Patellofemoral pain syndrome (also known as anterior knee pain) is characterized by pain around the kneecap that increases with prolonged activity or prolonged sitting. It is more common in females and is associated with weakness of the hip, particularly hip abductors, extensors and rotators (Prins et al. 2009) as Dr. Janda had proposed. This weakness is thought to lead to biomechanical deficits at the knee, most notably an increased knee abduction torque, which may alter patellar alignment over the distal femur at the knee. In addition, researchers (Leetun et al. 2004) have found that athletes with weak hip abductors and extensors in pre-participation screenings are more likely to be injured.

Therapeutic exercise programs strengthening the ‘proximal’ musculature (hip and core) have been successful in relieving symptoms of anterior knee pain. A research article in the American Journal of Sports Medicine reported on the outcomes of an exercise program in a series of young females with patellofemoral pain syndrome. After the 8-week exercise program, 17 out of 19 (89%) of the participants had successful outcomes. They had significant improvements in pain, functional ability, core endurance, and hip strength, as well as improvement in the knee abduction angle during gait. The main limitation of this study was the lack of a true control group, which would be able to identify if the exercise program was responsible for the improvements observed.

It would have been beneficial if the authors had identified specific muscle imbalance patterns within the individuals and prescribe an individualized program. In the current study, all participants performed the same exercises regardless of the presence of muscle imbalance. Such information would be helpful in determining if an individualized therapeutic exercise program can be more efficient and effective by targeting specific impairments.

Females with patellofemoral pain syndrome can benefit from a proximal strengthening program. A true control group and long-term follow-up would have been beneficial in further validating the efficacy of the program.

REFERENCE: Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011 Jan;39(1):154-63. Epub 2010 Oct 7.

Dr. Janda often prescribed sensorimotor training exercises using unstable surfaces for patients with chronic low back pain. Dr. Janda considered unstable surfaces such as balance boards as important tools in rehabilitation of chronic musculoskeletal pain syndromes. His Sensorimotor Training program utilizes unstable surfaces can help facilitate automatic postural reactions, which are not possible through voluntary muscle strengthening exercises. It’s important that patients perform sensorimotor training exercises at a level of challenge that allows them to maintain postural stability. Therefore, clinicians must prescribe the appropriate level of instability challenge in each patient for a particular exercise.

Researchers compared muscle activation patterns in patients with low back pain with healthy subjects. They measured trunk muscle activity, lumbar range of motion, and balance during 5 common lumbar stabilization exercises performed on stable and unstable surfaces using an inflatable disk: quadruped, side bridge, modified push-up, squat, and shoulder flexion.

They found that patients with low back pain had adaptive recruitment patterns while maintaining similar levels of balance and lumbar range of motion compared to healthy subjects. There was little increase in electromyographic (EMG) activation among low back pain patients between the stable and unstable surface, and some exercises actually increased lumbar range of motion on unstable surfaces, which is not desirable during lumbar stabilization exercise. Based on these findings, the researchers questioned the need and benefit for using labile surfaces in patients with low back pain.

Subjects in this study may have performed exercises at a level beyond their control, which was evident in the researchers finding increased movement of the lumbar spine on unstable surfaces. All exercises in this study were performed on the same high level of instability, an inflatable disk, which exceeds the challenge recommended by Dr. Janda using balance boards.

It’s also important to note that the researchers only investigated superficial abdominal and low back muscles. Unstable surfaces are thought to activate deeper stabilizing muscles, which is the reason clinicians use them when rehabilitating spine patients. It’s quite possible that deeper muscles were activated in this study because the lumbar spine was shown to move without increased activation of the superficial muscles.

Based on the results of this study, clinicians need to provide an appropriate level of instability to ensure the lumbar spine remains stable during the exercise.

REFERENCE: Desai I, Marshall PW. Acute effect of labile surfaces during core stability exercises in people with and without low back pain. J Electromyogr Kinesiol. 2010 Dec;20(6):1155-62.

