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in patients with patellofemoral pain syndrome: an electro- in physically active young adults.2 PFPS is defined as retropa-
myographic study. Arch Phys Med Rehabil 2001;82:1441-5. tellar or peripatellar pain, or both, that results from physical
and biochemical changes in the patellofemoral joint.3 The basic
Objective: To evaluate the electromyographic activities of origin and exact pathogenesis of PFPS are unknown, but many
vastus medialis obliquus (VMO) and vastus lateralis (VL) predisposing factors have been proposed, including acute
muscles in open and closed kinetic chain exercises in subjects trauma, knee ligament injury and surgery, instability, overuse,
with patellofemoral pain syndrome (PFPS). immobilization, overweight, genetic predisposition, malalign-
Design: Case-controlled study. ment or dysfunction of the knee extensor mechanism, congen-
Setting: Rehabilitation science center in a tertiary medical ital anomalies of the patella, prolonged synovitis, recurrent
center. hemorrhage into a joint, joint infection, and repetitive intraar-
Participants: Ten patients with bilateral knee pain diag- ticular injections of corticosteroids. In many cases, however,
nosed with PFPS and 10 healthy volunteers. there are no obvious reasons for the symptoms, and there is no
Interventions: Subjects performed open kinetic chain exer- clear association between the severity of the symptoms and the
cise on an isokinetic dynamometer and closed kinetic chain radiologic and arthroscopic findings.2
exercise by squat-to-stand and stand-to-squat tasks. Surface The biomechanics of the patellofemoral joint are controlled
electromyography was done for the VMO and VL muscles. by its static and dynamic components. The primary dynamic
Main Outcome Measures: VMO/VL ratios were calculated components are the 4 parts of the quadriceps femoris complex,
after normalization of muscle activities. with accessory input from the iliotibial band, the adductor
Results: The VMO/VL ratios of PFPS subjects were signif- magnus and longus, the pes anserine group, and the biceps
icantly lower than were those of unimpaired subjects during femoris. Some theories for the origin of nontraumatic gradual
knee isokinetic closed kinetic chain exercises (p ⫽ .047). onset of PFPS are: (1) neuromuscular imbalances of the vastus
However, there was no statistical difference in VMO/VL ratio medialis obliquus (VMO) and the vastus lateralis (VL) mus-
between subjects with and without PFPS during closed kinetic cles; (2) tightness of the lateral knee retinaculum, hamstrings,
chain exercises (p ⫽ .623). Maximum VMO/VL ratio was iliotibial band, and gastrocnemius; and (3) overpronation of the
obtained at 60° knee flexion in closed kinetic chain exercise. subtalar joint. Excessive lateral tracking of the patella in the
Conclusion: In closed kinetic chain exercises, more selec- trochlear groove of the femur is believed to be caused by the
tive VMO activation can be obtained at 60° knee flexion. previously mentioned factors. Lateral excessive tracking of the
Maximal VMO/VL ratio was observed at this knee flexion patella is evident in many people with PFPS.1,3,4
angle, and muscle contraction intensity was also greatest. The Q angle deserves special mention because a large Q
Key Words: Electromyography; Exercise; Femur; Knee; angle is often implicated as a predisposing factor in patients
Pain; Patella; Rehabilitation. with PFPS. It is defined as the angle between the quadriceps
© 2001 by the American Congress of Rehabilitation Medi- force vector and the patella-tibial tubercle axis.
cine and the American Academy of Physical Medicine and However, there is no consensus about its importance, and it
Rehabilitation has not been shown to vary significantly between symptomatic
and asymptomatic subjects.3
As stated earlier, PFPS has multifactorial causes. Many
rehabilitation strategies have been implemented for patients
with PFPS. In general, the goals of patellofemoral rehabilita-
From the Departments of Physical Medicine and Rehabilitation (Tang, Chen, Chou, tion are to maximize quadriceps strength while minimizing the
Hong) and Orthopedic Surgery (Hsu), Chang Gung Memorial Hospital, Tao-Yuan,
Taiwan; and Physical Medicine and Rehabilitation Service, VA Palo Alto Health Care
patellofemoral joint reaction forces and stress.5-10 Strengthen-
System, Stanford University School of Medicine, Palo Alto, CA (Lew). ing of the quadriceps mechanism is typically performed in the
Accepted in revised form January 3, 2001. last 30° of knee extension, but the selectivity of this method for
Supported by the National Science Council, Taiwan, Republic of China (grant no. strengthening only the VMO is debatable. Recent works by
NSC85-2331-B-182-064).
No commercial party having a direct financial interest in the results of the research
Steinkamp et al9 indicates that the best method to strengthen
supporting this article has or will confer a benefit upon the author(s) or upon any the quadriceps group while incurring the least patellofemoral
organization with which the author(s) is/are associated. joint reaction force and stress is with a short arc (⬍45° flexion
Reprint requests to Simon F.T. Tang, MD, Dept of Physical Medicine and Reha- to extension), closed kinetic chain exercise.9 Selective VMO
bilitation, Chang Gung Memorial Hospital, 5 Fu-Shin St, Kwei-Shan, Tao-Yuan 333,
Taiwan, e-mail: fttang@adm.cgmh.org.tw.
strengthening may possibly be enhanced by hip adduction
0003-9993/01/8210-6419$35.00/0 exercises, which may also give the VMO a stable origin from
doi:10.1053/apmr.2001.26252 which to contract. Hanten and Schulthies11 showed that during
METHODS
Subjects
Ten subjects (5 women, 5 men; age range, 21–32yr; mean,
25.7yr) with asymptomatic knees and 10 subjects (6 women, 4
men; age range, 19 – 48yr; mean, 28.2yr) with bilateral PFPS
were included in the study. Asymptomatic subjects were de-
fined as individuals with pain-free knees who had never had
significant knee or lower extremity pathology or surgery.
