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Closed kinetic chain exercises with or without additional hip strengthening

exercises in management of patellofemoral pain syndrome: a randomized
controlled trial

Article  in  European Journal of Physical and Rehabilitation Medicine · July 2013

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EUR J ­PHYS REHABIL MED 2013;49:687-98

Closed Kinetic Chain exercises

with or without additional hip strengthening exercises
in management of Patellofemoral pain syndrome:
a randomized controlled trial
M. M. ISMAIL, M. H. GAMALELDEIN, K. A. HASSA

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Background. Patellofemoral pain syndrome (PFPS) Orthopedic Physical Pherapy Department
is a common musculoskeletal pain condition, espe- Faculty of Physical Therapy
cially in females. Decreased hip muscle strength has Cairo University, Cairo, Egypt
been implicated as a contributing factor. Isolated

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open kinetic chain hip abductors and lateral rota-
tors exercises were added by many authors to the
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rehabilitation program. However, Closed Kinetic
Chain (CKC) exercises focusing on hip and knee
muscles were not investigated if they can produce (P<0.05) but pain and function improvements were
similar effect of hip strengthening and decreasing significantly greater in the CO group (P<0.05).
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pain without the need of isolated exercises for hip Conclusion. Six weeks CKC program focusing on knee
musculature. and hip strengthening has similar effect in improving
Aim. The aim of the present study was to determine
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hip muscles torque in patients with PFPS as a CKC

the effect of a CKC exercises program with or without exercises with additional hip strengthening exercises.
additional hip strengthening exercises on pain and However, adding isolated hip strengthening exercises
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hip abductors and lateral rotators peak torque. has the advantage of more pain relief.
Design. Prospective randomized clinical trial. Clinical Rehabilitation Impact. CKC exercises with ad-
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Setting. Patients with patellofemoral pain syndrome
referred to the outpatient physical therapy clinic of
the faculty of physical therapy, cairo university.
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ditional hip strengthening could be more beneficial
in decreasing pain in PFPS than CKC exercises alone.
Key words: Patellofemoral pain syndrome - Physical thera-

Population. Thirty two patients who had patellofemo-

ral pain syndrome with age ranged from eighteen to py modalities - Musculoskeletal pain.
thirty years.
Methods. Patients were randomly assigned into

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two groups: CKC group and CKC with hip muscles
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atellofemoral pain syndrome (PFPS) is one of the

strengthening exercises as a control (CO) group.
Treatment was given 3 times/week, for 6 weeks. Pa-
most common knee pain syndromes encountered
tients were evaluated pre- and post-treatment for their in the orthopedic physical therapy outpatient clinic.1,
2 The incidence rate for PFPS was 22/1000 person-
pain severity using VAS, function of knee joint using
Kujala questionnaire, hip abductors and external rota- years. Females were approximately 2 times more like-
tors concentric/eccentric peak torque. ly to develop PFPS compared with males.3, 4
Results. There were significant improvements in pain, PFPS is described as anterior or retropatellar
function and hip muscles peak torque in both groups
or other proprietary information of the Publisher.

knee pain in the absence of other pathology. Clini-

(P<0.05). However, there was no statistically signifi-
cant difference between groups in hip muscles torque
Corresponding author: M. Ismail, Orthopaedic Physical The-
rapy, Cairo University, Street no 9, Building no7107, Mokatam,
11439Egypt. E-mail: mfarrage69@cu.edu.eg
cal symptoms include diffuse anterior or retropatel-
lar knee pain exacerbated by activities such as stair
climbing, prolonged sitting, and squatting.5 Abnor-
mal lateral tracking of the patella has been proposed
as a contributing factor.6, 7