Imagine this case scenario: An elite triathlete is referred to your clinic for chronic hamstring cramps in his right leg. A traditional ‘structural’ approach would involve a stretching and strengthening program of the hamstrings. A more ‘functional’ approach would include an assessment of the entire lower kinetic chain, pelvis and trunk to look for biomechanical causes of his cramping perhaps from muscle fatigue.  This functional assessment is a hallmark of the Janda Approach.

Physical therapist Tracey Wagner and colleagues described a case report of such a patient. Rather than focusing on the site of the problem, they looked elsewhere for the source of the problem. As Prof Karel Lewit said, “He who treats the site of pain is often lost.”

The patient had bilateral hamstring tightness and bilateral gluteus maximus weakness. Dynamic assessment of gait, lunge, and step-down movements was performed. The therapists noted that a lack of knee extension in midstance and terminal swing bilaterally was consistent with the patient’s hamstring tightness. In addition, excessive hip adduction and internal rotation with posterior trunk lean supported the finding of hip weakness.

The therapists theorized that impaired gluteus maximus neuromuscular control increased the load on the hamstrings during terminal stance phase, leading to the overuse and cramping. They then referred the patient for assessment at the Musculoskeletal Biomechanical Research Lab at USC with Dr. Chris Powers.

The patient’s hamstring EMG was evaluated and was found to be relatively high (48% MVIC). This supported their functional diagnostic hypothesis, and led to their physical therapy treatment plan.

The patient completed a home exercise program over 8 months, attending physical therapy once a month. The program included 3 phases:

1. Isolated muscle recruitment (Weeks 0-4): gluteus maximus exercises including sidelying clam, prone isometric gluteus maximus, and quadruped triplanar movement.
2. Weight-bearing strengthening (Weeks 5-16): Monster walk, forward and backward walk with elastic band loop around thighs and step-downs
3. Functional training (Weeks 17-24): jumps and leg swings

After the intervention, the patient successfully completed 3 half-triathalons without cramping. His gluteus maximus strength increased  from 35.6 kg to 54.7 kg on the right (involved) and from 35.5 kg to 46.8 kg on the left.  In addition, his hamstring flexibility, functional performance, and hamstring EMG levels improved.

This case report supports addressing pelvic/trunk muscle dysfunction in hamstring pathology: a good biomechanical functional assessment led to an accurate pathomechanical diagnosis.

REFERENCE: Wagner T, et al. Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings. J Orthop Sports Phys Ther. 2010 Feb;40(2):112-9.

                Fans of Dr. Janda’s work know it’s always important to evaluate more than just the area of pain, particularly the proximal segments of a more distal pathology. Recently, hip weakness was associated with anterior knee pain in several studies, as suggested by Janda. These proximal muscle imbalances are thought to lead to altered motor control strategies and subsequent abnormal biomechanics at the knee during the stance phase of gait.

A new study from the United Kingdom on football (soccer) players with chronic groin strains found decreased gluteus medius (hip abductor) muscle activation on the injured leg. Healthy and injured subjects performed standing hip flexion to 90 degrees while Noraxon® surface electromyography (EMG) was collected. The activation ratio was determined between the hip abductors and adductors of the injured leg during both flexion and stance. The researchers also analyzed time-to-onset of muscle activation. Interestingly, this imbalance occurred in both the stance phase and kicking phase of a standing hip flexion test in the injured athletes. This decrease in activation led to muscle imbalance between the hip abductors and adductors. Tyler and colleagues (2001) also demonstrated hip muscle imbalance in the kicking leg of soccer players with groin injuries, although they showed weakness of the hip adductor muscles.

The researchers found a 40 to 50% decrease in activation and subsequently significant reduction in hip abductor:hip adductor ratio in the injured leg during stance. Muscle activation was delayed during all phases of movement as well. Interestingly, the athletes with chronic groin pain demonstrated muscle imbalances on the uninjured side as well. This result surprised the researchers, but clinicians often see these global imbalances in chronic musculoskeletal pain, supporting the etiology resulting from CNS dysregulation.

