Assessing Quadriceps Femoris Muscle Bulk with-Girth Measurements in Subjects with Patellofemoral Pain

Local neuromuscular characteristics associated with patellofemoral pain: A systematic review and meta-analysis

BACKGROUND

Local neuromuscular deficits have been reported in people with patellofemoral pain. We synthesised the neuromuscular characteristics associated with patellofemoral pain to help identify interventional targets and potential mechanisms.

METHODS

Five databases were searched for local neuromuscular characteristics in case-control studies. Electromyography, flexibility, muscle performance and cross-sectional area data were derived from functional or isolated task investigations and synthesised accordingly. An evidence gap map was constructed.

FINDINGS

Sixty-seven studies were included. In functional tasks, electromyographic investigations showed moderate evidence of small effect for vastus medialis onset-delays relative to vastus lateralis (0.44 [0.03, 0.85]) during stepping/stair negotiation tasks, and higher biceps femoris mean excitation amplitudes (0.55 [0.06, 1.04]) in single-leg triple-hop test. In isolated tasks, we found moderate evidence of medium effect for lower Hoffman-reflex amplitude of vastus medialis (-1.12 [-1.56, -0.67]). Muscle performance investigations showed; strong evidence with medium and small effects for lower extensors concentric (-0.61 [-0.81, -0.40]) and eccentric (-0.56 [-0.79, -0.33]) strength, and moderate evidence of medium effect of lower isometric (-0.64 [-0.87, -0.41]) strength, moderate evidence with small effect for rate of force development to 30% (-0.55[-0.89, -0.21]), 60% (-0.57[-0.90, -0.25]) and medium effect to 90% (-0.76[-1.43, -0.10]) of maximum voluntary contraction, and small effect for lower flexors concentric strength (-0.46 [-0.74, -0.19]) and extensors total work (-0.48 [-0.90, -0.07]). Flexibility investigations showed tighter hamstrings (-0.57 [-0.99, -0.14]).

INTERPRETATION

Differences within quadriceps and hamstrings motor-control, hamstrings tightness, and quadriceps and hamstrings weakness are associated with patellofemoral pain, and can be used to guide investigations of treatment effects.

Effects of Resting vs. Continuous Blood-Flow Restriction-Training on Strength, Fatigue Resistance, Muscle Thickness, and Perceived Discomfort

Introduction: The purpose of this study was to clarify whether blood-flow restriction during resting intervals [resting blood-flow restriction (rBFR)] is comparable to a continuous BFR (cBFR) training regarding its effects on maximum strength, hypertrophy, fatigue resistance, and perceived discomfort. Materials and Methods: Nineteen recreationally trained participants performed four sets (30-15-15-15 repetitions) with 20% 1RM on a 45° leg press twice a week for 6 weeks (cBFR, n = 10; rBFR, n = 9). Maximum strength, fatigue resistance, muscle thickness, and girth were assessed at three timepoints (pre, mid, and post). Subjective pain and perceived exertion were determined immediately after training at two timepoints (mid and post). Results: Maximum strength (p < 0.001), fatigue resistance (p < 0.001), muscle thickness (p < 0.001), and girth (p = 0.008) increased in both groups over time with no differences between groups (p > 0.05). During the intervention, the rBFR group exposed significantly lower perceived pain and exertion values compared to cBFR (p < 0.05). Discussion: Resting blood-flow restriction training led to similar gains in strength, fatigue resistance, and muscle hypertrophy as cBFR training while provoking less discomfort and perceived exertion in participants. In summary, rBFR training could provide a meaningful alternative to cBFR as this study showed similar functional and structural changes as well as less discomfort.

Dose atrophy of vastus medialis obliquus and vastus lateralis exist in patients with patellofemoral pain syndrome

Background

Whether vastus medialis obliquus atrophy exists in patients with patellofemoral pain syndrome and whether the amount of atrophy differs between the vastus medialis obliquus and vastus lateralis muscles remain unknown.

