The Effect of McConnell's Vastus Lateralis Inhibition Taping ...

The Effect of McConnell'sVastus Lateralis InhibitionTaping Technique on VastusLateralis and Vastus MedialisObliquus ActivityKey Words173Patellofemoral pain syndrome,VL:VMO activity,quadriceps imbalance,EMG, McConnell taping.by Sue TobinGill RobinsonSummary This study was conducted to investigate the effects ofJenny McConnell’s vastus lateralis (VL) inhibition taping techniqueon VL and vastus medialis obliquus (VMO) muscle activity, and itspossible application in quadriceps rehabilitation, particularly inpatellofemoral pain syndrome.Eighteen asymptomatic subjects (11 female and 7 male)participated, and completed a functional task (stair descent) underthree test conditions: no tape, placebo tape and active tape.Surface electrodes were used to determine theelectromyographic activity of VL and VMO during the tests.High variance and abnormal distribution meant that the datarequired non-parametric analysis, which was completed withFriedman and Wilcoxon tests for each muscle. Results of theFriedman test for VL revealed a significant difference in activityacross the conditions (p < 0.05). Further investigation with theWilcoxon tests revealed that the application of the active tape wasresponsible for significantly decreasing VL activity. The Friedmantest on VMO activity revealed no significant difference betweenexperimental conditions (p > 0.05), although a Wilcoxon testbetween the placebo tape and active tape conditions wassignificant.These findings suggest that McConnell’s VL inhibition tapingtechnique does inhibit VL, but the effects of this inhibition onVMO require further investigation.Tobin, S and Robinson, G(2000). ‘The effect ofMcConnell’s vastuslateralis inhibition tapingtechnique on vastuslateralis and vastusmedialis obliquusactivity’, Physiotherapy, 86,4, 173-183.IntroductionPatellofemoral pain syndrome (PFPS) is thesecond most common musculoskeletalcomplaint presented to physiotherapists(Witvrouw et al, 1996; Hilyard, 1990).Clinical features of PFPS include theinsidious onset of diffuse retropatellar pain,aggravated by squatting, kneeling, stairs,slopes, prolonged flexed knee sitting, andrising after prolonged sitting (Arroll et al,1997; Hilyard, 1990). Many factors areinvolved in complex interactions thatinfluence the patellofemoral joint, and theexact aetiology of PFPS is often enigmatic(Fulkerson and Hungerford, 1990;Finestone et al, 1993). However, there isconsensus that malalignment andmaltracking of the patella are major featuresof PFPS (Maclntyre and Robertson, 1992;Gerrard, 1989). While accepting that manyfactors and structures influence PFPS, thisstudy focuses on the role of the quadricepsfemoris muscle group, with particularemphasis on vastus lateralis (VL) and vastusmedialis obliquus (VMO).The force generated by and withinthe quadriceps is recognised as a majorinfluence on patellar tracking (Roberts,1989; Knight, 1985), and interplay withinthis group is vital to efficient functioning ofthe patellofemoral joint (Herrington andPayton, 1997; Witvrouw et al, 1996).Disruption of the tension characteristicsof component quadriceps can induceimbalance in the transverse forces acting onthe patella (Karst and Jewett, 1993). Relativeweakness in one of the quadriceps willdisrupt the normal synergy of the groupand induce imbalance. Although thereis disagreement whether quadricepsdysfunction is a primary or secondaryoccurrence in PFPS, it is accepted as aninherent part of the vicious cycle that isfrequently identified. A model for thepathogenesis of PFPS is presented in figure 1overleaf.There is a well-established link betweenVMO insufficiency and PFPS (Kowall et al,1996; McConnell, 1987b). Boucher et al(1992) found that increased severity of PFPSsymptoms correlated with decreasing VMOactivity. Ahmed et al (1988) found that a50% reduction in VMO activity produced a5 mm lateral shift of the patella, whichrepresents a considerable disruption topatellar tracking.Traditionally, the cornerstone ofphysiotherapeutic intervention in PFPS hasinvolved general quadriceps strengthening(Antich and Brewster, 1986; Karst andJewett, 1993), with many protocols beinghighlighted in literature from more than 50years ago (Nicoll, 1943; DeLorme, 1945).That they are still used today, despite laterPhysiotherapy April 2000/vol 86/no 4

