Muscle Length Assessment and Treatment Related to Patellofemoral Pain: Difference between revisions

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== Introduction ==
Patellofemoral pain often results from cumulative load. It reveals itself with prolonged and or repetitive activity or holding of a certain position. Subtle changes in load can add up over time to create a large load.<ref name=":0" /> Thorough assessment and the subjective interview will provide clues to causative factors of the patient's patellofemoral pain. 


== Introduction ==
For a review of the gait cycle, please read [[Gait#The Gait Cycle|this article]].
I want to chat to you about muscle length with respect to patellofemoral pain. So, we're going to work our way through different lower limb muscle groups and we're going to look at, biomechanically, why is it relevant for each one that we assess it? How should we assess and test for the muscle length? And ultimately, what we can do to treat.  


And often, I like to think about patellofemoral pain as a cumulative load. So, it's okay for a few steps, but what if you walk for a mile or run for five kilometres? What happens accumulatively? And so, these subtle changes in load can add up accumulatively to quite a lot more load.
== Hamstrings ==
[[File:Hip-hamstring-hamstrings-semi-membranosis-biceps-femoris-semitendinosus-tuber-ischiadicum-back-skin-names.png|Hamstrings in situ.  Note their relationship with the knee.|alt=|thumb]]
'''Why is it mechanically relevant to assess this muscle?'''


So, I want to be clear. There's nowhere near as much literature underpinning the flexibility work as there would be for quadriceps or hip strength, for example. But there is some, and I think what we can do is we can look at our basic principles of anatomy, biomechanics, exercise, physiology. We can look at what we know about changes in tone; we can look at the evidence, some of my work that is showing changes in the muscle architecture; and we can listen to the patient's narrative. So, if they're talking about cramping, tight muscles, or if they're getting pain in passive positions, there are big clues there aren't there that the muscle length really might be as issue?
* Tight, tense, and shortened hamstrings can pull the knee into excessive knee flexion. During the gait cycle, this can result in a greater knee flexion moment at initial contact or heel strike.
* Any resulting increase in knee flexion will increase patellofemoral contact pressures. Therefore, it is important to avoid the situation where the tibia is being pulled back and there is enhanced knee flexion.<ref name=":0">Robertson, C. Patellofemoral Joint Programme. Muscle Length Assessment and Treatment Related to Patellofemoral Pain. Physioplus. 2022.</ref>


So, do I give out flexibility work for all my patellofemoral pain suffers? No, but do I give out stretching regularly? Yes. So, it's back to listening to the narrative, clinically reasoning, thinking it through and really trying to come up with something that's very bespoke for the patient.


For a review of the gait cycle, please read [[Gait#The Gait Cycle|this article]].
'''How should we assess and test for muscle length?'''


== Hamstrings ==
* It is important to assess hamstring length in conjunction with stride length
'''Why is it mechanically relevant to assess?'''
* Bedside clinical exams: [[Sit and Reach Test|sit-and-reach]], [[Straight Leg Raise Test|straight leg raise]]
* It is important to assess and compare the muscle length of both hamstrings. The rehabilitation professional should also take the patient's relative flexibility into consideration, ie: is this patient's body flexible overall or tight. This will help determine the patient's muscle length norm.
* Other muscle groups to assess: [[Gluteal Muscles|gluteal extensors]]
* Clues from the patient interview or past medical history: a patient may state that they stretch regularly but have not noticed any change in their flexibility; a history of repeated injury to a muscle group might mean that it has more scarring in the intramuscular matter; having regular repeating injuries.<ref name=":0" />


* Tight, tense, and shortened hamstrings can pull the knee into excessive knee flexion.  This can result in a greater knee flexion moment at initial contact or heel strike part of the gait cycle.<ref name=":0">Robertson, C. Patellofemoral Joint Programme. Muscle Length Assessment and Treatment Related to Patellofemoral Pain. Physioplus. 2022.</ref> 
* Any resulting increase in knee flexion will increase the patellofemoral contact pressures.  Therefore it is important to avoid the situation where the tibia is being pulled back and there is enhanced knee flexion.<ref name=":0" />


'''How should we assess and test for the muscle length?'''
'''What treatments can we offer?'''


* It is important to assess hamstring length in conjunction with stride length
* The literature gives little insight into the duration or frequency of stretching.<ref name=":0" />
* Bedside clinical exams: [[Sit and Reach Test|sit-and-reach]], [[Straight Leg Raise Test|straight leg raise]] 
* Consistent, regular stretching that the patient will be able to complete is key. Find out about the patient's schedule and lifestyle and help them create an exercise programme they will be able to stick to and faithfully perform. Create easy, pragmatic exercises the patient will most likely complete.<ref name=":0" />
* It is important to assess and compare the muscle length of both hamstrings. The rehabilitation professional should also take the patient's relative flexibility into consideration, ie: is this patient's body overall flexible or tight. This will help determine the patient's muscle length norm.  
* Types of hamstring stretches: (1) standing static stretch, (2) dynamic stretching, (3) hold-relax (also known as contract-relax).
* Other muscle groups to assess: gluteal extensors
* There is some literature supporting that dynamic stretching is slightly more effective.<ref name=":0" /> In patients with inflexible hamstrings, dynamic hamstring stretching improved muscle activation time and clinical outcomes compared with static hamstring stretching, when both were combined with strengthening exercises.<ref>Lee JH, Jang KM, Kim E, Rhim HC, Kim HD. [https://scholar.google.com/scholar?output=instlink&q=info:DdpWGc-dxd8J:scholar.google.com/&hl=en&as_sdt=0,44&scillfp=2077570342394376331&oi=lle Effects of static and dynamic stretching with strengthening exercises in patients with patellofemoral pain who have inflexible hamstrings: a randomized controlled trial]. Sports health. 2021 Jan;13(1):49-56.</ref>  Hold-relax stretching tends to decrease muscle tone which allows the stretch to be deepened. However, it is important to create an exercise programme that is best suited for the patient.<ref name=":0" />
* Clues from the patient interview or past medical history: a patient may state that they stretch regularly but have not noticed any change in their flexibility, histories of repeated injury to a muscle group might mean that it's got more scarring in the intramuscular matter, having regular repeating injuries.  