Materials

From June 2016 to March 2019, 61 patients with patellofemoral pain syndrome were retrospectively included in the study group, and an age-, sex-, and body mass index-matched cohort of 61 patients with normal knees was randomly selected as the control group. All enrolled subjects had undergone CT scans in the supine position. The cross-sectional areas of the vastus medialis obliquus and the vastus lateralis muscle in the sections 0, 5, 10, 15, and 20 mm above the upper pole of the patella were measured, and the vastus medialis obliquus/vastus lateralis muscle area ratio was evaluated.

Results

In the study group, the vastus medialis obliquus areas and the vastus lateralis muscle areas in the sections that were 0, 5, 10, 15, and 20 mm above the upper pole of the patella were significantly smaller than the respective areas in the control group (P < 0.05). The vastus medialis obliquus/vastus lateralis muscle area ratio was significantly smaller at the upper pole of the patella (the section 0 mm above the upper pole of the patella) than the corresponding ratio in the control group (P < 0.05). No significant difference was noted between the two groups in the sections 5, 10, 15, and 20 mm above the upper pole of the patella (P > 0.05).

Conclusion

In patients with patellofemoral pain syndrome, vastus medialis obliquus and vastus lateralis muscle atrophy existed in sections 0–20 mm above the upper pole of the patella, compared with normal controls, and atrophy of the vastus medialis obliquus was more evident than that of the vastus lateralis muscle at the upper pole of the patella. These findings support the rationale for the use of general quadriceps exercise combined with vastus medialis obliquus strengthening exercise as part of the rehabilitation programme for the patients with patellofemoral pain syndrome.

Effects of blood flow restriction without additional exercise on strength reductions and muscular atrophy following immobilization: A systematic review

PURPOSE

To investigate whether blood flow restriction (BFR) without concomitant exercise mitigated strength reduction and atrophy of thigh muscles in subjects under immobilization for lower limbs.

METHODS

The following databases were searched: PubMed, CINAHL, PEDro, Web of Science, Central, and Scopus.

RESULTS

The search identified 3 eligible studies, and the total sample in the identified studies consisted of 38 participants. Isokinetic and isometric torque of the knee flexors and extensors was examined in 2 studies. Cross-sectional area of thigh muscles was evaluated in 1 study, and thigh girth was measured in 2 studies. The BFR protocol was 5 sets of 5 min of occlusion and 3 min of free flow, twice daily for approximately 2 weeks. As a whole, the included studies indicate that BFR without exercise is able to minimize strength reduction and muscular atrophy after immobilization. It is crucial to emphasize, however, that the included studies showed a high risk of bias, especially regarding allocation concealment, blinding of outcome assessment, intention-to-treat analyses, and group similarity at baseline.

CONCLUSION

Although potentially useful, the high risk of bias presented by original studies limits the indication of BFR without concomitant exercise as an effective countermeasure against strength reduction and atrophy mediated by immobilization.

Does quadriceps atrophy exist in individuals with patellofemoral pain? A systematic literature review with meta-analysis

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To investigate whether quadriceps atrophy is present in the affected limb of individuals with patellofemoral pain (PFP).

BACKGROUND

PFP is a common condition. Atrophy of the quadriceps femoris, in particular the vastus medialis obliquus, is often assumed to be present by clinicians, and its resolution may underpin the reported effectiveness of quadriceps strengthening intervention in PFP rehabilitation.

METHODS

A systematic search of the literature was conducted to identify studies that measured the size of the quadriceps in individuals with PFP. Meta-analyses were performed to determine whether quadriceps size in limbs with PFP differed from that in comparison limbs. Separate meta-analyses were performed for quadriceps size measured as girth and quadriceps size measured with imaging (thickness, cross-sectional area, and volume).

RESULTS

Ten studies were included in this review. The meta-analysis of girth measurements (3 studies) found no atrophy in limbs with PFP (P = .638). The meta-analyses for imaging techniques (thickness, cross-sectional area, or volume measurements) showed atrophy in the limb with PFP compared to both the asymptomatic limb (3 studies) (P = .036) and limbs from a comparison group (3 studies) (P = .001). The single study that compared the vastus medialis obliquus and vastus lateralis in individuals with PFP found atrophy of both the vastus medialis obliquus and vastus lateralis but no significant difference in the amount of atrophy between them (P = .179).

