L2: How to prescribe them part 2

How to prescribe them part 2

Careful consideration should be made when prescribing quadriceps exercises to those patients who have a history of anterior cruciate ligament injury or those that demonstrate quadriceps dominance, in particular female athletes (basketball, soccer, volleyball).28-31 Myer et al. report that32“Quadriceps dominance relates to an imbalance between knee extensor and flexor strength, recruitment and coordination.”33 This may be associated with anterior cruciate ligament injury due to a decrease in neuromuscular control leading to increased stress and potential failure of the ligament.34 Co-activation of the hamstrings and quadriceps has been suggested to have a protective effect against excessive anterior drawer, knee abduction and dynamic lower extremity valgus.35 

Hewitt et al.36 speculate that “If the hamstrings are under-recruited or weak, quadriceps activation may be reduced to provide the net flexor moment required to perform the movement. Deficits in strength and activation of the hamstrings may thus directly limit the potential for muscular co-contraction to protect ligaments. This potential absence of muscular control of the joint may lead to a ‘ligament-dominant’ or ‘quadriceps-dominant’ profile in the female athlete.37 Indeed, female athletes (compared with male athletes) tend towards a quadriceps dominant landing strategy without increasing their hamstring activity38 and this tendency is also observed in a single leg squat.”39 

One indicator of quadriceps dominance is the tendency to land with a relatively straight knee and upright posture and the observation of decreased knee flexion during running, cross-cutting and side cutting.40,41 

In these patients ensure a balanced exercise program is prescribed including hamstring and gluteal exercises. Jump-landing or plyometric training42,43 and ankle dorsiflexion flexibility44,45 training is also advised. 

There is no single identifiable cause of patellofemoral pain. Proposed factors in patellofemoral pain syndrome include: 

• Pes planus (pronation)46 
• Rear foot eversion47 
• Large Q angle* 48-51 
• Dynamic valgus15,52 
• Weak quadriceps 
• Weak vastus medialis obliques 
• Tight ilitibial bands53-55 
• Tight hamstrings27,56 
• Altered onset timing of hamstring contraction57 
• Weakness of the hip abductors6-11 
• Calf tightness58 
• Altered mechanosensitivity of the femoral nerve59,60 
• Patella instability/previous patella dislocation61 

*Caution should be used when discussing biomechanical variants as the research appears inconclusive on the relevance for patellofemoral pain and the patient may be discouraged from trialling exercise therapy.62 Many studies have found no relationship between Q-angle and the incidence of patellofemoral pain63-5 and recent reviews support the use of exercise as a key treatment for patellofemoral pain syndrome.66-68 

Other advice you may wish to provide to patients with patellofemoral pain include: 

• Avoid wearing high heels69 
• Temporarily avoiding aggravating activities (such as running, walking down stairs or hills, prolonged sitting) 
• Increase step rate and decrease step length during running (This reduces load on the patellofemoral joint and increases activity within the gluteus medius and maxiumus)70-73 
• Use a forefoot strike pattern and/or consider barefoot running (These techniques should be introduced in a graduated manner with appropriate supervision)71-76 
• Alter footwear and/or consider wearing orthotics77-79 
• Incorporate a slight forward trunk lean into running technique (Ensure this technique does not result in other symptoms such as lower back pain)80 
• Incorporate backward running into training (This may reduce the load on the patellofemoral joint, although some experts argue that it is the speed of running – which by default is slower with backward running – that reduces patellofemoral forces rather than backward running itself)81-83 
• Temporarily reduce running speed81 
• Address fear-avoidance beliefs84