174VMO functionQuadriceps imbalanceInhibition of musclefunctionDynamic patellarstabilisationOverpull by VLPainEffusionLateral displacement ofpatellaJoint damageArticular cartilagestressFig 1: Pathogenesis of patellofemoral pain syndrome (adapted from Stokes and Young (1994), Richardson (1985) and Pevsner et al (1979)advances in biomechanics, pathophysiologyand knowledge of specificity of musclefunction, gives cause for concern. AsRichardson wrote in 1985: ‘For too long, allmuscles have been exercised on the sameprinciples without accounting for thedifferent muscle types and their behaviourpatterns.’The use of quadriceps programmes thatdo not address muscle specificity and thecrucial interplay between the components ofthis muscle group may help to explain whymany treatment protocols have the poorlong-term success rates identified byDevereaux and Lachman (1984) andFitzgerald and McClure (1995), and whyPFPS frequently becomes a chronic disorder.The onus is on physiotherapists to establishmechanisms to isolate or disproportionatelystimulate the activity of one muscle withrespect to the others, ie to manipulate thecomponents of a muscle group to restoreoptimal synergy. That VMO and VL havedifferent specificity of function ishighlighted by their respective physiologicalfeatures, which are presented in table 1.Table 1: Physiological features of VL and VMOFeature VL VMO ReferenceMuscle type Mobility Stability Richardson (1985)Muscle fibre 15° to 18° to 46° to 52° to Lieb and Perry (1968)alignment femoral axis femoral axisMuscle fibre Predominantly Predominantly type I Herrington and Payton (1997)type type II fast twitch slow twitchMuscle activity Phasic power Tonic, endurance McConnell (1995)Action Leg extension Dynamic patellar Speakman andstabilisation Weisberg (1977)Active range Throughout knee Throughout knee Speakman andflexion/extension flexion/extension Weisberg (1977)Functional Maximal when Maximal in work Richardson (1985)activity distal segment associated withis freejoint compression,eg weightbearingInterrelationship Agonist Antagonist Hodges andRichardson (1993)Adaptive To become short To become long Norris (1996)tendencies and tight and weakPhysiotherapy April 2000/vol 86/no 4

Professional articles175The advent of the McConnell patellofemoraltreatment plan (1985) provideda development in physiotherapeuticintervention in PFPS. McConnell’s planworks on the premise that if a patient’ssymptoms are due to poor patellaralignment, then correcting this alignmentshould reduce the symptoms, allowingthe undertaking of a functional rehabilitationprogramme designed to stimulateVMO activity preferentially, therebyaddressing the accompanying quadricepsimbalance. By using tape toaddress patellar position, the VMO isassisted in its efforts to resist the pull of theVL and stabilise the patella (McConnell,1995). Facilitating the VMO away from alengthened position also optimises itspotential for cross-bridge formation (Harms-Ringdahl, 1993), and allows it to work froma position of increasing mechanicaladvantage, which should facilitate theincreased muscle activity required forhypertrophy.Research findings into McConnell’spatellar taping techniques are numerousand somewhat contradictory (Brockrath etal, 1993; Cerny, 1995; Crome et al, 1987;Gerrard, 1989; Shelton, 1992). However, allthese studies, as well as McConnell’s ownwork, have focused on directly increasingVMO activity to establish optimal VMO:VLbalance. None has addressed the possibilityof restoring this balance through thereduction of VL activity. Although Witvrouwet al (1996) briefly refer to retarding VLactivity, and McConnell herself has devised ataping technique designed to do this,literature searches revealed no studies inthis area.McConnell proposes in her course handbookthat her VL inhibition technique worksvia the type IV nociceptors, but does notelaborate. Given the