'''What can we do to treat?'''
<div class="row"> 
<div class="col-md-6">[[File:Hamstring Stretch on Chair.jpeg|thumb|Standing static stretch|alt=|center|500x500px]]</div>
<div class="col-md-6"> [[File:Hamstring Hold-Relax.jpeg|thumb|Hold-relax (contract-relax) stretch|alt=|center]]</div>
</div>


* The literature gives little insight to the duration or frequency of stretching
* Consistent, regular stretching that the patient will be able to complete is key.  Talk about the patient's schedule and lifestyle and help them create an exercise programme they will be able to stick to and faithfully perform. Create easy, pragmatic exercises the patient will most likely complete.
* Types of hamstring stretches: (1) standing static stretch, (2) dynamic stretching, (3) hold-relax (also known as contract-relax).
* There is some literature support that dynamic stretching is slightly more effective.  Hold-relax stretching tends to decrease muscle tone which allows the stretch to be deepened.  However, it is important to create a n exercise programme that is best suited for the patient. 




To learn more about the types of stretches and how stretching effects muscle anatomy and physiology, please read [[Stretching|this article]].
To learn more about the types of stretches and how stretching effects muscle anatomy and physiology, please read [[Stretching|this article]].  For demonstrations of various methods of hamstring stretching, please view the optional video in the additional resources section at the bottom of this page.


== Quadriceps ==
== Quadriceps ==
'''Why is it mechanically relevant to assess?'''  
[[File:Quadriceps muscle.jpg|thumb|Quadriceps in situ.  Please note their relationship with the patella and hip adductors.|alt=]]
'''Why is it mechanically relevant to assess this muscle?'''
 
* Look for clues in the patient's subjective interview and past medical history.
* If the patient reports knee pain with prolonged sitting (i.e. with the knee flexed), it is important to rule out: (1) quadriceps strength issues, (2) gluteal strength issues, (3) foot posture issues, (4) load issues when considering quadriceps length issues.
 
* So, when we sit for a prolonged period with tight quadriceps, we have a large compressive vector through our patellofemoral joint. This might be tolerated for a short while, but after a while the pressure in the subchondral bone can keep increasing. Eventually, the individual reaches a point where the only way they can alleviate that pressure pain is to straighten out their leg.<ref name=":0" />
 
 
'''How should we assess and test for muscle length?'''
 
* Bedside clinical exams: modified [[Thomas Test]]. 
** If the patient has some quadriceps tightness, the knee will maintain 45-60 degrees of knee flexion. This signals that the knee is hanging on quadriceps tension. And when they are passively moved to 90 degrees of knee flexion, the examiner can feel the level of resistance in the muscle.
** During this test test, if when the knee is flexed, the hip comes into more flexion, part of the tightness is from [[Rectus Femoris|rectus femoris;]] if the hip does not flex, then there is more tightness in the vastii muscles.
 
* Cinema Sign (also known as Theatre sign, Movie-goers sign, Movie sign): Pain in the knee results from compression in the patellofemoral joint caused by tight quadriceps with prolonged sitting in knee flexion.<ref name=":0" />
 
 
'''What treatments can we offer?'''
 
* Stretching of the quadriceps is needed, but may need to be modified based on the patient's level of tightness. 
** If the patient is currently experiencing a sore patellofemoral joint, performing a classic standing quadriceps stretch will most likely exacerbate their pain. This stretch can be modified by standing with their foot supported on a chair behind them. The following verbal cues are provided: "stand tall and imagine a helium balloon attached to your breastbone, pulling you up."<ref name=":0" />
** If the patient's knee is not irritated by this stretch, they can perform a hold-relax (contract-relax) in the same modified position described above. Ask them to push the foot down into the chair and perform an isometric hold for 10 seconds.<ref name=":0" />


Now, let's think about quadriceps. So, there might be some clues here in their history that quadriceps flexibility is an issue and my talk on subjective examination looks at this. So, tying in with that, what are they like when they sit still with their knee flexed? If that is a problem to them, there's no muscle strength issues either at rest, no gluteal strength issues at rest, no foot posture issues really at rest, no load issues. So, lots of the things that we would typically look at are an irrelevance, but if sitting still is painful for them, then we need to think about quadriceps length.  
* The patient can also attempt flexibility gains with eccentric exercise. However, patients with patellofemoral pain often will not tolerate exercises that take them eccentrically to end range.<ref name=":0" />
* There is a small amount of emerging evidence looking at dry needling to trigger points in the vastii muscles as being preferential to sham needling for patellofemoral pain management. A 2020 study by Ma et al.<ref>Ma YT, Li LH, Han Q, Wang XL, Jia PY, Huang QM, Zheng YJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354013/ Effects of trigger point dry needling on neuromuscular performance and pain of individuals affected by patellofemoral pain: a randomized controlled trial]. Journal of Pain Research. 2020;13:1677.</ref> found that dry needling of the quadriceps, when combined with stretching can reduce pain, improve function, and the coordination of the vastus medialis oblique (VMO) and vastus lateralis (VL) in patients with patellofemoral pain syndrome.
* Foam rolling<ref name=":0" />