CONCLUSION

Quadriceps muscle atrophy was shown to be present in PFP when analyzed by imaging, but not by girth measures. Insufficient data were available to determine if there was greater atrophy of the vastus medialis obliquus than the vastus lateralis. These findings support the rationale for use of quadriceps strengthening as part of a rehabilitation program for PFP.

What predicts functional outcome after treatment for patellofemoral pain?

PURPOSE

Although physical therapy is known to be effective in treating patellofemoral pain (PFP), there is considerable individual variation in the treatment response. It is unclear why some patients benefit from a specific treatment while others do not experience improvement. This study, using a prospective study design, aims to identify factors that could predict the short-term functional outcome and account for the variation frequently seen in the outcome after conservative treatment of PFP.

METHODS

Thirty-six patients (20 female and 16 male with a mean age of 23.8 ± 6.7 yr) followed a physical therapy rehabilitation program of 7 wk. Before this treatment, all patients were evaluated on subjective symptoms (pain on visual analog scales in millimeters) and functional performance (step test expressed as highest level, single-legged hop test in centimeters, and triple-hop test in centimeters). The concentric and eccentric knee extensor strength at 60°.s(-1) and 240°.s(-1) (N.m) were measured as well as the quadriceps muscle size by calculating the cross-sectional area (cm(2)) with magnetic resonance imaging. The success of the treatment was evaluated by the functional Kujala anterior knee pain scale. A linear regression model was used to identify predisposing factors for the functional outcome.

RESULTS

The total quadriceps cross-sectional area (P = 0.010), the eccentric average peak torque at 60°.s(-1) (P = 0.015), and the frequency of pain at baseline (P = 0.012) have been indicated as predisposing variables in the short-term functional outcome after a physical therapy rehabilitation program for PFP (adjusted R(2) = 0.46).

CONCLUSION

Patients with a greater quadriceps muscle size, lower eccentric knee strength, and less pain have a better short-term functional outcome after conservative treatment for PFP.

Vastus medialis obliquus atrophy: does it exist in patellofemoral pain syndrome?

BACKGROUND

Quadriceps atrophy and in particular atrophy of the vastus medialis obliquus (VMO) muscle have been frequently related with patellofemoral pain syndrome (PFPS), despite very little objective evidence.

HYPOTHESIS

Patients with PFPS exhibit atrophy of the VMO in comparison with healthy controls.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Forty-six patients with PFPS and 30 healthy control persons with similar age, gender, body mass index, and activity index distributions underwent magnetic resonance imaging (MRI) of the quadriceps. The muscle size was determined by calculating the cross-sectional area of the total quadriceps and its components.

RESULTS

The cross-sectional area (CSA) of the VMO was significantly smaller in the PFPS group than in the control group (16.67 ± 4.97 cm(2) vs 18.36 ± 5.25 cm(2)) (P = .040). A tendency was noted for a smaller total quadriceps CSA for the PFPS patients at midthigh level (66.99 ± 15.06 cm(2) vs 70.83 ± 15.30 cm(2)) (P = .074).

CONCLUSION

This is the first study to examine VMO size in PFPS patients by MRI. Patients with patellofemoral problems exhibited atrophy of the VMO. Although it is not clear whether this atrophy is a result or a cause of PFPS, the results of this study do show that atrophy of the VMO is a contributing factor in PFPS. Longitudinal, prospective studies are needed to establish the cause-effect relation of VMO atrophy and PFPS.

Women with patellofemoral pain syndrome have quadriceps femoris volume and strength deficiency

PURPOSE

the aim of this study was to assess muscle torque, total volume, and cross-sectional area, and lower limb function of the quadriceps muscle in women with unilateral patellofemoral pain syndrome (PFPS).

METHODS

twenty-four women with unilateral patellofemoral pain participated in the study, with each subject acting as their own internal control by using the unaffected limb. quadriceps muscle torque was measured with the Isomed 2000. The total volume and cross-sectional area (CSA) of the quadriceps muscle were measured by using magnetic resonance imaging. Lower limb function was assessed by hop and step-down tests.

