Gluteal Considerations for Patellofemoral Pain

Original Editor - Jacquie Kieck based on the course by Claire Robertson
Top Contributors - Jacquie Kieck, Wanda van Niekerk, Jess Bell, Kim Jackson and Tarina van der Stockt

Introduction

Patella malalignment is influenced not only by the patella, but also by the position of the femur and trochlear. The position of the femur and trochlear is altered by the gluteal muscles. Thus, it is necessary to assess the gluteal muscles when considering patellofemoral pain. The clinician should be cognisant that the assessment of the gluteal muscles in patellofemoral pain is not performed in isolation. Patellofemoral pain should be assessed holistically and consider various factors, including local factors around the knee, the whole limb assessment and psychosocial factors, such as fear of movement and pain catastrophisation.

Why Do We Need to Consider Each Muscle?

Understanding the gluteal muscles' function in each plane of movement is imperative for accurately assessing the performance of this muscle group and its influence on patellofemoral pain. When the clinician can specifically identify the plane of movement in which the dysfunction occurs, as well as isolate the problematic structure, targeted rehabilitation exercises can be prescribed.

Functional Role of the Gluteal Muscles

Gluteus Medius as an Abductor in the Frontal Plane

Gluteus medius acts as an abductor of the hip in the frontal plane. Poor hip abduction control in a single-stance, weight-bearing position leads to contralateral pelvis drop. In this scenario, the weight-bearing limb essentially falls into adduction, causing a functional valgus at the knee. This in turn creates greater load on the lateral patellofemoral joint (PFJ).

Chart illustrating the impact of poor gluteus medius control on patellofemoral pain.

Gluteus medius is assessed in the frontal plane by performing hip abduction against resistance. During the test, it is recommended that resistance against hip abduction is maintained for 10 seconds. By sustaining the resistance applied to the muscle, the tonic performance of the muscle can be assessed rather than the phasic performance (phasic performance is tested in the first couple of seconds of holding a position against resistance). This is important because gluteus medius should act as a postural endurance muscle to stabilise the pelvis. To recap muscle fibre types; type 1 muscle fibres produce low power contractions over longer periods and are slow to fatigue (tonic muscle performance), type 2 muscle fibres have fast contractions and can fatigue more quickly (phasic muscle performance).

Gluteus medius can also be assessed in a weight-bearing position. The assessor looks at the ability of the client to control their pelvis as they perform a contralateral hip drop when standing on a step. This position allows for the concentric and eccentric assessment of the gluteus medius. This position is also effective for strengthening this muscle.

Gluteus Medius as an External Rotator in the Horizontal Plane

The posterior fibres of gluteus medius are active as the primary external rotator of the hip at 0º to 20º of hip flexion. From 20º to 50º of hip flexion, the posterior fibres of gluteus medius are still active. Above 50º of hip flexion, gluteus maximus is the primary external rotator. To test gluteus medius, resistance must be given against hip external rotation when the hip is in 0º to 20º of flexion.

Hip Flexion	0º - 20º	20º - 50º	>50º
Primary external rotator of the hip	Gluteus medius	Gluteus medius is still active	Gluteus maximus

Gluteus Maximus as an External Rotator in the Horizontal Plane

Gluteus maximus externally rotates the hip when the hip is flexed. Testing of the gluteus maximus should be performed by providing resistance against external rotation of the hip when it is flexed. It is recommended to sustain the hold against external rotation in this position for ten seconds to test the tonic action of the muscle.

Rehabilitation Exercises

Gluteus Medius in the Frontal Plane (Hip Abduction)

Below are some examples of hip abduction rehabilitation exercises:

• 

  Hip Abduction in Standing

• 

  Hip Abduction Against Resistance in Standing

• 

  Hip Abduction in Sidelying

Gluteus Medius in the Horizontal Plane (Hip Lateral Rotation at <20º of Hip Flexion)

See below examples of hip lateral rotation at <20° of hip flexion rehabilitation exercises:

• 

  External Rotation of the Hip in Standing

• 

  External Rotation of the Hip in Shallow Hip Flexion

Gluteus Maximus in the Horizontal Plane (Hip External Rotation at >50º of Hip Flexion)

See the examples below for hip external rotation at >50° of hip flexion:

• 

  External Rotation of the Hip in 90º Hip Flexion

• 

  External Rotation of the Hip in 90º Hip Flexion/Sitting

Consider the Bridge Exercise

At the beginning of the bridge exercise, the hip is in deep hip flexion. This means that the gluteus maximus is most active as an external rotator of the hip. As the hip moves out of hip flexion into a more neutral position, gluteus maximus continues to work as a hip extensor, but the posterior fibres of gluteus medius become more prominent as a rotator.

Progressions of the bridge exercise to make it more challenging, include lifting the unaffected leg (i.e. perform a one-legged bridge) and adding a weight placed on the person's abdomen.

Functional Role with Different Activities

Gait

During gait, gluteus maximus works eccentrically to control rotation at the hip. After heel strike, to around 24% into weight bearing, the femur and the tibia internally rotate. This is an expected movement. However, this internal rotation should only occur for a short period. Excessive internal rotation ultimately results in excessive loading of the lateral patellofemoral joint. Mirror gait retraining can increase patient awareness of this movement and facilitate correction of faulty biomechanics.

Running

Increased running speed is associated with increased movement in the frontal plane i.e. contralateral pelvis drop with corresponding hip adduction and resultant knee valgus. This increases the load on the lateral patellofemoral joint. Bramah et al. demonstrated that for every 1° increase in pelvic drop during running, there was an 80% increase in the likelihood of being classified as injured. The same study by Bramah et al. showed that contralateral pelvis drop appeared to be the most strongly related variable to common running-related injuries, including patellofemoral pain.

Video: Excessive hip adduction

When rehabilitating a patient with patellofemoral pain where lack of control in the frontal plane is a contributing factor, it is useful to consider running speed. The clinician can suggest reducing running speed to offload / reduce load on the patellofemoral joint as an alternative to stopping sport altogether. In team sports, a change of position on the court / field to a position where the patient will not be required to run as fast can be helpful.

Landing From a Jump

It has been shown that jump-landing kinematics are affected by lower limb injuries, including patellofemoral pain. They are also affected by gluteal muscle strength, which influences dynamic knee valgus. Similarly, a systematic review and meta-analysis by DeBleecker et al. showed some evidence for the association of impaired jump-landing kinematics and lower extremity overuse injuries. This indicates that patellofemoral pain influences jump-landing kinematics, and that jump-landing kinematics is influenced by patellofemoral pain. Hence, it is important to assess jump-landing kinematics as a prevention strategy for lower extremity injuries, and to assess jump-landing kinematics in a person experiencing a lower extremity injury. For clients with patellofemoral pain who participate in sports that require jumping, it is important to assess the jump-landing kinematics to identify poor gluteal control as a possible contributing factor. Psychosocial factors such as kinesiophobia should also be considered when assessing landing from a jump.

Muscle Inhibition

A history of low back pain or ankle injuries have been shown to influence gluteal function. Low back pain can inhibit gluteus maximus, and ankle inversion injuries are related to gluteus medius inhibition. Because the relevance of the gluteal muscles in patellofemoral joint pain has been clearly established, it is important to establish if the patient presenting with patellofemoral pain has a history of low back pain or ankle injury.