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 Table of Contents  
Year : 2014  |  Volume : 14  |  Issue : 1  |  Page : 9-13

Combination of hip-quadriceps strengthening exercise: Is it more potential than single conventional strengthening exercise to reduce pain in patellofemoral pain syndrome patients?

1 Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
2 Faculty of Medicine, Universitas Indonesia; Department of Community Medicine, Sports Medicine Program, Jakarta, Indonesia

Date of Web Publication29-Apr-2014

Correspondence Address:
Bayushi Eka Putra
Faculty of Medicine, Universitas Indonesia Salemba Raya 6, Jakarta 10430
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DOI: 10.4103/1319-6308.131579

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Objective : To determine whether hip-strengthening exercise or combination exercise may relieve pain better than quadriceps-strengthening exercise in adult patellofemoral pain syndrome patients. Materials and Methods: Literature search was performed using PubMed and EMBASE database. Studies were appraised by using the center of evidence-based medicine therapeutic study appraisal sheet. The visual analog scale (VAS) reduction was measured and plotted into forest plot using excel program. Results: Two studies showed better result of hip-quadriceps-strengthening exercise to quadriceps-strengthening exercise [3.31 ± 3.12 vs. 1.5 ± 3.04 and 3.6 ± 2.6 vs. 1.5 ± 2.8], while the other one compared hip-strengthening therapy to quadriceps-strengthening exercise [2.2 ± 4.5 vs. 0.1 ± 4.8]. Conclusion: Hip-quadriceps strengthening exercise gives better result in reducing pain perception in Patellofemoral pain syndrome (PFPS) patients compared with hip-strengthening exercise or quadriceps-strengthening exercise.

  Abstract in Arabic 

ملخص :
دمج تمارين تقوية الورك ــ العضلة مربعة الرؤوس : هل هو أفضل من التمارين التقليدية الوحيدة من أجل خفض الألم في المفصل الفخذي الرضفي
الهدف : لتقرير فى ما إذا كان دمج تمارين تقوية الورك مع تقوية العضلة مربعة الرؤوس هي أفضل من تمارين تقوية العضلة مربعة الرؤوس في خفض الألم في المفصل الرضفي الفخذي.
المواد والطرق: تم مراجعة الدراسات المنشورة باستخدام مصادر Pub Med و EMBASE وتم تقييم الدراسات باستخدام نماذج دراسات مركز العلاجات الطبية المعتمدة على البراهين . تم قياس خفض مقياس النظير البصري (VAS) وعرضه في صورة باستخدام برنامج أكسل (Excel).
النتائج : أظهرت دراستان وجود نتائج أفضل عند استخدام تمارين تقوية الورك والعضلة مربعة الرؤوس مقارنة بتمارين تقوية العضلة مربعة الرؤوس ( 31ر3 ± 12ر3 مقارنة بـ 5ر1 ± 04ر3 و 6ر3 ± 6ر2 مقارنة بـ 5ر1 ± 8ر2) بينما قارنت الدراسة الأخرى بين تمارين تقوية الورك إلي تمارين تقوية العضلة مربعة الرؤوس (2ر2 ± 5ر4 مقارنة مع 1ر0 ± 8ر4).
الاستنتاج : أن دمج تمارين الورك مع العضلة مربعة الرؤوس يعطي نتائج أفضل في خفض الألم في المفصل الرضفي الفخذي مقارنة مع تمارين تقوية الورك أو تمارين تقوية العضلة مربعة الرؤوس.

Keywords: Adult, evidence-based case report, hip and quadriceps strengthening exercise, patellofemoral pain syndrome, VAS reduction

How to cite this article:
Putra BE, Sutarina N. Combination of hip-quadriceps strengthening exercise: Is it more potential than single conventional strengthening exercise to reduce pain in patellofemoral pain syndrome patients?. Saudi J Sports Med 2014;14:9-13

How to cite this URL:
Putra BE, Sutarina N. Combination of hip-quadriceps strengthening exercise: Is it more potential than single conventional strengthening exercise to reduce pain in patellofemoral pain syndrome patients?. Saudi J Sports Med [serial online] 2014 [cited 2017 Mar 29];14:9-13. Available from: http://www.sjosm.org/text.asp?2014/14/1/9/131579