Vol. 49 - No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 687

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
ISMAIL CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT
Possible causes of abnormal lateral tracking of
the patella include: neuromuscular imbalance of
the vastus medialis obliqus (VMO) and the vastus
lateralis (VL) muscles 8-11 (2) tightness of the lateral
knee retinaculum, hamstrings, iliotibial band, and
gastrocnemius;12 and (3) overpronation of the sub-
talar joint.13
Hip muscles weakness has been proposed to con-
tribute to patella-femoral mal-alignment and the de-
velopment of PFPS.14-16 Hip musculature plays an
important role in controlling transverse-plane and
frontal-plane motions of the femur.17, 18
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Robinson and Nee 19 suggested that poor hip ad-
duction and internal rotation control during weight-
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bearing activities related to PFPS in female athletes
is due to weakness in hip abductor and external
rotators muscles. Excessive femoral adduction and
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internal rotation lead to lateral patellar tracking as
the femur medially rotates underneath the patel-
la.14 Repetitive movements during functional activi-
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ties with this malalignment can overload the lateral
patellar retinaculum and retropatellar articular car-
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tilage and cause pain.20
Recent studies have reported significant im-
pairments in hip abduction and lateral rotation
strength.7, 16, 18, 19, 20 These reports suggest improv-
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ing pain and hip lateral rotator and abductor mus-
cles strength to improve function in patients with
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patellofemoral pain.
To date, 4 randomized clinical trials (RCTs) have
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assessed the influence of hip muscle strengthen-
ing on PFP symptoms. In two studies conducted
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by Nakagawa 21 et al. and Fukuda et al.22 the com-
bination of hip and quadriceps strengthening was
compared to a program of quadriceps strength-
IN
ening alone. The quad­riceps strengthening was
performed by both open and CKC exercises while
that of hip was performed by open kinetic chain
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exercises focused on abduction and lateral rota-
tion. Results dem­onstrated that the combination
of hip and quadriceps strengthening was better
than quadriceps strengthening alone in reducing
PFP. The third study is that of Dolak et al.23 who
compared the influence of isolated hip strength-
ening versus quadriceps strengthening prior to the
or other proprietary information of the Publisher.
initiation of CKC. Results revealed that 4 weeks of
isolated hip strengthening prior to the initiation
of 4 weeks of CKC exercise reduced self-reported
symptoms earlier than when 4 weeks of quadri-
ceps strengthening was performed prior to the
688 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013
same CKC program. The fourth study is that of
khayambashi et al.24 who determined the isolated
influence of hip muscle strengthening on PFP and
observed an improvement of pain, health status
and bilateral hip strength.
Although these four studies provide evidence in
support of hip strengthening for persons with PFP,
hip strength was measured only in the pilot study
of Nakagawa et al.21 and the results revealed no
statistically significant difference in the hip mus-
cles torque in either group. Previously Tyler et al.25
demonstrated that improvement of hip abduction
strength was not related to successful outcome in
patient with PFPS. In contrast, Mascal et al.26 re-
ported in a two cases that 14 weeks of hip, pelvis
and trunk muscles strengthening exercises pro-
duce pain symptoms improvement associated with
strength gains.
This controversy in the result of hip strength
suggests that hip strengthening exercises could in-
fluence pain without a significant increase of hip
strength. Differing results in the literature, war-
rants further investigation in this topic especially
if selected closed kinetic chain exercises were
performed to focus on both hip musculature and
quadriceps muscle without isolated hip strengthen-
ing exercises.
Based on two research’s findings we theorized
that CKC exercises emphasizing knee and hip mus-
culature may be enough to reduce pain and increas-
ing hip strength without the need of isolated hip
strengthening exercise. The first is certain CKC ex-
ercise produce greater activation of gluteus medius
and hip adductor muscles 27, 28, 29, 30, 31, 32. The sec-
ond finding is hip abductors and external rotators
strengthening exercises improve pain and functions
in PFPS.21, 22, 23, 24
Therefore, the purpose of the current study was
to determine the effect of a CKC exercises program
on pain intensity, and hip abductors and lateral ro-
tators eccentric and concentric torques in patients
with PFPS compared with the same program of CKC
exercise with additional isolated open kinetic hip
muscles exercises.
It was hypothesized that there will be no signifi-
cant difference between those who receive CKC ex-
ercises program with or without hip musculature ex-
ercises concerning pain and hip abductor and lateral
rotator torque.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.

Subjects

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Figure 1.—Participant flow diagram.

