Eccentric exercise in the prevention of patellofemoral pain in high-volume runners: A rationale for integration

Abstract

Patellofemoral pain (PFP) is a common overuse condition seen in high-volume runners, such as military recruits. Exercise is commonly prescribed, with benefit, for the rehabilitation of individuals with PFP. However, a substantial number of individuals with the condition do not achieve an optimal outcome, suggesting the condition can be difficult and complex. Given the challenging nature of the condition, and the risk of developing PFP in high-volume runners, it seems logical to investigate options for injury prevention. Eccentric exercise has been useful in the prevention of some pathologies so its utility in preventing PFP should be explored. Current evidence regarding prevention programs for PFP are limited. Preventative exercise programs for PFP have not been well described or reported, and questions remain regarding their effectiveness. Based on available evidence or lack thereof, and known physiological and clinical effects of eccentric exercise, suggestions for integration of eccentric exercise into PFP prevention programs are offered. Eccentric exercise may be useful for PFP prevention from a theoretical framework however additional longitudinal cohort studies would be useful in determining its utility.

Keywords

Anterior knee pain / Exercise / Injury prevention / Patellofemoral joint

References

[[1]] R.W. Willy, L.T. Hoglund, C.J. Barton, et al.. Patellofemoral pain. J Orthop Sports Phys Ther, 49 (9) ( 2019), pp. CPG1-CPG95, DOI: 10.2519/jospt.2019.0302

[[2]] B.S. Neal, S.D. Lack, N.E. Lankhorst, A. Raye, D. Morrissey, M. van Middelkoop. Risk factors for patellofemoral pain: a systematic review and meta-analysis. Br J Sports Med, 53 (5) (2019 Mar), pp.270-281, DOI: 10.1136/bjsports-2017-098890

[[3]] B.E. Smith, J. Selfe, D. Thacker, et al.. Incidence and prevalence of patellofemoral pain: a systematic review and meta-analysis. PloS One, 13 (1) ( 2018), Article e0190892, DOI: 10.1371/journal.pone.0190892

[[4]] M.C. Boling, D.A. Padua, R. Alexander Creighton. Concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain. J Athl Train, 44 (1) ( 2009), pp. 7-13, DOI: 10.4085/1062-6050-44.1.7

[[5]] T.H. Nakagawa, M. Baldon Rde, T.B. Muniz, F.V. Serrão. Relationship among eccentric hip and knee torques, symptom severity and functional capacity in females with patellofemoral pain syndrome. Phys Ther Sport, 12 (3) ( 2011), pp. 133-139, DOI: 10.1016/j.ptsp.2011.04.004

[[6]] L.K. Lepley, A.S. Lepley, J.A. Onate, D.R. Grooms. Eccentric exercise to enhance neuromuscular control. Sport Health, 9 (4) ( 2017), pp. 333-340, DOI: 10.1177/1941738117710913

[[7]] C.N. Fick, C. Grant, F.T. Sheehan. Patellofemoral pain in adolescents: understanding patellofemoral morphology and its relationship to maltracking. Am J Sports Med, 48 (2) (2020 Feb), pp.341-350, DOI: 10.1177/0363546519889347

[[8]] R.A. van der Heijden, J.L. de Kanter, S.M. Bierma-Zeinstra, et al.. Structural abnormalities on magnetic resonance imaging in patients with patellofemoral pain: a cross-sectional case-control study. Am J Sports Med, 44 (9) ( 2016), pp. 2339-2346, DOI: 10.1177/0363546516646107

[[9]] A.P. Goode, M.P. Reiman, L. Harris, et al.. Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review and meta-analysis. Br J Sports Med, 49 (6) (2015 Mar), pp.349-356, DOI: 10.1136/bjsports-2014-093466

[[10]] A.J.H. Arundale, M. Bizzini, A. Giordano, et al.. Exercise-Based knee and anterior cruciate ligament injury prevention. J Orthop Sports Phys Ther, 48 (9) (2018 Sep), pp.A1-A42, DOI: 10.2519/jospt. 2018.0303

[[11]] K.M. Crossley, M. van Middelkoop, M.J. Callaghan, N.J. Collins, M.S. Rathleff, C.J. Barton. Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med, 50 (14) ( 2016), pp. 844-852, DOI: 10.1136/bjsports-2016-096268

[[12]] N.E. Lankhorst, M. van Middelkoop, K.M. Crossley, et al.. Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med, 50 (14) ( 2016), pp. 881-886, DOI: 10.1136/bjsports-2015-094664

[[13]] L.R. Maclachlan, N.J. Collins, M.L.G. Matthews, P.W. Hodges, B. Vicenzino. The psychological features of patellofemoral pain: a systematic review. Br J Sports Med, 51 (9) (2017 May), pp.732-742, DOI: 10.1136/bjsports-2016-096705

[[14]] D. De Oliveira Silva, M.S. Rathleff, K. Petersen, F.M. Azevedo, C.J. Barton. Manifestations of pain sensitization across different painful knee disorders: a systematic review including meta-analysis and metaregression. Pain Med, 20 (2) ( 2019), pp. 335-358, DOI: 10.1093/pm/pny177

[[15]] Neumann D A. Kinesiology of the Musculoskeletal System:Foundations for Physical Rehabilitation, third ed.ed. Elsevier. 2017.