'''How should we assess and test for the muscle length?'''
<div class="row"> 
<div class="col-md-6">[[File:Quadriceps Stretch with Chair.jpeg|none|thumb|Standing modified quadriceps stretch]]</div>
<div class="col-md-6">[[File:Quadriceps Stretch.png|thumb|alt=|center|416x416px|Standing classic quadriceps stretch]]</div>
</div>


So, when we sit for a prolonged period with tight quads, we have a large compressive vector through our patellofemoral joint, which might be tolerated for a short while, but after a while that pressure in the subchondral bone can go up and up and up and they get to the point where the only way they can alleviate that pressure pain is to straighten out their leg. So, if we are suspicious that the quadriceps length is an issue, then what are we going to do? Well, we need to objectify that, we need to assess it. And I have a big fan of the modified Thomas test. I think it's a really useful, easy-to-do assessment that doesn't take long, it doesn't need equipment, and yet is very revealing. And in some instances, the patients will say, that's my pain when you go into that position, or certainly when you passively flex the knee. And just to remind you, if you flex the knee and the hip comes into more flexion, that's reminding you that part of the tightness is rectus femoris. If the hip does not flex, then it's more tightness in the vastii. So, if we've got some quadriceps tightness, the knee won't just hang at 90 degrees with gravity. It will hang out around about 45, 50, 60 degrees. So, it's hanging on that tension. And often when you take them passively to 90 degrees, you can really feel the level of resistance there. And of course, when they then sit at 90 degrees, that's what they're facing. They're facing that level of resistance and that level of compression through their patellofemoral joint. And for some patients, you know, cinema sign is one of the worst problems. You know, they dread long journeys, dread going to the cinema or theatre because sitting still with their knee flexed is just too difficult to cope with.


'''What can we do to treat?'''
'''What does the literature say?'''


So, it's important to assess this quadriceps tightness. And if we find it, there is inherently a little dilemma immediately. If I ask someone with a sore patellofemoral joint to do a classic quad stretch, take their foot to their bottom a couple of times a day, guess what will probably happen to their patellofemoral pain? It will probably get a bit worse. They won't like the treatment. But if they are that tight, they don't need to go into that much knee flexion. So, what I get them to do is I get them to stand with a chair behind them, pop their foot on the chair, and stand tall and I say, "imagine a helium balloon attached to your breastbone, pulling you up". And that change in posture tends to bring the pelvis forwards and tension up the quads and that usually is enough, but it won't aggravate their knee. So, it's quite a useful little trick. If they're not irritable, you can also do hold-relax by getting them to push the foot down into the chair and try and use that as the isometric hold for 10 seconds.
* Bethel et al.<ref name=":1" /> studied the effects of a 7-week stretching programme on healthy adults. They found that completing three sets of a three-stretch programme, three times per week created a significant decrease in the muscle fibre angle in both the VMO and the VL.<ref name=":1">Bethel J, Killingback A, Robertson C, Adds PJ. [https://www.jstage.jst.go.jp/article/jpts/34/2/34_2021-158/_pdf The effect of stretching exercises on the fibre angle of the vastus lateralis and vastus medialis oblique: an ultrasound study.] Journal of Physical Therapy Science. 2022;34(2):161-6.</ref> To learn more about changing the muscle architecture of the quadriceps, please read [[Effective Quadriceps Training in Patellofemoral Pain#Quadriceps and patellar control|this article]].
* Torrente et al.<ref name=":2" /> looked at the effects of self myofascial release using a foam roller on hypertrophy of the quadriceps. The study found that a 7-week programme of self myofascial release resulted in a statistically significant decrease in the pennation angles of both the VMO and VL in healthy adult males.<ref name=":2">Torrente QM, Killingback A, Robertson C, Adds PJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9159710/ The effect of self-myofascial release on the pennation angle of the vastus medialis oblique and the vastus lateralis in athletic male individuals: an ultrasound investigation]. International Journal of Sports Physical Therapy. 2022;17(4):636.</ref>
== Iliotibial Band  ==
'''Why is it mechanically relevant to assess this structure?'''


Okay. We can also look at flexibility gains with eccentric exercise. But as much as the literature helps us understand that, the pragmatics I find are that the patients won't tolerate those type of exercises that take them eccentrically to end of range. So, for me, I tend to be looking more to static stretching, possibly dynamic stretching, hold-relax.
The iliotibial band (ITB) can be a controversial anatomical structure. It is very strong and thick, and it is not capable of changing length.<ref name=":0" /> <blockquote>"Gratz investigated the tensile properties of human TFL muscle and found similarities with those of “soft steel”, based on its tendon-like histologic structure comprised of an inconspicuous number of elastic fibres."<ref>Seeber GH, Wilhelm MP, Sizer Jr PS, Guthikonda A, Matthijs A, Matthijs OC, Lazovic D, Brismée JM, Gilbert KK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296993/ The tensile behaviours OF the iliotibial band–a cadaveric investigation]. International journal of sports physical therapy. 2020 May;15(3):451.</ref></blockquote>
[[File:Iliotibial tract.jpg|thumb|The Iliotibial band in situ.  Please note the relationship between the tensor fascia lata and the gluteus maximus.]]
The origins of the ITB are contractile: the [[Tensor Fascia Lata|tensor fascia lata]] (TFL) and the [[Gluteus Maximus|gluteus maximus]]. If there is muscle tension or hypertrophy causing a shortening of the soft tissue structures, then it is going to proximate the ITB. This can cause two issues which can irritate the patellofemoral joint: (1) it can cause a lateral tilt of the patella and (2) through its tibial attachment beyond about 60 degrees of knee flexion, it can externally rotate the tibia. This ultimately will create a functional knee valgus moment, a large [[Q Angle|Q-angle]], which can overload the lateral patellofemoral joint.<ref name=":0" />