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Materials and methods

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location of symptoms and reproduction of pain with

agnosed clinically with unilateral PFPS (according to
12-month period. Thirty six consecutive patients di-
Participants were identified and recruited over
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EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

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CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT

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689
ing activities regardless of the level of pain intensity:
Subjects who met the following inclusion criteria
were asked to participate in the study: 1) anterior or
clinic of the faculty of Physical Therapy, Cairo Universi-
activities commonly associated with this condition) and
ISMAIL

referred to the outpatient orthopedic physical therapy

retropatellar knee pain from at least 2 of the follow-

ty, were examined for eligibility in the study (Figure 1).
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
ISMAIL CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT
prolonged sitting, stair climbing, squatting, running,
kneeling and hopping/ jumping; 2) insidious onset
of symptoms unrelated to a traumatic incident and
persistent for at least 6 weeks; 3) had not previously
received physical therapy.
Subjects were excluded from the study if they had
a history of any of the following condition: meniscal
or other intra articular pathologic conditions; cruci-
ate or collateral ligament involvement, patellar sub-
luxation or dislocation, previous surgery in the knee
and hip joints, knee and hip joints osteoarthritis, any
conditions affects muscle strength like diabetes mel-
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litus or rheumatoid arthritis.
Of the initial thirty six patients, two were exclud-
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ed due to a previous history of knee ligamentous
injury and two refused to participate in the study
for work reasons. After our protocol was approved
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by the institutional review Board, 32 subjects with
age ranged from 18 to 30 years signed an informed
consent. The subjects were randomly assigned into
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two groups by a blinded and independent research
assistant who opened sealed envelopes that con-
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tained a computer generated randomization card.
Sixteen patients (11 females and 5 males) were al-
located to the CKC group and 16 patients (12 fe-
males and 4 males) were allocated to the CKC and
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hip strengthening exercises as a control group (CO)
group.
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Outcome measures
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Before and after the end of the last session of the
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6 weeks of the study period, each subject completed
the Visual Analog Scale (VAS) and Kujala question-
naire for patellofemoral joint pain. The 10 cm vi-
IN
sual analog scale range from zero as “no pain” to 10
as the “worst pain possible”. The individuals were
asked to rate their response based on the average
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pain in the knee during the previous week. The pro-
cedure is valid, reliable and responsive in assessing
the outcome in persons with patellofemoral pain
syndrome.33
The individuals function status was assessed using
Kujala questionnaire for patellofemoral joint pain.34
It is a 13-items knee specific self-report question-
or other proprietary information of the Publisher.
naire, it documents response to six activities thought
to be associated specifically with anterior knee pain
syndrome (walking, running, jumping, climbing
stairs, squatting, and sitting for prolonged periods
with knees bent),as well as symptoms such as limp,
690 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013
inability to bear weight through the affected limb,
swelling, abnormal patellar movement, muscle atro-
phy, pain and limitation of knee flexion .The maxi-
mum total score of this assessment tool is 100, with
higher scores indicating greater levels of function
with lower levels of pain. This scale shows high test-
retest reliability, moderate responsiveness, and ad-
equate validity.35
The dynamic muscle strength was measured be-
fore and after the 6-week training period for both
groups using Biodex System 3 Dynamometer and
Biodex Advantage Software Package (Biodex Medi-
cal Systems, Inc, New York, NY) to determine iso-
kinetic peak torque/body mass index values for
concentric and eccentric hip abduction and external
rotation. Biodex dynamometers allow precise and
reliable measurement and storage of data from iso-
kinetic muscular action of hip abduction and ex-
ternal rotation.36 The ICC value for eccentric peak
torque of hip abduction and external rotation were
0.97 (0.07 Nm/kg) and 0.87 (0.07 Nm/kg) respective-
ly1.37 The ICC value for concentric peak torque of
hip abduction was 0.81 and for external rotation was
0.93. All strength testing were performed at 60º/s.
Calibration of the dynamometer was carried out be-
fore measurement. Before testing, participants were
provided with detailed instructions for the strength
testing procedures. Five maximal repetitions for hip
external rotation and abduction were performed for
each strength test.4
Unilateral isokinetic mode, concentric/eccentric
contraction type, at a speed of 60º/ sec with 10 sec-
onds rest between 2 sets of test was used. For each
test two trial repetitions were performed then the
test was conducted. The patient was verbally en-
couraged to maintain muscle contraction through-
out the ROM.
For the hip external rotation test, participants
were positioned so that the seat orientation was
at 90°, and seatback tilt was at 85º. The hip and
knee flexed to 90°, and the axis of rotation of the
dynamometer was aligned with the long axis of
the femur. The hip attachment was adjusted to be
proximal to the patient’s lateral maleolus then se-
cured by its strap. Shoulder and thigh stabiliza-
tion straps were fastened according to the Biodex
system 3 pro manual. The dynamometer ROM was
set, with 30ºexternal rotation away and 0º (neutral
position) toward (concentric away and eccentric
toward).
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT ISMAIL

