Multiplanar, Eccentric Loading is Critical to Patellofemoral Pain Management| Article of The Week 9

Progression to eccentric multiplanar excercise is critical to the successful recovery of PFP.

Exercise is essential to successful management of patellofemoral pain (PFP). Programmes often being with simple local knee strengthening and progress to proximal exercises which target the hip and pelvis. This is because RCTs show that this results in short-term improvement to pain and function. That being said long-term recovery from PFP is mixed with up to 50% of patients having unfavourable recovery at 5-8 years. This is likely down to the complex etiology of the condition but also likely attributable to the lack of consensus on optimal exercise regime.

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It is possible that the variability in exercise management stems from clinician interpretation of proximal strengthening. To some this may be simple hip focused exercises and to others more dynamic movements can be involved. There is a growing argument that the correct approach would be to base the choice of exercise on the pathomechanics associated with PFP.  Examples could be targetting exercise at reducing excessive or undercontrolled internal rotation of the femur.

This would shift rehab from simple exercises to a more task specific approach where exercises are progressed via specificity and loading principles. This would involved exposing patients to single limb loading, eccentric strengthening and movements across multiple planes. Although there have been numerous reviews investigating PFP mamagement none have particualrly explored individual content of exercise programmes. The aim of this systematic review was to assess the exercise content from RCTs implementing a proximal approach to the management of PFP.


19 studies adhered to the screening and eligibility process of the review protocol. The average score of the included studies was PEDro 6.2 with the most common limitation ebing a lack of blinding. In total 178 exercises were extracted from the 19 studies of these:

  • 22.9% were multiplanar
  • Saggital/Frontal plane was used in 58.9% of multiplanar exercises
  • Saggital/Transverse only 5 exercises
  • Frontal/Transverse only 6 exercises
  • Only 5 triplanar exercises
  • Saggital plane was used and represented in 67.4% of all exercises with most common exercise being standing hip extension in open chain
  • Frontal plane was used and represented in 38.8% of all exercises with most common exercise being open chain hip abduction
  • Transverse plane was used in 20.8% of exercises and most common exercise was seated external rotation
  • 11.2% of the exercises was eccentric with quads being most targeted group

It’s fair to say that the majority of exercises included within the literature for proximal strengthening for PFP are simplistic and tend to be isolated to the saggital plane with concentric loading undertaken in a non-weightbearing position. This does not follow a pathomechanial approach to managing the condition. Especially when you consider that hip musculature must quickly decelerate the lower limbs during walking and running, the most common causes of pain.

Clinical Implications

PFP exercise programmes should focus on proximal hip strengthening which focusses on neuromotor control and eccentric loading of the glutes and deep lateral hip rotators. Yes, simple single or multiplanar exercises can be used in the early stages but progression of exercises hsould exist with the emphasis on function.

Become at Expert at Differentiating Patellar Pain

The knee joint is comprised of the patellofemoral and tibiofemoral joint. There are a variety of structures within both joints that can cause pain in and around the knee joint. Differentiating between the patellofemoral and tibiofemoral joint as a source of symptoms helps to manage a person’s symptoms effectively. Information can be obtained from the subjective and objective examination to obtain a comprehensive clinical picture. In this course, Claire Robertson describes the different assessment findings that can help you determine whether the persons knee pain is arising from tibiofemoral or patellofemoral structures.

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