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PFPS REHABILITATION

Gluteus medius rehabilitation This is an area that is always referred to, but specific retraining regimes are some- times varied. Many professionals have very different approaches to, and opinions regarding this, but it is becoming more widely accepted that a lack of Gm control, particularly eccentrically, means that dynamic control of lower limb rotation will be poor. Even more specifically it is the posterior fibres of Gm whose action is of the most importance.

An underactive Gm is often teamed with a tight ITB and overactive TFL and this imbalance needs to be addressed.

A good exercise to activate Gm is to assume a starting position in side lying with the knees and hips in a comfortable degree of flexion, the lumbopelvic region in neutral and the patient well supported on a firm plinth.

Palpating the TFL and the posterior fibres of Gm, the patient is asked to externally rotate the superior hip, keeping the lum- bopelvic region in neutral and the heels together. An ideal result would be that the patient has their full range of external rotation with the movement initiated and predominately controlled by Gm contrac- tion and there is no associated movement at the lumbar spine or pelvis.

This is usually a very interesting test for patients with unilateral problems, as the symptomatic side often performs very poorly.

To rehabilitate this muscle, this exact assessment can be a very good starting point. Practised ‘little and often’ patients quickly get the idea of activating the Gm and switching off the TFL.

To progress this exercise the patient needs to go to a functional, closed chain weight bearing position.

In front of a mirror with the patient pal- pating the Gm and the opposite quadratus lumborum (potential cheating muscle to ‘hip hitch’) the asymptomatic side foot is placed on a small step.

©1999 Primal Pictures Ltd

Figure 4: Isometric VMO adduction contractions with biofeedback

From here the exercise can be incorporat- ed into others, eg. lunges, small single leg squats, plyometrics and whatever else may be required.

Vastus medialis oblique rehabilitation Anatomically the muscle fibres in the VMO are orientated such that when they con- tract they cause a medial rather than an extensor moment about the PFJ (2). Findings in the literature are not conclu- sive however there is increasing support for the idea of retraining isolated activa- tion of the VMO.

This isolated activation is not necessarily from the VL but from the hamstring mus- cles.

In patients with chronic anterior

knee pain there is a tendency toward overactive and tight hamstrings.

An interesting and worthwhile assessment of VMO versus hamstring activation about the knee joint can be done in a position of approximately 20 degrees knee flexion in long sitting. Concurrently palpate the VMO fibres and the medial and lateral hamstring tendons and ask the patient to isometrically activate the VMO.

A useful The patient is

asked to activate the Gm on the sympto- matic side to keep the pelvis level, as they attempt to lift the other foot up off the step. Monitoring any cheating manoeuvre is of paramount importance.

cue for this is to ask the patient to imag- ine they are lifting their heel off the plinth or pulling their patella in a cephalad direction. Commonly the result is that on the symptomatic side teaching an isolated VMO contraction is very difficult.

©1999 Primal Pictures Ltd Figure 5: Single leg squat to active VMO

A step back from here is to perform the exercise in a position in which the quadri- ceps are at their optimal length for con- traction with some weight bearing.

With

the patient sitting with knees parallel and the feet in contact with the floor they are asked to perform the same exercise as above. A useful cue in this position is to instruct the patient to imagine they are sliding their heel forward along the floor.

Once the patient can achieve 10 repeti- tions of 10 second isolated contractions in both of these positions this exercise can then be incorporated into other func- tional activities.

Obviously in weight

bearing, closed chain exercise there is a need for co-contraction around the knee joint.

For joint protection, control and

minimising of shear forces at the joint for exercises like lunges and squats a ratio of 1:1 is probably ideal. This can be trained

The work on the VMO and Gm and on alignment and posture probably con- tribute significantly to proprioceptive awareness in the whole lower limb region as well.

using biofeedback machines or just with the patient’s own proprioceptive sense. Emphasis should be given to eccentric training, given that these patients often complain of more problems going downhill or downstairs. An example of this would be step-downs or emphasising the down-

SportEX 17

TIP

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