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Figure 2.—Subject performing mini wall squat exercise. A) Starting position with the back supported on the wall and a ball between knees;
B) End position with knee bent (0-40o) and ball squeezing.
IN

For the hip abduction test, participants were po- 30º hip abduction away and 0°(neutral position)
sitioned so that the seat orientation was 0º, and toward (concentric away and eccentric toward).
seatback fully reclined. The patient lied in side-
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All peak torque data (Nm) was normalized to body

lying position on the chair of the apparatus with mass index (BMI) (Nm/kg/m²). All measures were
face away from dynamometer, the tested leg on performed by the same assessor who was blinded
top of the non-tested leg, and the thigh of the non- to the training program.
tested leg and trunk were stabilized with straps.
The dynamometer’s rotation axis was aligned su-
perior and medial to greater trochanter on the Treatment procedure
or other proprietary information of the Publisher.

tested leg, and the seat height and position were

adjusted for accurate alignment. The hip attach- Each patient in both groups received a three su-
ment length was adjusted to be proximal to the pervised physical therapy sessions per week for 6
patient’s lateral femoral condyle (Biodex system 3 weeks of CKC exercises program and instruction
pro manual).The dynamometer ROM was set, with for conventional static stretching of hamstring, ili-

Vol. 49 - No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 691

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

ISMAIL CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT

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P A
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Figure 3.—Patient (A) starting position and (B) ending position of forward step up.

otibial band, gastrocnemius and quadriceps. All sub-
jects were instructed to perform three repetitions of
30-second static stretch of these muscle groups. The
CO group received additional exercises for hip ab-
duction and external rotation.
or other proprietary information of the Publisher.
on the wall and put ball between both knees, with
the feet approximately 1ft away from the wall (Fig-
ure 2). The patient was asked to lower his trunk on
the wall while squeezing the ball between his knees
by hip adduction and medial rotation, and held this

The CKC exercise program included mini wall
squat exercise, forward step up, lateral step up, and
terminal knee extension.29, 30, 31, 32, 38
Mini wall squat exercise was performed from 0-40
degrees. The patient stand with his back supported
position for 6 sec count, then return back to the
starting position.
Forward and Lateral step up exercises were per-
formed on a wooden step with 8 inches height.36
The subject stands either in front or at side of the

692 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT ISMAIL

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P A
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Figure 4.—Patient (A) starting position and (B) ending position of lateral step up.

step and raise his body up to stand on the involved repetitions with 1 minute rest before proceeding to
limb for 6 sec, then return back to the starting posi- the next exercise.29, 31
M

tion and relax (Figures 3, 4).
Terminal knee extension was performed in stand-
ing position with feet shoulder-width apart, facing
toward the plinth, and one end of the theraband at-
tached around the knee and another to the plinth leg
(Figure 5). The patient was asked to bend the knee to
or other proprietary information of the Publisher.
The hip strengthening exercises for the CO group
include resistive exercise for hip abductors and ex-
ternal rotators. For Hip abduction strengthening ex-
ercise, the patient lay in side lying position on the
non-affected side with knee bent. Ankle cuff was
wrapped just proximal to lateral malleolus and the

30 degrees (keeping the foot on the floor) and then
straighten the leg to full extension against resistance
of band, hold this position for 6 sec, then the patient
was asked to return to starting position and relax.38
Each exercise in CKC program was performed for 10
patient was asked to raise his limb in abduction
while the pelvis was stabilized, hold for 6 s, then
return to starting position and relax.
For hip external rotation strengthening exercise,
the patient’s position was sitting at the edge of the

Vol. 49 - No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 693

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

ISMAIL CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT

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Figure 5.—Patient (A) starting position and (B) ending position of terminal knee extension using theraband.