RESULTS

there was a significant difference in the total volume (P < 0.05) and in the cross-sectional area (P < 0.05) of the quadriceps muscle between affected and unaffected sides. There was a significant difference in the peak torque of the quadriceps muscle at 60°/s between affected and unaffected sides (P < 0.05). There were significant correlations between quadriceps largest CSA and volume on the affected side (P < 0.05) and on the unaffected side (P < 0.05). There were significant negative correlations between the smallest CSA and the peak torque at 180°/s (P < 0.05) and at 60°/s (P < 0.05) on the affected side.

CONCLUSIONS

decreased torque, total volume, and CSA of the quadriceps muscle are presented in unilateral with PFPS although cause or effect cannot be established. Large prospective longitudinal studies are needed to detect the changes in the muscle structure and to establish whether these features are a cause of PFPS.

Quantitative sensory testing of patients with long lasting Patellofemoral pain syndrome

BACKGROUND

Anterior knee pain, diagnosed as Patellofemoral Pain Syndrome (PFPS), is one of the most common musculoskeletal problems found in adolescents and young adults. There is no consensus in medical literature concerning the aetiology of the PFPS.

AIMS

To assess by means of Quantitative Sensory Testing (QST) whether patients suffering from long-lasting unilateral PFPS demonstrate somatosensory dysfunction related to afferent fibres from the local pain area.

METHODS

A descriptive non-experimental study with two independent samples, consisting of 25 men and women between 18 and 44 years of age with unilateral PFPS, and a comparable group of 23 healthy subjects. Somedic Thermotest apparatus was used to assess thresholds of thermal perception, and of heat and cold pain thresholds. Von Frey filaments were used to detect tactile sensitivity. Furthermore, quality and intensity of knee pain, symptoms and signs from a clinical neurological examination were recorded.

RESULTS

Decreased sensitivity to tactile stimulation, when tested with von Frey filaments, was demonstrated on both the painful and pain-free knee in subjects with PFPS, compared to the mean between the knees of the control group (p< or =0.001). The mean detection threshold for warmth was increased by 1.9 degrees C (p< or =0.01) in the painful knee, and 1.4 degrees C (p< or =0.01) in the non-painful knee in the PFPS group, compared to the mean of the healthy control group. The mean detection threshold for cold was increased by 1.6 degrees C (p< or =0.01) in the painful knee of the PFPS group, compared to the control group. These findings were supported by clinical sensory tests. No significant differences of mean thermal pain thresholds between the PFPS group and controls were found, and there were no significant differences in mean detection thresholds for warmth, cold or thermal pain thresholds between the painful and the non-painful knees in the PFPS group.

CONCLUSION

This study demonstrated an abnormal sensory function in the painful and non-painful knee in some individuals with long lasting unilateral Patellofemoral Pain Syndrome using Quantitative Sensory Testing supported by clinical neurological examinations. A dysfunction of the peripheral and/or the central nervous system may cause neuropathic pain in some subjects with PFPS.

Comprehensive functional evaluation of the injured runner

In most cases, a detailed history provides the information that is necessary for the clinician to diagnose the injured runner correctly; however, to treat the injury and guide a successful rehabilitation program, the physical examination must go beyond the standard regional musculoskeletal examination. The victims (tissue injury) and the culprits (biomechanical deficits) must be identified to facilitate treatment (Table 3). Gait and other dynamic assessments help to reveal underlying deficits in function that may have contributed to injury. In short, the entire functional kinetic chain must be considered and weak links identified.

Inter- and Intratester Reliability of Lower Extremity Circumference Measurements

The purpose of this study was to examine the inter- and intratester reliability of lower extremity circumference measurements obtained by two testers using the same tape measure and two different tape measures. Twenty-one male high school student-athletes participated in this study. Two testers measured lower extremity circumference at three sites using a standard flexible tape measure and a Lufkin tape measure with a Gulick spring-loaded handle attachment. Measurement sites were medial joint line, 20 cm above medial joint line, and 15 cm below medial joint line. Intraclass correlation coefficients were computed for inter- and intratester comparisons for each measuring device and each measurement site. Results indicated high reliability but a significant difference between the two tape measures. These findings indicate that the reliability of lower extremity circumference measurements is not influenced by tester experience and that the Lufkin tape measure with the Gulick handle attachment is the more accurate of the two tape measures.