REFERENCE: Morrissey D, et al. Coronal plane hip muscle activation in football code athletes with chronic adductor groin strain injury during standing hip flexion. Man Ther. 2012 Apr;17(2):145-9.

Thoracic Outlet Syndrome (TOS) is a complex and sometimes difficult condition to identify and treat. Thoracic outlet syndrome occurs with compromise of the nerves and blood vessels passing from the neck into the arm through a region known as the “thoracic outlet”. Entrapment of this neurovascular bundle can lead to both neurological symptoms (numbness and burning of the entire hand) and vascular symptoms (coolness and discoloration of the hand).

A majority of thoracic outlet patients will have neurological signs and symptoms. Signs of TOS include changes in sensation across multiple dermatomes or changes in the radial pulse with different positions of provocation; these respective symptoms help differentiate between neurological and vascular entrapment.

Regardless of the symptom differentiation, the cause of thoracic outlet syndrome should be classified as a structural or functional origin in order to provide an appropriate intervention. Conservative treatment is recommended for all types of TOS and surgery is only indicated if conservative approaches fail.

A paper in the journal Manual Therapy, described an interesting approach to conservative management of thoracic outlet syndrome: look at the scapula! Because the thoracic outlet passes underneath the clavicle and coracoid (a possible location for entrapment), the position and control of scapular movement may be a missing link’ in thoracic outlet rehabilitation.

Influence of scapular position on the thoracic outlet

The authors, Watson and colleagues, noted that most neurologic-type TOS patients present with depressed scapula, both at rest as well as during shoulder abduction and flexion. Lifting the arm with insufficient upward rotation, scapular winging, and anterior tilt of the scapula may reduce clearance of the thoracic outlet. Interestingly, this pattern of dynamic scapular dysfunction is associated with muscle imbalance: tightness of the upper trapezius, levator scapula, and pectoralis minor with weakness of the serratus anterior, lower trapezius, and rhomboids. This pattern is also commonly seen in shoulder impingement and instability. Watson et al. suggested the upper trapezius might be prone to weakness in thoracic outlet syndrome; however, no EMG evidence exists in thoracic outlet syndrome patients to substantiate this relationship.

The authors proposed a rehabilitation program for thoracic outlet syndrome focusing on scapular position and control, beginning in lower ranges of abduction and progressing to higher levels of elevation. Patients begin with scapular setting drills and progress to lower levels of abduction (30, 45, and 90 degrees) and flexion below 90 degrees. Patients then progress to maintaining upward rotation and elevation with synchronous activation of the trapezus and serratus muscles.

The authors note that this approach is based on their clinical approach with only anecdotal evidence of success. Further research is needed to validate this treatment approach, but it serves as a great suggestion for conservative management of thoracic outlet syndrome.

REFERENCE: Watson LA, Pizzari T, Balster S.  Thoracic outlet syndrome part 2: conservative management of thoracic outlet. Man Ther. 2010 Aug;15(4):305-14.

I’ve been a fan of Pavel Kolář’s work in merging the work of Vojta and Janda. Dr. Janda said Pavel was one of his best students, and often pointed to his emerging work with developmental kinesiology at the time and its implications in rehabilitation. I’ve attended several of the “pre-DNS” (Dynamic Neuromuscular Stabilization) courses including one at Motol Hospital in Prague. As with Janda, I’ve been challenged to support Prague School theories with evidence. Much of the Prague School evidence is rooted in the teaching and daily practice of ‘founders’ Janda, Lewit, Vojta, and Vele. I was very pleased to see a paper authored by Kolář and colleagues in Prague in the recent issue of Journal of Orthopedic and Sports Physical Therapy.