The symptomatic subjects had no history of direct trauma to
the patellofemoral joint, but had bilateral anterior knee pain for
a minimum of 6 weeks. The pain was elicited by squatting, stair
climbing, kneeling, and prolonged sitting. Patients with con-
comitant ligamentous injury were excluded. Examinations of
the knees with merchant’s views confirmed patellofemoral
malalignment. The symptomatic group was diagnosed and ex-
amined by the same physiatrist (SFTT).
Procedures
Subjects performed all tasks under instructions from an
engineer at the Rehabilitation Science & Engineering Service
Center of Chang Gung Memorial Hospital, Taiwan. Informed
consent was obtained from all subjects before they entered the
study.
To prepare the area for attachment of surface electromyo-
Fig 1. Closed kinetic chain exercise by squatting and standing.
graphic electrodes, the anterior thigh and medial tibial crest
were cleaned with isopropyl alcohol. Surface electrodes were
centered on the muscle bellies of the VMO and distal VL, as thigh straps were fastened for stabilization. Quadriceps con-
described by Basmajian and Blumenstein.12 A MyoSystem centric and eccentric contractions were recorded at between 0°
200b was used to acquire electromyographic signals from 9 and 90° of knee flexion. All the tests were done at the angular
channels, of which 8 signals were from the surface electrodes velocity of 120°/s. Both legs of symptomatic subjects were
placed on the lower limbs. The last channel was used as an tested, with the order of testing chosen randomly. After testing
event marker. The raw electromyographic signals were band- there was a 5-minute cool-down period, after which ice was
pass filtered (15–500Hz) and sampled at 1000Hz. The signals applied for 10 minutes to the examined knees.
were rectified and low-pass filtered (cutoff frequency, 6Hz). In the closed kinetic chain exercise, stand-to-squat, and
This system used bipolar gold-plated surface electrodes to squat-to-stand tasks were repeated twice in our gait laboratory
collect electromyographic signals. with a Vicon 370 motion analysis systemc with 6 cameras
Both legs of subjects in the symptomatic group were tested. containing infrared light-emitting diodes. Reflective markers
Because there is no evidence of a relation between unilateral were placed on the sacrum, bilateral anterosuperior iliac spines,
patellofemoral dysfunction and leg dominance, we tested ran- greater trochanters, anterior thighs, medial and lateral malleoli,
domly chosen legs of the asymptomatic subjects. Every subject anterior tibia, dorsum of the foot, fifth metatarsal heads, and
in both groups was tested under 2 exercise modes, the open posterior heels. Motion analysis of the lower extremity was
kinetic chain and the closed kinetic chain. then determined for the sagittal plane. The trunk was kept
In the isokinetic open kinetic chain exercise, a KIN-COM upright and, to obtain better balance control, the subjects were
isokinetic dynamometer was used. The testing procedure began asked to hold the 2 arms of a walker (fig 1). Quadriceps
with a 5-minute warm-up on a stationary bicycle, followed by eccentric contraction intensity was recorded during squatting,
stretching of the quadriceps, hamstrings, iliotibial band, and whereas quadriceps concentric contraction intensity was re-
calf musculatures. Subjects’ positioning on the dynamometer corded during squatting-to-standing tasks. The contraction in-
was according to the manufacturer’s protocol, with the the back tensities were recorded by surface polyelectromyography. Sub-
supported and the hip flexed to approximately 80°. Trunk and jects performed all the tasks at a speed comfortable to them.
15. Palmitier RA, An KN, Scott SG, Chao EY. Kinetic chain exercise concentric and eccentric isokinetic contractions. Isokinet Exerc
in knee rehabilitation. Sports Med 1991;11:404-13. Sci 1991;1:26-30.
16. Souza DR, Gross MT. Comparison of MVO:VL integrated elec-
tromyographic ratios between healthy subjects and patients with Suppliers
patellofemoral pain. Phys Ther 1991;71:310-20. a. Chattecx Corp, 4717 Hixson Rd, PO Box 489, Hixson, TN 34343.
17. Callaghan MJ, McCarthy CJ, Al-Omar A, Oldham JA. The repro- b. Noraxon USA Inc, 13430 N Scottsdale Rd, Ste 104, Scottsdale, AZ
ducibility of multi-joint isokinetic and isometric assessments in a 85254.
healthy and patient population. Clin Biomech 2000;15:678-83. c. Oxford Metrics Ltd, Unit 14, 7 West Way, Oxford OX2 OJB,
18. Dvir Z, Halperin N, Shklar A, Robinson D. Quadriceps function England.
and patellofemoral pain syndrome. Part I: pain provocation during d. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.