrument used to quantify the amplitude of the angles formed by the joints in several movements, and through the fleximeter, equipment that was used to assess flexibility, providing the values in degrees. The goniometric evaluation was performed by two evaluators, one responsible for reading the goniometer and another responsible for stabilizing the hip joint, and the goniometer reading was expressed in degrees. The evaluator responsible for reading placed the goniometer at the recommended test position and followed the movement of the joint to the maximum amplitude reached by the evaluated and, at the end of the movement, read the instrument, which was recorded in an individual file. The goniometry of the hip flexion movement is made in the dorsal decubitus position with the knee flexed, the goniometer arm was in the medial line of the trunk, the movable arm on the lateral surface of the thigh, the axis at the greater trochanter level, and the movement was moving the leg toward the trunk, being normal angle from 0 to 125º.(14) The hip extension movement is made in the ventral decubitus with the knee extended, the fixed arm in the median line of the trunk, the movable arm in the lateral part of the thigh, the axis at the greater trochanter level, making a movement to raise the maximum of the leg, being normal angle from 0 to 10º. The abduction movement of the hip is made in dorsal decubitus with extended knee, fixed arm on the line drawn between the antero-superior iliac spine (ASIS), movable arm on the anterior region of the thigh, axis on ASIS, doing abduction movement, being normal angle from 0 to 45º. The adduction movement of the hip is made in dorsal decubitus with extended knee in the leg that was not test in abduction, fixed arm on the line drawn between the ASIS, movable arm on the anterior thigh, axis on the ASIS, approaching the leg tested from the other, being normal angle from 0 to 15º. The internal rotation of the hip is made with the individual sitting with the legs hanging, fixed arm in the anterior midline of the tibia, movable arm in the anterior midline of the tibia, axis in the anterior face of the patella, making the movement of the leg to the outside, being normal angle from 0 to 45º. The external rotation of the hip is made with the individual sitting with the legs hanging, fixed arm in the anterior midline of the tibia, movable arm in the anterior midline of the tibia, axis in the anterior face of the patella, making the movement of the leg to the inside, being normal angle from 0 to 45º. For flexibility assessment, using the fleximeter, the hip extension movement was performed with the individual in the
METHODS This is a descriptive cross-sectional study. According to the Resolution 466/12 of the National Health Council of the Ministry of Health, this project was approved by the Research Ethics Committee of the “Universidade de Rio Verde – UniRV” and the identity of the people evaluated was not disclosed at all, but only the data obtained. The information collected through the evaluation was archived with the researchers. The research was conducted at the Clinical School of Physiotherapy of the UniRV (Universidade de Rio Verde), located in the city of Rio Verde – Goiás, and had duration of 20 minutes for evaluation of each volunteer, and the stipulated time was 14h 40minutes. The suit worn by them was gym clothes. The population of this study was composed of 40 academics of the UniRV, aged between 18 and 30 years, divided into two groups of equal size, being composed of academics with PFPS (group with pain), diagnosed by special tests performed by qualified professionals, and the other group by academics without PFPS (group without pain). Inclusion criteria were female between 18 and 30 years old, university students who accepted to participate in the study, with PFPS constant over 3 months (confirmed by the positivity of the femur-patellar compression test and the Femur-patellar friction), practicing physical activity and signed the free and informed consent form. On the other hand, the exclusion criteria were academic who are not enrolled in the Physiotherapy course of the UniRV or who did not accept to participate in the study, with age under 18 years or above 30 years, sedentary, volunteer who had other associated lesions such as ligaments, meniscal or osteomioarticular injuries, volunteers who underwent knee 2
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ventral decubitus, making the hip extension movement with the knee extended, stabilizing the pelvis and the fleximeter was fixed on the lateral face of the distal part of the thigh, being the normal angle from 0 to 10º.(15) The hip flexion movement was performed with the individual in the ventral decubitus, making the hip flexion movement with the knee Of the leg tested and the fleximeter was fixed on the lateral face of the distal part of the thigh, being the normal angle from 0 to 125º. The abduction movement was in lateral decubitus with the leg to be tested facing upwards, and the individual made the abduction movement, and the fleximeter was fixed on the posterior face of the distal part of the thigh, being the angle from 0 to 45º. The adduction movement was in lateral decubitus and the evaluated member was upward, and the individual made the adduction movement with the evaluated leg jumping out of the stretcher, and the fleximeter was fixed on the posterior face of the distal part of the thigh, being the normal angle from 0 to 15º. The internal rotation of the hip was made with the individual seated on the stretcher, with the segment to be measured extended, and made the internal rotation movement with the foot, and the fleximeter was positioned on the sole of the foot, being the normal angle from 0 to 45º. The external rotation of the hip was made with the individual seated on the stretcher, with the segment to be measured extended, and made the external movement with the foot, and the fleximeter was positioned on the sole of the foot, being the normal angle from 0 to 45º. The quantitative data were organized and analyzed for frequency of occurrence and the results were presented through graphs and tables, using the data tabulation program. Student t test was used to compare ROM values and hip flexibility between groups. The program used for the calculation was the SPSS 22.0 and were considered significant values of p