L1: What to prescribe them for and how to prescribe them part 1

What to prescribe them for

Patellofemoral pain2,3 

How to prescribe them

In the case of an acute episode we recommend that the patient has achieved some level of relief from your other treatment modalities prior to prescribing these exercises (the reduction of effusion and pain should be the initial focus). They can be prescribed in a 20-minute, one-on-one consultation. Follow-up consultations are recommended to assess technique and outcomes. For optimal results they should be performed once per day and two to four sets of ten is recommended.4 It is important the patient does not experience pain during these exercises. For those patients that do not tolerate open chain exercises you may wish to prescribe closed chain exercises or exercise for the gluteals.

Recently researchers are turning their attention to abnormal hip function and its association with patellofemoral pain.5 Hip abductor strengthening programs have demonstrated improvements and some consider hip abduction strength should be addressed prior to the quadriceps strength.6-12 

A single leg squat may be an appropriate screening test for patients at risk of injury and those that should focus on hip strengthening exercises.13,14 One of the key factors considered to contribute to excessive medial femoral rotation during a single leg squat is hip abductor weakness.15 Refer to beginner exercise for the hip and intermediate exercises for the gluteals for exercises.

Note that adductor strength has not been incorporated into this exercise prescription. Adductor strength exercises have previously been prescribed due to the observation that the vastus medialis obliquus fibres arise from the adductor magnus tendon. A study in 1993 reported that co-contraction of the hip adductors during open chain exercises could result in greater vastus medialis obliquus activation,16 but only at maximal ranges, while another study demonstrated greater activity of vastus medialis obliquus during hip adduction exercises.17 More recent research does not support these findings.18 Furthermore, some experts disagree with the prescription of adduction for patients with patellofemoral pain syndrome given the condition is often association with dynamic valgus alignment.5,19 It has been suggested that hip adduction is the main factor in excessive dynamic knee valgus,20,21 a phenomenon associated with patellofemoral pain.22 This would suggest that adductor exercises could be detrimental in this population and a focus on hip abductors would be more suitable. 

There is some evidence that stretching can improve pain, function and range of motion in patients with patellofemoral pain.23-27 Many studies investigating strength exercises also incorporate stretching exercises.4 Please refer to stretches for the lower body for exercises.