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plinth with the hip and knee flexed to 90 degree, Results
and his hand behind him for support. Ankle cuff
was wrapped just proximal to lateral malleolus , the Baseline and demographic data
patient was asked to rotate the leg inward toward

IG E
the non-affected side while the thigh was stabilized,
hold for 6 sec, then return to starting position and
There were no statistically significant differences
(P>0.05) between subjects in both groups concern-
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relax. ing age, weight, height, and gender (Table I). There
Each strengthening exercise of hip was performed were also no statistically significant differences be-
for 2 sets of 10 repetitions with 1 minute rest after tween groups for any of the outcome variables at
each set. Each patient was trained at 60% of 10-rep- baseline (pre-intervention) (Table II).
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etition maximum (the amount of weight that could

Pain and function
be lifted and lowered through available range of
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motion exactly 10 times). A new 10 repetition maxi- There was statistically significant group-by-time
mum was established weekly for adjustment.39 interaction for the 2-by -2 mixed model ANOVAs for
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the VAS and the Kujala score (P<0.05). Planned pair-

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wise comparisons indicated that the individuals in

Statistical analysis
both the CKC and the CO group had decreased pain
To determine similarity between the groups at base- and improved function at 6 week post-intervention
IN

line, subject age, height, and body weight were com-
pared using independent t tests. Descriptive statistics
on gender was compared using chi square tests for
homogeneity. Hip abductors and external rotators iso-
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when compared to baseline (P=0.001, P=0.01). The
analysis of difference between groups showed that
the changes from baseline to 6 weeks post interven-
tion was statistically significant (P=0.03, P=0.04 for

kinetic peak torque/body mass index, VAS and Kujala
score were analyzed using separate 2-factor mixed
model analyses of variance (ANOVAs) (2 groups by
2 time points), with times as the repeated factor to
determine the effects of the intervention programs. If
a significant interaction was observed, paired t tests
or other proprietary information of the Publisher.
VAS and Kujala score respectively).
Strength
The ANOVAs evaluating changes in hip abduction
and lateral rotation peak torque\BMI from baseline
to the end of the 6-week intervention revealed non-

were used. Parametric tests were justified, based on
the data being normally distributed and the variance
being equal between groups. Statistical significance
was defined as p < 0.05. For statistical analyses, SPSS
18.0 software was used.
significant group-by-time interaction in all measured
isokinetic tests (P=0.28 for hip abduction concentric
mode and P=0.25 in the eccentric mode, for hip ex-
ternal rotation concentric mode P=0.43 and P=0.17
in the eccentric mode).

694 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT ISMAIL

® A
Figure 6.—Hip abduction (Abd) torque/BMI in concentric (Conc) Figure 7.—Hip external rotation (Ext rot) torque/BMI in concentric
and eccentric (ecc) mode for the CO and CKC groups. (Conc) and eccentric (ecc) mode for the CO and CKC groups.

T C
H DI
Table I.—Comparison of subject characteristics at baseline by group.
Subject characteristics CKCH group CKH group P value

Age (y)* 20.8±2.7 21.2±3.2 0.71†

Height (cm) *
Weight (kg) *.
Gender (females, males) IG E 64.46±9.6
163.6±8.5
11.5
66.6±9.8
165.7±5.3
12.4
0.43†
0.55†
0.66‡
R M
*mean±SD; †independent t test; ‡χ2 test
P A

Table II.—Pre- and post-training VAS, Kujala questionnaire There was a significant main effect across time
score and isokinetic data for both groups. in all measured isokinetic tests while there was no
O V

Post- intervention Difference group main effect. Paired t test revealed significant
Variables Baseline
(6 wk) (6 wk-baseline) change from baseline to the end of 6-week interven-
C ER

VAS(0-10)* tion in both groups with P<0.05.

CKCH 5.3±1.6 2.0±1.1 3.2±0.9
Y

CKC 4.5±1.8 2.3±1.1 2.26±1.3

Kujala score (0-100) † Discussion
CKCH 71.5±7.8 85.1±6.2 13.7±5.5
IN

CKC 76.4±10.4 85.0±6.7 8.6±7.3 The results of the present study indicate a signifi-
Hip abd conc cant decrease in pain and improvement of function in
CKCH 1.7±0.6 2.4±0.8 0.7±0.9
CKC 2.1±0.6 2.5±0.7 0.4±0.5
both groups. However, CKC exercises supplemented
M

Hip abd ecc

by hip abduction and lateral rotation exercises were
CKCH 2.0±0.6 2.4±0.8 0.3±0.3 more effective in decreasing pain and improving func-
CKC 2.2±0.5 2.4±0.5 0.2±0.3 tion in subjects with PFPS more than CKC exercises
Hip ext rot conc alone. This can be explained by the combined effect
CKCH 0.9±0.6 1.3±0.6 0.3±0.5 of CKC exercises and the isolated hip abduction and
CKC 1.0±0.4 1.2±0.4 0.2±0.3 lateral rotator exercises. Earl 40 found that mini squat
Hip ext rot ecc
1.4±0.4 1.8±0.8 0.4±0.5
with concurrent hip adduction (squeeze ball in our
or other proprietary information of the Publisher.