[[16]] C.M. Powers, E. Witvrouw, I.S. Davis, K.M. Crossley.Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3. Br J Sports Med, 51 (24) ( 2017), pp. 1713-1723, DOI: 10.1136/bjsports-2017-098717

[[17]] D. De Oliveira Silva, R.W. Willy, C.J. Barton, K. Christensen, M.F. Pazzinatto, F.M. Azevedo. Pain and disability in women with patellofemoral pain relate to kinesiophobia, but not to patellofemoral joint loading variables. Scand J Med Sci Sports, 30 (11) ( 2020), pp. 2215-2221, DOI: 10.1111/sms.13767

[[18]] B.S. Neal, C.J. Barton, R. Gallie, P. O'Halloran, D. Morrissey. Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: a systematic review and meta-analysis. Gait Posture, 45 ( 2016), pp. 69-82, DOI: 10.1016/j.gaitpost.2015.11.018

[[19]] I.S. Davis, A.S. Tenforde, B.S. Neal, J.L. Roper, R.W. Willy. Gait retraining as an intervention for patellofemoral pain. Curr Rev Musculoskelet Med, 13 (1) ( 2020), pp. 103-114, DOI: 10.1007/s12178-020-09605-3

[[20]] P.C. LaStayo, J.M. Woolf, M.D. Lewek, L. Snyder-Mackler, T. Reich, S.L. Lindstedt. Eccentric muscle contractions: their contribution to injury, prevention, rehabilitation, and sport. J Orthop Sports Phys Ther, 33 (10) ( 2003), pp. 557-571, DOI: 10.2519/jospt.2003.33.10.557

[[21]] J. Douglas, S. Pearson, A. Ross, M. McGuigan. Eccentric exercise: physiological characteristics and acute responses. Sports Med, 47 (4) ( 2017), pp. 663-675, DOI: 10.1007/s40279-016-0624-8

[[22]] J. Douglas, S. Pearson, A. Ross, M. McGuigan. Chronic adaptations to eccentric training: a systematic review. Sports Med, 47 (5) ( 2017), pp. 917-941, DOI: 10.1007/s40279-016-0628-4

[[23]] N.D. Reeves, C.N. Maganaris, S. Longo, M.V. Narici. Differential adaptations to eccentric versus conventional resistance training in older humans. Exp Physiol, 94 (7) ( 2009), pp. 825-833, DOI: 10.1113/expphysiol.2009.046599

[[24]] M. Roig, D.L. Macintyre, J.J. Eng, M.V. Narici, C.N. Maganaris, W.D. Reid. Preservation of eccentric strength in older adults: evidence, mechanisms and implications for training and rehabilitation. Exp Gerontol, 45 (6) ( 2010), pp. 400-409, DOI: 10.1016/j.exger.2010.03.008

[[25]] S. Hody, J.L. Croisier, T. Bury, B. Rogister, P. Leprince.Eccentric muscle contractions: risks and benefits. Front Physiol, 10 ( 2019), p. 536, DOI: 10.3389/fphys.2019.00536

[[26]] Y. Fang, V. Siemionow, V. Sahgal, F. Xiong, G.H. Yue. Distinct brain activation patterns for human maximal voluntary eccentric and concentric muscle actions. Brain Res, 1023 (2) ( 2004), pp. 200-212, DOI: 10.1016/j.brainres.2004.07.035

[[27]] M. Linari, L. Lucii, M. Reconditi, et al.. A combined mechanical and X-ray diffraction study of stretch potentiation in single frog muscle fibres. J Physiol, 526 Pt 3 (Pt 3) ( 2000), pp. 589-596, DOI: 10.1111/j.1469-7793.2000.00589.x

[[28]] B. Bazgir, R. Fathi, M. Rezazadeh Valojerdi, P. Mozdziak, A. Asgari. Satellite cells contribution to exercise mediated muscle hypertrophy and repair. Cell J, 18 (4) ( 2017), pp. 473-484, DOI: 10.22074/cellj.2016.4714

[[29]] M.V. Franchi, N.D. Reeves, M.V. Narici.Skeletal muscle remodeling in response to eccentric vs. Concentric loading: morphological, molecular, and metabolic adaptations. Front Physiol, 8 ( 2017), p. 447, DOI: 10.3389/fphys.2017.00447

[[30]] R.G. Timmins, A.J. Shield, M.D. Williams, C. Lorenzen, D.A. Opar. Architectural adaptations of muscle to training and injury: a narrative review outlining the contributions by fascicle length, pennation angle and muscle thickness. Br J Sports Med, 50 (23) ( 2016), pp. 1467-1472, DOI: 10.1136/bjsports-2015-094881