Reliability of lower extremity girth measurements after anterior cruciate ligament reconstruction

The purpose of this study was to determine the intra- and inter-rater reliability of lower extremity girth measurements in patients recovering from anterior cruciate ligament (ACL) reconstructive surgery. Nine subjects, within several months of their surgery, volunteered. Circumferential measurements were taken of the involved and uninvolved legs at the following locations: 15 cm inferior to the joint line; 5, 10 and 15 cm superior to the joint line; at the joint line; and at mid-thigh. All subjects were supine with the knee in extension whilst a specially designed device, formulated to make circumferential measurements at locations around the knee, was applied to the extremity. Three physical therapists each repeated all measurements on two occasions, in random order, during the same test session. Intra-tester intraclass correlation (ICCs) calculated showed high coefficients (0.82-1.0) for both the involved and uninvolved sides for all locations of the measurement. Inter-tester ICCs ranged from 0.72 to 0.97. The measurements established sufficiently high reliability to justify their use both within and between examiners for subjects recovering from surgery of the ACL.

Anterior knee pain: the need for objective measurement

Anterior knee pain is a very common condition, particularly amongst young people. Those patients who have demonstrable pathological or biomechanical abnormalities can often be helped surgically. However, there are many others who have severe patellar pain despite normal, or near normal, clinical and arthroscopic examination. There have been a plethora of conservative treatments the mainstays of which are rest and exercise. However, the rationale behind these conservative methods has been largely empirical, and progress subjective. Treatment may be more effectively applied if further evidence is established about the relationship between the foot and ankle biomechanics and the patellofemoral joint. Kinematic and kinetic gait analyses have recently been reported as being of major importance in the objective measurement of lower limb function and its effects on the patellofemoral joint.

Measurement of anterior tibial muscle size using real-time ultrasound imaging

Cross-sectional images of the anterior tibial muscle group were obtained using real-time ultrasound scanning in 17 normal women. From photographs taken of the images, the cross-sectional area (CSA) and two linear measurements of muscle cross-section were determined. A measurement of the shortest distance of the muscle depth was termed DS, and a measurement of the longest distance through the muscle group was termed DL. Both linear dimensions showed a positive correlation with CSA and the best correlations were obtained when the dimensions were squared or combined (DS x DL). The correlation values were: CSA vs DS2, r = 0.9; CSA vs DL2, r = 0.75 and CSA vs DS x DL, r = 0.88. An approximate value for CSA could be calculated from DS2 by the equation 2 x DS2 + 1. A shape ratio, obtained by dividing DL by DS, was consistent within the group [mean 2.1 (SD 0.2)] and characterised the muscle geometrically. The CSA of repeated scans was assessed for repeatability between-days and between-scans by analysis of variance and the coefficient of variation (CV) calculated. Areas were repeatable between-days (CV 6.5%) and between-scans (CV 3.6%). Linear dimensions of the anterior tibial muscle group reflected CSA and their potential for assessing changes in muscle size with atrophy and hypertrophy have yet to be established.

Rehabilitation of a collegiate football placekicker with patellofemoral arthritis

A 24-year-old NCAA Division I collegiate football placekicker presented in the clinic 4 months postseason complaining he had begun to experience pain and stiffness in his knee with subsequent loss of power and distance with his kicks toward the latter part of the previous season. He was placed on a rehabilitation program which included utilizing end-range isotonics for the quadriceps, short-arc isokinetics at intermediate speeds, and full range isokinetics at high contractile speeds for knee extension and flexion, lower extremity stretching, electrical stimulation to the quadricep musculature, and underwater kicking workouts along with placekicking and kickoff workouts. The patient was treated in the clinic 3 times per week for 8 weeks and upon discharge subjectively reported having regained distance and power with his kicks. Pre- and post-Cybex testing revealed an increase in peak torque at 60 and 180 degrees /sec of 14 and 15%, respectively, of the quadriceps in the affected kicking leg. This study details one form of intervention in patellofemoral syndrome associated with the specialized sport skill of placekicking.J Orthop Sports Phys Ther 1988:10(6):224-227.