  Introduction Top

To relieve pain in patient with acute patellofemoral pain syndrome, activity modification, and nonsteroidal anti-inflammatory drugs (NSAIDs) are needed. [1],[2],[3] Though, for the recovery phase, muscle strengthening exercise is the main treatment to correct joint disability. [4] The usual exercise emphasize on quadriceps femoris training as it directly affect the stability of the patella, though recent studies showed the effect of hip soft tissue regimens training which speeds up the recovery of function and pain as strengthening of hip musculature (external rotator and abductor) will increase the stability of the pelvic and contribute to leg alignment. [2],[5],[6],[7],[8],[9] Therefore, we aimed to evaluate the combination hip-quadriceps strengthening exercise over quadriceps-strengthening exercise to evaluate its effect to pain relieve.

Case illustration

A 52-year-old Indonesian female patient came with chief complaint of pain on the right knee for the last 1 month, which worsened over time. Originally the pain had been there for about 5 years, but she usually managed to overcome the pain by over-the-counter pain medication. Pain was felt especially when patient flexed the knee or when patient tried to walk. No history of morning stiffness or gelling phenomenon noted, nor the history of trauma before the pain showed up. Risk factor for excessive loading to the knee based on her history of squatting position 4-5 h every day for a total of 30 years. Physical examination showed that she had body mass index of 28 (obesity 1). No bony enlargement or crepitus was found based on the examination of both knees. However, the Q angle of right knee was 45°, while the left knee was 20°. Patellofemoral compression test was noted on her right knee. She was diagnosed as right patellofemoral pain syndrome.

We wonder the best exercise management for this patient, whether a newly developed hip-strengthening exercise may give better result than the conventional quadriceps-strengthening exercise.

Clinical question

Is hip-strengthening exercise or hip-strengthening and quadriceps-strengthening exercise combination may relieve the pain better than quadriceps-strengthening exercise in patellofemoral pain syndrome patients?

  Materials and Methods Top

Literature search

On the basis of formulated clinical question, a search was performed for articles published in English from 1 June 1993 to 1 June 2013 from PubMed and EMBASE [Table 1].
Table 1: Search strategy

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Critical appraisal and data extraction

The main authors conducted the appraisal individually using center of evidence based medicine therapeutic study appraisal sheet. Extracted data, in the form of visual analog scale (VAS) (from 0 to 10) mean differences were plotted into forest plot chart using Excel Program. The result of VAS changes by Nakagawa was plotted individually to get better view of pain perception in several positions, which patients with PFPS get to feel pain [Table 2].
Table 2: Summary of included studies

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  Results Top

The search process resulted in three articles that fulfilled the selection criteria [Figure 1]:
Figure 1: Searching process

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Basically, the subjects were grouped into case and control groups. Different from the two others whose case group did hip- and quadriceps-strengthening exercise, Dolak's case group received only hip-strengthening exercise. Though, the comparator, control group, of the three studies was all received quadriceps-strengthening exercise only [Table 2].


Three studies compared the reduction of VAS score in 4 weeks strengthening exercise; with Nakagawa specifically compared the VAS reduction in several activities related to pain in usual patients diagnosed with PFPS. VAS scores were measured before and after treatment to determine and the end-result; therefore, the mean difference of VAS reduction can be calculated and compared [Table 3].
Table 3: The validity and applicability of the studies

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On the basis of the studies [Table 4], subjects with combination therapy, namely hip- and quadriceps-strengthening exercise, gave better mean difference in VAS reduction than quadriceps strengthening exercise alone (3.31 ± 3.12 vs. 1.5 ± 3.04 and 3.6 ± 2.6 vs. 1.5 ± 2.8). [7],[10],[11] The same goes with hip-strengthening exercise only, which also gave better result than quadriceps-strengthening exercise only (2.2 ± 4.5 vs. 0.1 ± 4.8). All of VAS reductions were statistically significant, except for the control group in Nakagawa studies. [10]
Table 4: Comparison of visual analog scale reduction between studies

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The perception of pain before and after the treatment in various positions related to pain in PFPS patients was measured in Nakagawa's study [Figure 3]; the results are plotted as they will be easily compared by looking at the forest plot. On the basis of the several conditions shown above, case groups showed better VAS reduction than control groups, which the most reduced pain was when patient on the squatting position.

