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and tensor fascia latae (TFL) is important, as is that between the hamstring and quadriceps and hamstring and gluteus maximus (GM).

For example, gluteus medius and TFL are synergists in the movement of hip adduc- tion, however if due to injury the TFL becomes overactive and tight, it is gener- ally activated earlier with gluteus medius being inhibited. For hamstrings and quadriceps, the relationship for co-con- traction around the knee joint should be around a 1:1 ratio. With knee pain the quadriceps become inhibited and the hamstrings activated so this ratio becomes imbalanced.

Gluteus medius and maximus have addi- tional roles in weight-bearing above and beyond the hamstrings and TFL, as they are important for pelvic stability. When the hamstrings and TFL are overactive, pelvic stability is compromised because they are multijoint muscles, located far from the axis of the joint and when they are active, without the controlling influ- ence of the gluteals, the pelvis may tilt, translate or rotate excessively during movement.

Functional activity assessment This will depend on the type of aggravat- ing factors that the patient describes. Performance of a single leg and a double leg squat is useful and usually provoca- tive. In addition, gait analysis and a test for a Trendelenberg sign will give further useful information.

Physiotherapy treatment Each rehabilitation regime must be designed with the assessment results and the individuals’ requirements in mind.

Elements of the following procedures may be included as appropriate, with the addi- tion of any other treatment techniques deemed necessary to address other con- tributing problems.

Patella taping There is still controversy in the literature with respect to the effects of patella tap- ing. There is though, a general consensus that taping helps relieve pain. This then is a legitimate reason alone to include taping in a patient’s regime, if indeed it allows them to exercise pain free.

Figure 3: Gluteus medius strengthening exercise 16 SportEX

How this pain relief occurs is still the sub- ject of debate because there is still doubt as to where the pain originates. The most commonly accepted theory is that the pain arises secondary to excessive stress on the lateral patella facet that is then transferred to the richly innervated sub- chondral bone of the patella.

Taping is then thought to decrease this lateral stress by improving the position of the patella within the femoral trochlear groove.

A reduction in pain may then

reduce any pain inhibition of the quadri- ceps muscle to further improve exercise efficacy.

Taping may also have an effect

on the timing of the VMO muscle activa- tion so that it fires earlier to overcome abnormal lateral tracking of the patella.

To apply a McConnell patella tape, the position of the patella in 20 degrees knee flexion must be assessed to determine if it is shifted laterally, rotated and/or tilted in the trochlear groove.

Correction of

each of these elements can then be per- formed.

A medial glide tape should be applied first, followed by a piece to correct (usu- ally) lateral tilt and finally a piece to cor- rect rotation.

These three pieces should

be done with rigid tape and underneath it the skin should be shaved and a protec- tive barrier of adhesive gauze tape applied.

The patient’s immediate reaction to the tape should be analysed by reassessing an aggravating movement.

As always when using tape the potential for an allergic reaction should be remem- bered and the patient cautioned to watch for signs of this.

Soft-tissue treatment techniques Soft tissue treatment techniques includ- ing myofascial release, frictions, specific soft tissue mobilisations, and any others deemed appropriate are extremely benefi- cial.

These can be used to address any

type of tissue tightness, particularly around the lateral retinaculum, ITB, TFL, vastus lateralis and the like. Some excel- lent immediate results can often be obtained using this type of treatment.

Alignment and postural correction This is central to the rehabilitation pro- gramme. Each patient must be taught to recognise what he or she is doing wrong, how to correct it and what muscles should be working to perform a particular task.

The use of mirrors and videos can be a very good adjunct to treatment at all phases of rehabilitation. Positioning a patient in front of a mirror and going through a simple exercise such as a lunge, while analysing spinal, pelvic, hip, knee and foot and ankle posture, is a very use- ful tool. It augments what has already been commented on in the initial assess- ment and gives the patients the tools to self-correct.

If the patient doesn’t know when they are performing an exercise incorrectly then their practice time can be undermined.