One of the main tenets of DNS according to Kolář is the importance of the diaphragm in providing both trunk stabilization and respiration function. Janda spoke of the diaphragm as a muscle prone to inhibition, and Lewit described the ‘core’ as a neurologically-connected group of 4 muscles: transverse abdominus, multifidus, diaphragm, and pelvic floor. Subsequent work by Australian researchers at the University of Queensland found that not only were these muscles often poorly activated (both in intensity and speed of contraction) in low back pain patients, but they were also involved in both posture and respiration.

In their JOSPT study, Kolář and colleagues compared 29 healthy subjects (examined in an earlier study) with 18 patients suffering from chronic low back pain. They measured the excursion of different parts of the diaphragm during breathing using dynamic MRI, as well as the position of the diaphragm during inspiration and expiration. They also compared the excursion of the diaphragm while the subjects performed isometric flexion of the legs and arms (below). (Interestingly, the authors called this isometric flexion movement, a “postural activity.”)

They found that while diaphragm excursion and position were not different between controls and low back pain patients during resting breathing, the patients did exhibit reduced diaphragm movement with isometric contraction of the arms or legs, particularly in the anterior and middle portions, resulting in a steeper angle in the middle-posterior part of the diaphragm; this helps support Kolář’s representation of an inspiratory diaphragmatic posture.

Their findings are similar to the work of Paul Hodges and colleagues from Queensland, who examined the EMG activation and timing of the transverse abdominus and multifidus, pelvic floor, and diaphragm during arm and leg movements as well; however, the Australian testing was generally performed in standing and sitting in contrast to Kolář et al., who tested subjects in supine using dynamic MRI. I would have been very interested to see measurement of intraabominal pressure, as well as activation of the transverse abdominus and other core-stabilizing muscles concomitantly because of their coordinated efforts in posture and stabilization. As Dr. Stu McGill suggests, one muscle by itself cannot provide core stabilization. Kolář and colleagues also correctly noted this present study does not infer causation, and it can’t be determined if the diaphragm dysfunction is a cause or result of chronic low back pain.

The authors noted several limitations in their study, including a baseline difference in age and sex; however, they adjusted for these differences statistically by treating age as a covariate. Another possible issue not mentioned by the authors was the lack of intra-rater reliability and lack of blinding of the examiner. Finally, statistical power was not reported, nor were clinically meaningful differences. While these “statistical” limitations should not detract from the findings of this study, they should be considered when interpreting the results.

In summary, this study contributes to the body of knowledge supporting Kolář’s DNS approach and movement dysfunction in low back pain. As with any clinical research on patients, there are many variables that are difficult to control; nonetheless, these results offer some insight to the combined postural and respiratory function of the diaphragm. While this study is important in identifying the presence of diaphragm dysfunction, future research should investigate its etiology and successful interventions.

If you’re interested in taking DNS courses, I recommend my Assessment and Treatment of Muscle Imbalance: The Janda Approach co-authors and certified DNS instructors, Clare Frank or Robert Lardner. Listen to an interview by Clare for more information on DNS.

REFERENCE: Kolář P, et al. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther. 2012;42(4):352-62. Epub 2011 Dec 21.

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I recently received a question about the difference between Janda’s Type A Lower Crossed Syndrome and Type B Lower Crossed Syndrome. Janda talked about his Lower Crossed Syndrome have 2 different presentations in patients; one manifested in the lower back (Type B) and the other in the hip (Type A).

Janda's Lower Crossed Syndrome Type A

Janda Lower Crossed Syndrome Type B

 According to Assessment and Treatment of Muscle Imbalance: The Janda Approach co-author Robert Lardner PT:

The two types are similar and display the same main muscle imbalance characteristics. However, Type B is due to primarily weakness and length of the abdominal wall giving a shallower, longer lordosis (when compared to Type A) which extends into the thoracolumbar area, with a more cranial shift of the kyphosis, anterior pelvic tilt, and genu recurvatum. While Type A is chiefly due to the shortness of the hip flexors leading to a deeper, shorter lordosis (when compared to Type B), it does not extend into the thoracolumbar region and is confined to the lumbar spine with chronic shortening of the hip flexors leading to knee flexion.