A couple of other things too. There is some small amount of emerging evidence looking at dry needling to trigger points in the vastii as being preferential to sham needling. And also, we can look at foam rolling, and I've just finished a study recently, well I've done two studies, one's been published, one has just been accepted to be published. So, the first one looked at the architecture change on the vastus lateralis after a programme of static stretching. So, I looked at the architecture with the VMO, with respect to getting the VMO stronger, and we found that the stronger people got, the more angle, the bigger the angle of pennation, the fibre relative to the femoral axis, their fibre came down and we got that nice horizontal fibre insertion onto the patella.
* The patient may reveal that, in addition to their patellofemoral pain, they have some pain at the side of their pelvis when walking. This may indicate that they have a tight and overactive TFL as well.
* They may have a positive cinema sign, but it is more enhanced when their legs are crossed.<ref name=":0" />


Conversely, those people, particularly those who started with a tight, bulky vastus lateralis, after a programme of stretching, they had a more vertical fibre orientation. So, smaller angle. So, that was a great finding because intuitively that fitted with what I was seeing in my clinical practice. So, those people that come in with big, hypertrophied VL, like the cyclists sometimes we see, who you feed instinctively you want to get your hands on, that feels tight, tense, you want to stretch them out, they did well with stretching. And we replicated this study with foam rolling and found the same results. So, there is an anatomical, physiological underpinning for what is going on here with our stretching and our rolling. We need to choose our candidates carefully to make sure we're effective and we need to choose how, in particular, we're stretching, we are doing that.


== Iliotibial Band ==
'''How should we assess and test for muscle length?'''
'''Why is it mechanically relevant to assess?'''


So, let's move on now to thinking about the ITB, very controversial anatomical structure. So, the ITB is, it's very strong and thick and it is not capable of changing length. Someone, Glen Hunter I think it was, did some work in the anatomy labs or bioengineering labs actually and found that it has the same tensile strength of steel. So, we're not stretching the ITB. Absolutely not. And having worked quite a bit in the dissection rooms and seeing the structure, it really is a very big, tough structure.
* Bedside clinical exams: [[Ober's Test|Obers test]] (however this can be a challenging position for patients to maintain and for the clinician to fully assess all needed angles).<ref name=":0" />


So, what are we doing? Well, don't forget higher up the chain, proximally it blends with muscles. So, its origins are contractile, and we've got tensor fascia lata and we've also got gluteus maximus. So, if there's tension, hypertrophy, shortening in those structures, then it's going to proximise the ITB. And that can do two things that are undesirable. The first thing is it can cause lateral tilt of the patella and the second thing is through its tibial attachment beyond about 60 degrees of knee flexion, it can externally rotate the tibia. And that's a problem because it brings round the attachments to quads and creates a functional valgus in other words, a big Q angle, which is going to overload the lateral patellofemoral joint and is clearly undesirable. So, we don't want tension in that top area.


'''How should we assess and test for the muscle length?'''  
'''What does the literature say?''' Kwan et al.<ref name=":3" /> looked at the relationship between hip adduction and patellar position as an alternative to the Obers test. Excessive hip adduction can lead to knee valgus and increased Q-angle which predisposes the patient to patellar displacement. This phenomenon is caused by the tightening of the ITB during hip adduction which places stress on the lateral retinaculum, and leads to lateral patellar movement. This study found that hip adduction consistently produced a smaller patella-condyle distance than the neutral position. This indicates a lateral patellar displacement which could increase the relative load on the lateral patellofemoral joint and cause pain. This study also demonstrated that ultrasound was a reliable assessment tool for patella displacement.<ref name=":3">Kwan LY, Killingback A, Robertson C, Adds P. [https://www.jstage.jst.go.jp/article/jpts/33/7/33_2020-222/_pdf Ultrasound investigation into the relationship between hip adduction and the patellofemoral joint]. Journal of Physical Therapy Science. 2021;33(7):511-6.</ref>


So, historically people have looked at the ITB using Obers but personally, I find particularly if I've got somebody bigger, particularly like a big male having them on their side, holding their leg, trying to manoeuvre them, and then I've run out of hands. I can't see their patella. I can't see their face adequately. I've always found it quite unsatisfactory actually and difficult to perform and not that helpful. So, I set about looking at supine hip adduction and we've just published this paper recently looking at ultrasound to measure the gap between the edge of the patella laterally and the femoral epicondyle, so the gap, and looking as you go into adduction at what happens to that gap and seeing the patellar tilt down. And, of course, in people who are tight proximally, that tilt is more aggressive and more enhanced. So, I put the patient in supine and get their other leg out the way off the plinth and block the pelvis and I just bring them into hip adduction and I'm looking how much change that creates at the patella. It will create a tiny bit of change on everyone but some people it's much more dramatic and in some patients, it will bring on their pain. So, then again, happy days, because then, you know, you've implicated proximal contractile structures in their patellofemoral pain picture.
''To perform this test'': with the patient in supine and legs in neutral, assess the initial tilt of the patella.  Move the leg to be tested into hip adduction and reassess the tilt of the patella.<ref name=":0" />


'''What can we do to treat?'''
* If the patellar tilt is driven purely by the retinaculum, it will not change much with hip adduction
* If the tilt is from the lateral structures also crossing the hip, then it will change dramatically with hip adduction<ref name=":0" />


So, what are we going to do for those? Well, we can do some release work with something like a spiky massage ball on, particularly on TFL. Leaning against the wall against that can be quite effective. We can look at some stretches. So, crossover stretch in standing. Looping the leg over in long sitting for gluteus maximus. And I will try both of those stretches because sometimes it becomes very apparent that one is really tight, and the other is fine. And I struggle to differentiate that out with my testing, so I find by just doing the stretches, it's as good as I need to reveal which of these structures really need the regular stretching work.