CKCH study) significantly increases the quadriceps activity

CKC 1.4±0.4 1.6±0.3 0.2±0.3
as a whole which is a main factor in relieving pain.
Abd: abduction; CKC: closed kinetic chain; CKCH: closed kinetic chain hip;
conc: concentric; ecc: eccentric; ext rot: external rotation. The same findings were observed by Boling et
*0-10 cm, Larger number indicating more pain. al.30 who concluded that active hip adduction dur-
†Higher score indicating better function.
ing dynamic mini squat increases quadriceps activ-

Vol. 49 - No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 695

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
ISMAIL CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT
ity but without significant change in vastus medialis
obliqus. But in the mini squat used in the current
study, instruction was given to the patient to squeeze
ball not only by adduction but also with internal
rotation which was found by Lam and Ng 32 that it
facilitates the activity of the VMO during semisquat-
ting of 40 degrees knee flexion more than without
hip internal rotation. They also suggested that the as-
sociated medial tibial rotation during semi-squatting
with hip medially rotated facilitated VMO contrac-
tion. Patients with PFPS may tolerate closed kinetic
chain exercises better and consequently may exhibit
® A
better functional results.41 The training protocols
used in this study are mainly designed to increase
T C
quadriceps strength and hip abductors and external
rotators. Natri et al.42 identified a strong correlation
between quadriceps muscle strength and the long
H DI
term outcome in patients with patellofemoral pain.
The effect of CKC exercises were combined
with the effect of hip abductors and lateral rota-
IG E
tors strengthening exercises in decreasing pain and
improving function. By a similar study design con-
R M
sisting of two groups of patients with PFPS receiv-
ing either a knee exercises program or the knee
program supplemented by hip abduction and lat-
eral rotation strengthening, Fukuda et al.22 obtained
P A
a similar results of pain relieving and function to
those obtained in the current study. But they didn’t
O V
measured hip strength. Our results suggest that the
cause of pain relieve produced by hip strengthen-
C ER
ing is not due to increased torque but perhaps due
to increased EMG activation or alignment change
Y
and better motor control of hip motion during the
functional activities. This suggestion is based on the
result obtained by Nagakawa 21 who found signifi-
IN
cant pain improvement and increased gluteus me-
dius EMG activity without significant increase in hip
muscle torque after a program of hip abductors and
M
lateral rotators strengthening in patients with PFPS.
Our findings of pain and function improvement are
in agreement with the results of Witvrouw et al.31 Bol-
ing et al.29, 30 who also reported improvement in pain
and function after a program of CKC exercises.
Despite the significant difference between groups
in pain and function in favor to the CO group, pain
or other proprietary information of the Publisher.
was decreased in the CKC group by more than 1.5
points which is the minimal clinically important dif-
ference identified in a previous study.33 This indi-
cated that the change seen in the CKC group was
clinically relevant.
696 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE October 2013
Analysis of the results showed that there were no
significant differences between the CKC exercise
group and the CKC supplemented by hip abduction
and external rotation exercises group in peak torque
of hip abductors and external rotators normalized
by body mass index at speed of 60o/s. However,
there was a significant increase of the peak torque/
BMI values from pretest to post test for both groups.
Sixty degrees/s was chosen because a muscle pro-
duces greater concentric force at slower isokinetic
testing velocities. Furthermore, as velocity increases
during eccentric contractions, the force-producing
capability stays the same or slightly increases.43 In
addition, a higher angular speed of 180°/sec was
tested in our lab and it was found that eccentric
torque is more difficult and needs concentration
and training especially to hip external rotators. As a
conclusion, slower velocities tend to be more com-
fortable and a good representation of both the con-
centric and eccentric force-producing capabilities of
each muscle group we assessed.
No previous studies have investigated the effect of
CKC exercises versus CKC exercises supplemented by
hip abduction and external rotation strength and si-
multaneously measured peak torque for the intended
muscles, pain and function. Our results demonstrated
similar improvement of hip abductor and external ro-
tators isokinetic concentric and eccentric peak torque
in both groups. This means that such improvement in
strength is mainly due to the CKC exercises.
There are many causes that contribute to the im-
provement of muscle strength through the use of
CKC exercises. One is the effect of the selected ex-
ercises on strengthening hip abductors and lateral