  Discussion Top

On the basis of the several results shown above, clearly hip-strengthening exercise gives better result in reducing pain perception than quadriceps-strengthening exercise. This applied to single therapy of hip-strengthening exercise or to combination of hip-quadriceps-strengthening exercise; though, using the combination therapy might increase the difference in VAS reduction. The superiority of hip-strengthening exercise compared with quadriceps-strengthening exercise was already clear by looking at the result, but the hip-strengthening exercise alone may also give no effect to the potential of causing harm, judging by how the result crossed the 0 number. This result was different from the combination of hip-quadriceps-strengthening exercise, considering the result of the combination therapy did not cross 0 number as shown in [Figure 2].
Figure 2: Forest plot of visual analog scale (VAS) reduction in the studies. The analysis of mean changes was done in Excel program. Plotted into a forest plot diagram to compare and determine the effect of VAS reduction in several studies. The VAS reduction was plotted in a usual pain condition

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Figure 3: Forest plot of visual analog scale reduction in several condition (Nakagawa et al.,[11]) *Case groups consist of patients with hip and quadriceps muscle-strengthening exercise, *Control groups consist of patients with quadriceps muscle only strengthening exercise, *All case groups: P < 0.005, except in prolonged sitting, *All control groups: P > 0.005

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Several positions, as studied by Nakagawa, might give more pain than the other; therefore, the reduction of VAS was measured in several positions. Surprisingly, VAS was reduced the most in squatting position, the position of which the knee received the load of the body the most (seven times of the body weight) compared with other activities or positions (descending stairs, climbing stairs, and prolonged sitting). Therefore, it showed the efficacy of the treatment, which may reduce the intensity of pain in the most knee-strenuous position.

The only downside of using combination therapy is the time consumed. Of course by using the combination therapy, the patient may need more effort to do hip-strengthening exercise and quadriceps-strengthening exercise separately. But, considering the result, the benefit of doing it outweighs the detriment. [2],[3]

  References Top

1.O'Connor FG, Mulvaney SW. Patellofemoral pain syndrome. USA: UpToDate. Inc; 2013 Available from: http://www.uptodate.com/contents/patellofemoral-pain-syndrome [Last updated on 2013 May 28; Last accessed on 2013 Jul 05].  Back to cited text no. 1
2.Linschoten RV, Koëter S. Patellofemoral pain: an overview of exercise therapy and surgery. Patellofemoral pain syndrome and exercise therapy. 1 ed . Rotterdam: Optima Grafische Communicatie; 2010. p. 103-15.   Back to cited text no. 2
3.Juhn MS. Patellofemoral pain syndrome: A review and guidelines for treatment. Am Fam Physician 1999;60:2012-8.  Back to cited text no. 3
4.Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW. Pharmacotherapy for patellofemoral pain syndrome. The Cochrane database of systematic reviews. [Meta-Analysis Review]. 2004:CD003470.  Back to cited text no. 4
5.Witvrouw E, Werner S, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G. Clinical classification of patellofemoral pain syndrome: Guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc. [Review]. 2005 Mar;13:122-30.  Back to cited text no. 5
6.Tyler TF, Nicholas SJ, Mullaney MJ, McHugh MP. The role of hip muscle function in the treatment of patellofemoral pain syndrome. Am J Sports Med 2006;34:630-6.  Back to cited text no. 6
7.Razeghi M, Etemadi Y, Taghizadeh S, Ghaem H. Could hip and knee muscle strengthening alter the pain intensity in patellofemoral pain syndrome? Iran Red Crescent Med J 2010;12:104-10.  Back to cited text no. 7
8.LaBotz M. Patellofemoral syndrome. Phys Sportsmed 2004;32:1-11.  Back to cited text no. 8
9.Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW. Exercise therapy for patellofemoral pain syndrome. Cochrane Database Syst Rev 2003:CD003472.  Back to cited text no. 9
10.Dolak KL, Silkman C, Medina McKeon J, Hosey RG, Lattermann C, Uhl TL. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: A randomized clinical trial. J Orthop Sports Phys Ther [Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov't]. 2011;41:560-70.  Back to cited text no. 10
11.Nakagawa TH, Muniz TB, Baldon Rde M, Dias Maciel C, de Menezes Reiff RB, Serrao FV. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: A randomized controlled pilot study. Clin Rehabil. [Randomized Controlled Trial Research Support, Non-U.S. Gov't] 2008;22:1051-60.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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