Anterior knee pain is often associated with hip muscle weakness of the abductors, extensors and external rotators. Dr. Vladimir Janda noted these muscles were particularly susceptible to inhibition and weakness. Patellofemoral pain is often associated with muscle imbalance. Hip weakness is particularly prevalent in females with anterior knee pain.

This hip weakness is thought to result in abnormal forces occurring at the knee during stance, allowing the femur to adduct more than normal, possibly leading to excessive force and/or abnormal tracking of the patellofemoral joint.

Traditionally, anterior knee pain was thought to result from quadriceps weakness, particularly from the vastus medialis muscle. Recent biomechanical and epidemiological data suggest however, that hip weakness may play a more important role in the etiology of patellofemoral pain. 

Dr. Khalil Khayambashi and colleagues performed a randomized controlled trial of hip exercise on females with patellofemoral pain. The experimental exercise group performed hip strengthening exercises 3 times a day for 8 weeks. Hip extension and external rotation exercises were performed on both legs using Thera-Band® elastic tubing.  

The control group did not exercise. Both groups were tested before and after the program for hip strength, pain, and self-report WOMAC scores.  There were 14 participants in each group, and no significant differences at baseline between groups.

After the 8 week intervention, the hip exercise group significantly decreased in knee pain and significantly improved their health status, whereas the control group did not improve.  In addition, the exercise group improved in hip strength significantly more than the control group, between 32 and 56%.  These improvements were maintained at the 6 month follow-up as well.

While these results are impressive given the simplicity of the exercise program, the study had a few limitations. Subjects were not categorized as having hip weakness before the program; it would be interesting to know if their knee pain was actually associated with hip weakness.  The researchers didn’t evaluate kinematics in subjects; therefore, it’s not clear if the strengthening program had a biomechanical effect. Finally, the relatively small sample size limits the generalizability of the findings.

In summary, a simple 8 week Thera-Band exercise program with only 2 hip exercises significantly reduces pain in females with anterior knee pain.

REFERENCE: Khayambashi K, et al.The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain.J Orthop Sports Phys Ther. 2012. 42(1):22-29.

About half the population suffers from headaches, and 15 to 20% of those headaches include head and neck pain. This type of headache is recognized as a ‘cervicogenic headache.’  It’s important to make an accurate diagnosis of cervicogenic headaches to initiate the proper treatment. Dr. Vladimir Janda discussed the presence of his Upper Crossed Syndrome in cervicogenic headache patients, which has been validated in several epidemiological studies.

Recently, Dr. Phil Page presented a webinar with Multi Radiance Medical on Cervicogenic Headaches. In the webinar, he explains current concepts in evaluation and treatment of cervicogenic headaches, including the use of manual therapy, modalities, and exercise. You can view the webinar for free by clicking here, thanks to Multi Radiance Medical. Dr. Page recently published a review paper on Cervicogenic Headaches which is also available for free download here.

The International Journal of Sports Physical Therapy recently published my paper on the clinical management of cervicogenic headaches.  The paper provides a background and etiology, as well as assessment and evidence-led interventions.  In the paper, I describe how Janda’s Upper Crossed Syndrome is typically present in patients with cervicogenic headaches, and discuss specific clinical tests to lead to an accurate diagnosis. Interventions such as modalities (TENS, Low-level laser therapy), manual therapy, stretching, soft tissue mobilization (Graston, ASTYM), and therapeutic exercise are also discussed.

Abstract: Cervicogenic headache (CGH), as the diagnosis suggests, refers to a headache of cervical origin. Historically, these types of headaches were difficult to diagnose and treat because their etiology and pathophysiology was not well-understood. Even today, management of a CGH remains challenging for sports rehabilitation specialists. The purpose of this clinical suggestion is to review the literature on CGH and develop an evidence-led approach to assessment and clinical management of CGH.

Download the article here: Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 6(3):254-266