And it's very interesting the number of patients who as part of that dialogue will say, "Do you know, as well as having my patellofemoral pain, I do get some pain at the side of my pelvis when I'm walking". Those are the patients that really tight, overactive in their TFL as well. So, it's really important that we're looking at that and a little clue in their subjective might be that they get cinema sign, but it's much more enhanced when they cross their legs. So, when they cross their legs and they go into hip adduction and tension those lateral structures, then it's demonstrating that their tightness in their ITB complex is a problem.
'''What treatments can we offer?'''
 
* Manual therapy for myofascial release of the contractile tissues of the ITB.
* Instrument-assisted soft tissue release using a spiky massage ball, particularly on TFL.
* Leaning against the wall to provide pressure over the contractile tissues of the ITB.
* Trialing a variety of stretches which impact the contractile tissues and assess which give the best relief. The most effective can be added to the patient's home exercise programme.<ref name=":0" />
[[File:ITB Stretch.jpeg|thumb|alt=|center|400x400px|Standing TFL stretch]]


== Gastrocnemius and Soleus ==
== Gastrocnemius and Soleus ==
'''Why is it mechanically relevant to assess?'''  
[[File:Anatomy of the calf muscles.jpg|thumb|Gastrocnemius and soleus in situ.  Please note their relationship with the knee.]]
'''Why is it mechanically relevant to assess these muscles?'''


Okay. Finally, and by no means least is the calf. So, let's think about why the calf is important if it's tight. So, during the gait cycle, we've got initial contact with the heel and then in midstance, we want the tibia to be coming over the foot. Now, if they don't have more than plantigrade possible at the calf, they can't get past that point, can they? You've shown that on the plinth. So, therefore, to get past that, they've got to do one of two things. They've either got to excessively pronate, well, we know that's not a good thing for tibial rotation and patellofemoral pain, or they're going to have an early heel rise in their gait cycle. The heel flicks up and the knee bends. That's not good either 'cause it shoots the patellofemoral contact pressure up or they might have a bit of both. So, we don't want a tight calf at all. And in fact, there is literature to show that people with osteoarthritic patellofemoral joints have more bone oedema in their patellofemoral joint if they've got more knee flexion at the end of their gait cycle. So, there's only two things that are going to cause that. One is the tight calf, also tight hip flexors. If you have tight hip flexors, you can't get into hip extension. So again, you have to flex the knee to offload the hip.  
* During the gait cycle, heel strike occurs at initial contact, then the tibia must translate over the foot in midstance. Tightness in the calf muscles can prevent this from happening. To compensate patients with tight calf muscles will: (1) move into excessive pronation or (2) have an early heel rise in the gait cycle. Both of these compensations have negative effects on the patellofemoral joint causing tibial rotation and patellofemoral pain, and increasing patellofemoral contact pressure respectively.<ref name=":0" />
* A study performed in 2015 showed that people with osteoarthritic patellofemoral joints have more bone oedema in their patellofemoral joint if they have increased knee flexion at the end of their gait cycle.<ref>Teng HL, MacLeod TD, Link TM, Majumdar S, Souza RB. [https://www.jospt.org/doi/pdf/10.2519/jospt.2015.5859?download=true Higher knee flexion moment during the second half of the stance phase of gait is associated with the progression of osteoarthritis of the patellofemoral joint on magnetic resonance imaging]. journal of orthopaedic & sports physical therapy. 2015 Sep;45(9):656-64.</ref> This can be caused in two ways: (1) tight calf muscles or (2) tight hip flexors which limit the ability to get into hip extension. This will make the patient have to flex the knee to offload the hip.<ref name=":0" />
* The patient may reveal that they stretch often, but that their calf muscles will not stop cramping or are always tight. In these cases, it is important to assess their hip flexor endurance. The patient may be pushing through their calf muscles to compensate for a lack of ability to pull through their hip flexors.<ref name=":0" />
* 


'''How should we assess and test for the muscle length?'''


So, it's really important to look at the calf and also, we need to make sure we're distinguishing between gastrocnemius and soleus. So, for example, a skier with a flexed knee is constantly working soleus. So, if they're getting patellofemoral pain when they're skiing, I'm going to be much more interested in soleus. So, looking at gastrocnemius with the straight knee, soleus with a flexed knee. We can do that in supine, or we can do a - for soleus, we can do a knee-to-wall test.
'''How should we assess and test for muscle length?'''


'''What can we do to treat?'''
* It is important to distinguish between the [[gastrocnemius]] and [[soleus]].
* Assess the gastrocnemius with a straight knee, soleus with a flexed knee. Testing can be done in supine for either muscle or the standing [[Knee to Wall Test|knee-to-wall test]] can assess the soleus.<ref name=":0" />


So, following this through, if we have found the gastrocnemius and/or soleus are tight, then it's up to us to, first of all, look at causative factors and there's definitely a group that have slender build but with big calves. They often comment, "I stretch and stretch, and I just can't seem to get my calves to stop cramping and they're really tight". And I think those patients, it's worth having a look at their hip flexor endurance, because if they're not pulling through at all from their hip flexor, they'll be push, push, push from their calf during their run.