rotators. Performing double leg squat with proper
biomechanics may improve hip muscle recruitment
and force production of the extensors and abductors
during functional as well as sport specific activities.44
Lubahn et al.33, 45 indicated that double leg squat and
front step up produce gluteus medius muscle activa-
tion that is greater in the front set up than double
leg squat. They also reported activation of 43.5%
maximum voluntary isometric contraction (MVIC) in
the gluteus medius muscle during the front step up
exercises. This level of activation was required to
strengthen hip musculature as reported by Ekstrom
et al.46 Although the double leg squat applied by
Lubahn et al.33 was without wall support, we expect
that the double squat performed in our program
also produce activation of gluteus medius muscle.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
CLOSED KINETIC CHAIN EXERCISES WITH OR WITHOUT ADDITIONAL HIP STRENGTHENING EXERCISES IN MANAGEMENT ISMAIL
Second cause contributing to improvement of
muscle strength is the effect of CKC exercise on the
different portions of the gluteus medius especially
the posterior subdivision involved in hip lateral rota-
tion. The gluteus medius muscle consisted of three
distinct portions; anterior, middle and posterior. The
anterior and posterior portions act as medial and
lateral rotators respectively as indicated by their ori-
entation and insertion patterns as well as the find-
ings from electromyography (EMG) studies.15, 29, 40, 47
O’sullivan et al.28 reported that single leg wall squat
activate the posterior (lateral rotation) and middle
® A
(abduction) subdivision significantly more than the
anterior division. Accordingly, we suggested that the
T C
double leg wall squat used in our program could ac-
tivate the gluteus medius posterior portion respon-
sible for lateral rotation and middle portion respon-
H DI
sible for abduction. This activation had reached the
peak required for strengthening as indicated by the
measured peak torque. Of particular relevance are
IG E
the recent findings of Cowan et al.8 who demon-
strated delayed activation of both the anterior and
R M
posterior portion of the gluteus medius in subjects
with patellofemoral pain syndrome.
Third cause is the effect of step up exercises on
gluteus medius muscle. It have been reported by
P A
Mercer et al.27 that lateral step up exercises required
greater gluteus medius muscle activation than for-
O V
ward step up exercises. Although their studies was
conducted on older adults, it had been previously
C ER
confirmed by the results of Ekstrom et al.42, 46 who
reported EMG activity levels of 43% of the MVIC for
Y
lateral step up exercises in young and middle aged
adults. They have also explained this greater acti-
vation by the different biomechanical demands on
IN
the two lower extremities during the ascent and de-
scend phase of lateral step up to control the lateral
displacement of the center of mass.
M
Overall, the wall mini squat together with the front
and lateral step up exercises caused significant chang-
es in hip abductors and lateral rotator peak torque/
BMI, even they are not very similar to the exercises
mentioned above but the results are in line with all
the studies investigating the activation of the gluteus
medius muscle during squatting and set up exercises.
or other proprietary information of the Publisher.
There are several limitations of our study, ac-
knowledge as follow. First, this study lack power
analysis and sample size calculation but we recruit-
ed 16 patients in each group based on previously
published data 15 to detect difference in strength and
Vol. 49 - No. 5 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 697
pain with 80% power and at alpha level of 0.05. Sec-
ond, we did not assess the long term effect of the
additional hip strengthening exercises to the CKC on
pain, function and strength. A Third limitation was
the absence of control group of PFPS patients who
received no treatment but this type of study was
considered unethical. Further research should in-
clude a greater sample size and a follow-up period.
Conclusions
The findings of decreased pain and increased func-
tion more in the CO group support the use of hip
abductors and lateral rotators strengthening exercises
in the rehabilitation program of PFPS. Based on our
results, we recommend the uses of selected CKC ex-
ercises as strengthening exercises which focus on hip
abductors and lateral rotators together with knee ex-
tensors specially the vastus medialis to produce both
strength gain and pain relief in cases needing pain re-
lief to the clinical relevant level . However, additional
isolated hip abductors and lateral rotators strengthen-
ing exercises have the advantage of more pain relief.
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Conflicts of interest.—The authors certify that there is no conflict
of interest with any financial organization regarding the material
discussed in the manuscript.
Received on September 27, 2012.
Accepted for publication on April 2, 2013.
Epub ahead of print on July 2, 2013.