[[31]] S.C. Bodine, R.R. Roy, D.A. Meadows, et al.. Architectural, histochemical, and contractile characteristics of a unique biarticular muscle: the cat semitendinosus. J Neurophysiol, 48 (1) ( 1982), pp. 192-201, DOI: 10.1152/jn.1982.48.1.192

[[32]] D.L. Morgan, J.A. Talbot. The addition of sarcomeres in series is the main protective mechanism following eccentric exercise. J Mech Med Biol, 2 ( 2002), pp. 421-431. 03n04

[[33]] S.P. Magnusson, M.V. Narici, C.N. Maganaris, M. Kjaer. Human tendon behaviour and adaptation, in vivo. J Physiol, 586 (1) ( 2008), pp. 71-81, DOI: 10.1113/jphysiol.2007.139105

[[34]] C.N. Maganaris, P. Chatzistergos, N.D. Reeves, M.V. Narici.Quantification of internal stress-strain fields in human tendon: unraveling the mechanisms that underlie regional tendon adaptations and mal-adaptations to mechanical loading and the effectiveness of therapeutic eccentric exercise. Front Physiol, 8 ( 2017), p. 91, DOI: 10.3389/fphys.2017.00091

[[35]] J. Kaux, P. Drion, V. Libertiaux, et al.. Eccentric training improves tendon biomechanical properties: a rat model, 093494.155. Br J Sports Med, 48 (7) ( 2014), p. 617, DOI: 10.1136/bjsports-2014-093494.155

[[36]] B.C. Abbott, B. Bigland, J.M. Ritchie. The physiological cost of negative work. J Physiol, 117 (3) ( 1952), pp. 380-390, DOI: 10.1113/jphysiol.1952.sp004755

[[37]] T.J. Overend, T.H. Versteegh, E. Thompson, T.B. Birmingham, A.A. Vandervoort.Cardiovascular stress associated with concentric and eccentric isokinetic exercise in young and older adults. J Gerontol A Biol Sci Med Sci, 55 (4) ( 2000), p. 177, DOI: 10.1093/gerona/55.4.b177

[[38]] J. Duchateau, R.M. Enoka. Neural control of lengthening contractions. J Exp Biol, 219 (Pt 2) ( 2016), pp. 197-204, DOI: 10.1242/jeb.123158

[[39]] R.O. Kollock, C. Andrews, A. Johnston, et al.. A meta-analysis to determine if lower extremity muscle strengthening should Be included in military knee overuse injury-prevention programs. J Athl Train, 51 (11) ( 2016), pp. 919-926, DOI: 10.4085/1062-6050-51.4.09

[[40]] K.R. Kaufman, S.K. Brodine, R.A. Shaffer, C.W. Johnson, T.R. Cullison. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med, 27 (5) ( 1999), pp. 585-593, DOI: 10.1177/03635465990270050701

[[41]] N. Duvigneaud, E. Bernard, V. Stevens, E. Witvrouw, D. Van Tiggelen. Isokinetic assessment of patellofemoral pain syndrome: a prospective study in female recruits. Isokinet Exerc Sci, 16 (4) ( 2008), pp. 213-219

[[42]] M. Baldon Rde, F.V. Serrão, R. Scattone Silva, S.R. Piva. Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: a randomized clinical trial. J Orthop Sports Phys Ther, 44 (4) ( 2014), pp. 240-251, DOI: 10.2519/jospt.2014.4940. A1-A8

[[43]] D. Van Tiggelen, E. Witvrouw, P. Coorevits, J. Croisier, P. Roget. Analysis of isokinetic parameters in the development of anterior knee pain syndrome: a prospective study in a military setting. Isokinet Exerc Sci, 12 (4) ( 2004), pp. 223-228

[[44]] M. Roig, K. O'Brien, G. Kirk, et al.. The effects of eccentric versus concentric resistance training on muscle strength and mass in healthy adults: a systematic review with meta-analysis. Br J Sports Med, 43 (8) ( 2009), pp. 556-568, DOI: 10.1136/bjsm.2008.051417

[[45]] R.M. Enoka.Eccentric contractions require unique activation strategies by the nervous system. ( 1985). J Appl Physiol, 81 (6) ( 1996), pp. 2339-2346, DOI: 10.1152/jappl.1996.81.6.2339

[[46]] L.J. Distefano, J.T. Blackburn, S.W. Marshall, D.A. Padua. Gluteal muscle activation during common therapeutic exercises. J Orthop Sports Phys Ther, 39 (7) ( 2009), pp. 532-540, DOI: 10.2519/jospt.2009.2796

[[47]] American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc, 41 (3) ( 2009), pp. 687-708, DOI: 10.1249/MSS.0b013e3181915670