So, looking at causative factors. So, if we want to treat, we again have a similar array of choices. We can do some release work, they can foam roll their calves if they're thick and tight, we can look at dynamic stretching, maybe on and off the step, up and down. Remember knee extension if it's gastrocnemius, knee flexion if it's soleus, or we can use that same off the step position statically for static stretching. Or we can use stride standing, forwards lean against a wall. Really, it's whatever works for that patient.
'''What treatments can we offer?'''
 
* Manual therapy for myofascial release or instrument-assisted soft tissue release
* Foam rolling
* Dynamic stretching<ref name=":0" />
 
<div class="row"> 
<div class="col-md-6">[[File:Gastrocnemius Stretching.jpeg|none|thumb|alt=|403x403px]]</div>
<div class="col-md-6">[[File:Gastrocnemius Stretching Against Wall.jpeg|none|thumb|alt=|400x400px]]</div>
</div>


== Resources  ==
== Resources  ==
'''Clinical Resources:'''
'''Optional Viewing:'''


* Handouts for special tests
Please view this short video for demonstrations of various types of hamstring stretches.
{{#ev:youtube| oRdXgERlSag |500}}<ref>YouTube. Hamstring Stretches for Tight or Sore Hamstrings - Ask Doctor Jo. Available from: https://www.youtube.com/watch?v=oRdXgERlSag [last accessed 29/08/2022]</ref>
 
 
'''Optional Suggested Physiopedia Pages:'''
 
* [[Patellofemoral Pain Syndrome]]
* [[Patellofemoral Pain Syndrome and Hip Strength]]




'''Additional Optional Reading:'''
'''Additional Optional Reading:'''
* Bethel J, Killingback A, Robertson C, Adds PJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8860688/ The effect of stretching exercises on the fibre angle of the vastus lateralis and vastus medialis oblique: an ultrasound study.] Journal of Physical Therapy Science. 2022;34(2):161-6.
* Fredericson M, White JJ, MacMahon JM, Andriacchi TP. [https://www.researchgate.net/profile/Michael-Fredericson/publication/11375416_Quantitative_analysis_of_the_relative_effectiveness_of_3_iliotibial_band_stretches/links/5a25961daca2727dd880e0e5/Quantitative-analysis-of-the-relative-effectiveness-of-3-iliotibial-band-stretches.pdf Quantitative analysis of the relative effectiveness of 3 iliotibial band stretches]. Archives of physical medicine and rehabilitation. 2002 May 1;83(5):589-92.
* Torrente QM, Killingback A, Robertson C, Adds PJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9159710/ The effect of self-myofascial release on the pennation angle of the vastus medialis oblique and the vastus lateralis in athletic male individuals: an ultrasound investigation]. International Journal of Sports Physical Therapy. 2022;17(4):636.


== References  ==
== References  ==
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<references />
[[Category:Course Pages]]
[[Category:Course Pages]]
[[Category:Physioplus Content]]
[[Category:Plus Content]]
[[Category:Plus Content]]
[[Category:Knee]]
[[Category:Musculoskeletal/Orthopaedics]]

Latest revision as of 14:42, 24 October 2023

Original Editor - Stacy Schiurring based on the course by Claire Robertson

Top Contributors - Stacy Schiurring, Jess Bell and Kim Jackson

Introduction[edit | edit source]

Patellofemoral pain often results from cumulative load. It reveals itself with prolonged and or repetitive activity or holding of a certain position. Subtle changes in load can add up over time to create a large load.[1] Thorough assessment and the subjective interview will provide clues to causative factors of the patient's patellofemoral pain.

For a review of the gait cycle, please read this article.

Hamstrings[edit | edit source]

Hamstrings in situ. Note their relationship with the knee.

Why is it mechanically relevant to assess this muscle?

  • Tight, tense, and shortened hamstrings can pull the knee into excessive knee flexion. During the gait cycle, this can result in a greater knee flexion moment at initial contact or heel strike.
  • Any resulting increase in knee flexion will increase patellofemoral contact pressures. Therefore, it is important to avoid the situation where the tibia is being pulled back and there is enhanced knee flexion.[1]


How should we assess and test for muscle length?

  • It is important to assess hamstring length in conjunction with stride length
  • Bedside clinical exams: sit-and-reach, straight leg raise
  • It is important to assess and compare the muscle length of both hamstrings. The rehabilitation professional should also take the patient's relative flexibility into consideration, ie: is this patient's body flexible overall or tight. This will help determine the patient's muscle length norm.
  • Other muscle groups to assess: gluteal extensors
  • Clues from the patient interview or past medical history: a patient may state that they stretch regularly but have not noticed any change in their flexibility; a history of repeated injury to a muscle group might mean that it has more scarring in the intramuscular matter; having regular repeating injuries.[1]


What treatments can we offer?

  • The literature gives little insight into the duration or frequency of stretching.[1]
  • Consistent, regular stretching that the patient will be able to complete is key. Find out about the patient's schedule and lifestyle and help them create an exercise programme they will be able to stick to and faithfully perform. Create easy, pragmatic exercises the patient will most likely complete.[1]
  • Types of hamstring stretches: (1) standing static stretch, (2) dynamic stretching, (3) hold-relax (also known as contract-relax).
  • There is some literature supporting that dynamic stretching is slightly more effective.[1] In patients with inflexible hamstrings, dynamic hamstring stretching improved muscle activation time and clinical outcomes compared with static hamstring stretching, when both were combined with strengthening exercises.[2] Hold-relax stretching tends to decrease muscle tone which allows the stretch to be deepened. However, it is important to create an exercise programme that is best suited for the patient.[1]
Standing static stretch
Hold-relax (contract-relax) stretch


To learn more about the types of stretches and how stretching effects muscle anatomy and physiology, please read this article. For demonstrations of various methods of hamstring stretching, please view the optional video in the additional resources section at the bottom of this page.

Quadriceps[edit | edit source]

Quadriceps in situ. Please note their relationship with the patella and hip adductors.

Why is it mechanically relevant to assess this muscle?

  • Look for clues in the patient's subjective interview and past medical history.
  • If the patient reports knee pain with prolonged sitting (i.e. with the knee flexed), it is important to rule out: (1) quadriceps strength issues, (2) gluteal strength issues, (3) foot posture issues, (4) load issues when considering quadriceps length issues.
  • So, when we sit for a prolonged period with tight quadriceps, we have a large compressive vector through our patellofemoral joint. This might be tolerated for a short while, but after a while the pressure in the subchondral bone can keep increasing. Eventually, the individual reaches a point where the only way they can alleviate that pressure pain is to straighten out their leg.[1]


How should we assess and test for muscle length?

  • Bedside clinical exams: modified Thomas Test.
    • If the patient has some quadriceps tightness, the knee will maintain 45-60 degrees of knee flexion. This signals that the knee is hanging on quadriceps tension. And when they are passively moved to 90 degrees of knee flexion, the examiner can feel the level of resistance in the muscle.
    • During this test test, if when the knee is flexed, the hip comes into more flexion, part of the tightness is from rectus femoris; if the hip does not flex, then there is more tightness in the vastii muscles.
  • Cinema Sign (also known as Theatre sign, Movie-goers sign, Movie sign): Pain in the knee results from compression in the patellofemoral joint caused by tight quadriceps with prolonged sitting in knee flexion.[1]


What treatments can we offer?

  • Stretching of the quadriceps is needed, but may need to be modified based on the patient's level of tightness.
    • If the patient is currently experiencing a sore patellofemoral joint, performing a classic standing quadriceps stretch will most likely exacerbate their pain. This stretch can be modified by standing with their foot supported on a chair behind them. The following verbal cues are provided: "stand tall and imagine a helium balloon attached to your breastbone, pulling you up."[1]
    • If the patient's knee is not irritated by this stretch, they can perform a hold-relax (contract-relax) in the same modified position described above. Ask them to push the foot down into the chair and perform an isometric hold for 10 seconds.[1]
  • The patient can also attempt flexibility gains with eccentric exercise. However, patients with patellofemoral pain often will not tolerate exercises that take them eccentrically to end range.[1]
  • There is a small amount of emerging evidence looking at dry needling to trigger points in the vastii muscles as being preferential to sham needling for patellofemoral pain management. A 2020 study by Ma et al.[3] found that dry needling of the quadriceps, when combined with stretching can reduce pain, improve function, and the coordination of the vastus medialis oblique (VMO) and vastus lateralis (VL) in patients with patellofemoral pain syndrome.
  • Foam rolling[1]
Standing modified quadriceps stretch
Standing classic quadriceps stretch


What does the literature say?

  • Bethel et al.[4] studied the effects of a 7-week stretching programme on healthy adults. They found that completing three sets of a three-stretch programme, three times per week created a significant decrease in the muscle fibre angle in both the VMO and the VL.[4] To learn more about changing the muscle architecture of the quadriceps, please read this article.
  • Torrente et al.[5] looked at the effects of self myofascial release using a foam roller on hypertrophy of the quadriceps. The study found that a 7-week programme of self myofascial release resulted in a statistically significant decrease in the pennation angles of both the VMO and VL in healthy adult males.[5]

Iliotibial Band[edit | edit source]

Why is it mechanically relevant to assess this structure?

The iliotibial band (ITB) can be a controversial anatomical structure. It is very strong and thick, and it is not capable of changing length.[1]

"Gratz investigated the tensile properties of human TFL muscle and found similarities with those of “soft steel”, based on its tendon-like histologic structure comprised of an inconspicuous number of elastic fibres."[6]

The Iliotibial band in situ. Please note the relationship between the tensor fascia lata and the gluteus maximus.

The origins of the ITB are contractile: the tensor fascia lata (TFL) and the gluteus maximus. If there is muscle tension or hypertrophy causing a shortening of the soft tissue structures, then it is going to proximate the ITB. This can cause two issues which can irritate the patellofemoral joint: (1) it can cause a lateral tilt of the patella and (2) through its tibial attachment beyond about 60 degrees of knee flexion, it can externally rotate the tibia. This ultimately will create a functional knee valgus moment, a large Q-angle, which can overload the lateral patellofemoral joint.[1]

  • The patient may reveal that, in addition to their patellofemoral pain, they have some pain at the side of their pelvis when walking. This may indicate that they have a tight and overactive TFL as well.
  • They may have a positive cinema sign, but it is more enhanced when their legs are crossed.[1]


How should we assess and test for muscle length?

  • Bedside clinical exams: Obers test (however this can be a challenging position for patients to maintain and for the clinician to fully assess all needed angles).[1]


What does the literature say? Kwan et al.[7] looked at the relationship between hip adduction and patellar position as an alternative to the Obers test. Excessive hip adduction can lead to knee valgus and increased Q-angle which predisposes the patient to patellar displacement. This phenomenon is caused by the tightening of the ITB during hip adduction which places stress on the lateral retinaculum, and leads to lateral patellar movement. This study found that hip adduction consistently produced a smaller patella-condyle distance than the neutral position. This indicates a lateral patellar displacement which could increase the relative load on the lateral patellofemoral joint and cause pain. This study also demonstrated that ultrasound was a reliable assessment tool for patella displacement.[7]

To perform this test: with the patient in supine and legs in neutral, assess the initial tilt of the patella. Move the leg to be tested into hip adduction and reassess the tilt of the patella.[1]

  • If the patellar tilt is driven purely by the retinaculum, it will not change much with hip adduction
  • If the tilt is from the lateral structures also crossing the hip, then it will change dramatically with hip adduction[1]


What treatments can we offer?

  • Manual therapy for myofascial release of the contractile tissues of the ITB.
  • Instrument-assisted soft tissue release using a spiky massage ball, particularly on TFL.
  • Leaning against the wall to provide pressure over the contractile tissues of the ITB.
  • Trialing a variety of stretches which impact the contractile tissues and assess which give the best relief. The most effective can be added to the patient's home exercise programme.[1]
Standing TFL stretch

Gastrocnemius and Soleus[edit | edit source]

Gastrocnemius and soleus in situ. Please note their relationship with the knee.

Why is it mechanically relevant to assess these muscles?

  • During the gait cycle, heel strike occurs at initial contact, then the tibia must translate over the foot in midstance. Tightness in the calf muscles can prevent this from happening. To compensate patients with tight calf muscles will: (1) move into excessive pronation or (2) have an early heel rise in the gait cycle. Both of these compensations have negative effects on the patellofemoral joint causing tibial rotation and patellofemoral pain, and increasing patellofemoral contact pressure respectively.[1]
  • A study performed in 2015 showed that people with osteoarthritic patellofemoral joints have more bone oedema in their patellofemoral joint if they have increased knee flexion at the end of their gait cycle.[8] This can be caused in two ways: (1) tight calf muscles or (2) tight hip flexors which limit the ability to get into hip extension. This will make the patient have to flex the knee to offload the hip.[1]
  • The patient may reveal that they stretch often, but that their calf muscles will not stop cramping or are always tight. In these cases, it is important to assess their hip flexor endurance. The patient may be pushing through their calf muscles to compensate for a lack of ability to pull through their hip flexors.[1]


How should we assess and test for muscle length?

  • It is important to distinguish between the gastrocnemius and soleus.
  • Assess the gastrocnemius with a straight knee, soleus with a flexed knee. Testing can be done in supine for either muscle or the standing knee-to-wall test can assess the soleus.[1]


What treatments can we offer?

  • Manual therapy for myofascial release or instrument-assisted soft tissue release
  • Foam rolling
  • Dynamic stretching[1]

Resources[edit | edit source]

Optional Viewing:

Please view this short video for demonstrations of various types of hamstring stretches.

[9]


Optional Suggested Physiopedia Pages:


Additional Optional Reading:

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 Robertson, C. Patellofemoral Joint Programme. Muscle Length Assessment and Treatment Related to Patellofemoral Pain. Physioplus. 2022.
  2. ↑ Lee JH, Jang KM, Kim E, Rhim HC, Kim HD. Effects of static and dynamic stretching with strengthening exercises in patients with patellofemoral pain who have inflexible hamstrings: a randomized controlled trial. Sports health. 2021 Jan;13(1):49-56.
  3. ↑ Ma YT, Li LH, Han Q, Wang XL, Jia PY, Huang QM, Zheng YJ. Effects of trigger point dry needling on neuromuscular performance and pain of individuals affected by patellofemoral pain: a randomized controlled trial. Journal of Pain Research. 2020;13:1677.
  4. ↑ 4.0 4.1 Bethel J, Killingback A, Robertson C, Adds PJ. The effect of stretching exercises on the fibre angle of the vastus lateralis and vastus medialis oblique: an ultrasound study. Journal of Physical Therapy Science. 2022;34(2):161-6.
  5. ↑ 5.0 5.1 Torrente QM, Killingback A, Robertson C, Adds PJ. The effect of self-myofascial release on the pennation angle of the vastus medialis oblique and the vastus lateralis in athletic male individuals: an ultrasound investigation. International Journal of Sports Physical Therapy. 2022;17(4):636.
  6. ↑ Seeber GH, Wilhelm MP, Sizer Jr PS, Guthikonda A, Matthijs A, Matthijs OC, Lazovic D, Brismée JM, Gilbert KK. The tensile behaviours OF the iliotibial band–a cadaveric investigation. International journal of sports physical therapy. 2020 May;15(3):451.
  7. ↑ 7.0 7.1 Kwan LY, Killingback A, Robertson C, Adds P. Ultrasound investigation into the relationship between hip adduction and the patellofemoral joint. Journal of Physical Therapy Science. 2021;33(7):511-6.
  8. ↑ Teng HL, MacLeod TD, Link TM, Majumdar S, Souza RB. Higher knee flexion moment during the second half of the stance phase of gait is associated with the progression of osteoarthritis of the patellofemoral joint on magnetic resonance imaging. journal of orthopaedic & sports physical therapy. 2015 Sep;45(9):656-64.
  9. ↑ YouTube. Hamstring Stretches for Tight or Sore Hamstrings - Ask Doctor Jo. Available from: https://www.youtube.com/watch?v=oRdXgERlSag [last accessed 29/08/2022]
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