dearth of relevantliterature, it is appropriate to proposemechanisms by which application of thistechnique could inhibit VL activity, and alsofacilitate VMO activity.Type IV nociceptors respond to deepmechanical stimuli, and have small diameterC-fibre afferents which bifurcate uponentering lamina I and lamina II (substantiagelatinosa) of the dorsal horn in the spinalcord (Kandel et al, 1991, page 386).It is therefore conceivable that, via thelocal inhibitory interneurones, alpha motorneurones of VL are inhibited by thestimulation of nociceptors. This wouldreduce the electrical activity withinVL, which should be detectable byelectromyography (EMG). Whether thehigher centres, stimulated by projectionneurones, would exert any influence isunclear.For the proposed influence on VMOmuscle activity there are at least two possiblemechanisms. The first is biomechanical/physiological and involves the previouslymentioned facilitation of VMO into aposition of increasing mechanical advantageand cross-bridge formation. This mechanismrequires adaptive shortening and would takeseveral days for any effect to becomeapparent. The second possibility isneurological and counters the VLmechanism. Nociceptive afferents fromVL could influence local excitatoryinterneurones supplying the alpha motorneurones of the antagonist muscle, ie VMO.Similar types of neural circuits are alreadyestablished, eg the flexor withdrawal reflex(Kandel et al, 1991, page 588). If this neuralcircuit were used, the electrical activity inVMO would increase which should bedetectable by EMG.DesignEighteen asymptomatic volunteers took partin a same subject test-retest study, therebyensuring optimal group matching (Robson,1996, page 94). Counterbalancing was usedto overcome inherent dangers of order,fatigue and carry-over effects (Hicks, 1995,page 72).The activity chosen for analysis was stairdescent, partly for its functional relevanceto daily activities, and partly because it formspart of McConnell’s VMO trainingprogramme (McConnell, 1995).The experiment involved three testconditions: no tape (control); placebo tape;and active tape.Each subject was tested three times undereach of the experimental conditions, withEMG being used as an appropriate measureof muscle activity (Kumar and Mital, 1996).Apparatus and MaterialsFixomull ® stretch tapeLeukotape ® P tapeEMG with MIE MT8-MBM base unit andtelemetry belt2 x 4 k pre-amplifiersSelf-adhesive silver-silver chloride electrodesMyodat 5.0 software packageSPSS software packageAuthorsSue Tobin BHSc MCSP isa physiotherapist at theRoyal LiverpoolUniversity Hospital. Thisis an abridged version ofher dissertation, whichwas submitted in parialfulfilment of the BHScphysiotherapy course atthe University of Leeds.Gill Robinson MCSPDipTP is a seniorlecturer, Division ofPhysiotherapy, School ofHuman and HealthSciences, University ofHuddersfield HD1 3DH.She was the projectsupervisor.This article was receivedon February 22, 1999,and accepted onDecember 2, 1999.Address forCorrespondenceMiss S Tobin BHSc MCSP.PhysiotherapyDepartment, RoyalLiverpool UniversityHospital. Prescot Street,Liverpool L7 8XP.Physiotherapy April 2000/vol 86/no 4

176placed 2 cm from the superomedial borderof the patella. Correct electrode position wasconfirmed by palpation during quadricepscontraction with and without hip adductionto distinguish between the VMO and thevastus medialis longus (Bose et al, 1980).Ground electrodes for both muscles wereplaced over convenient, electricallyindependent bony landmarks (Worrell et al,1995). For the VL, the head of fibula wasdeemed appropriate, and for the VMO it wasthe anterior tibial shaft.Fig 2: Tape standardisation linesFig 3: Application of three pieces of Fixomull ®ProcedureAreas required for electrode placement wereshaved, lightly abraded with sandpaper andcleaned with acetone to reduce impedance(Kumar and Mital, 1996).Active electrodes for VL and VMO wereplaced parallel to each other with an interelectrodedistance of 1 cm (Herrington andPayton, 1997), and orientated according toLieb and Perry (1968) ie 15˚-18˚ to thefemoral axis for VL and 46˚-52˚ for VMO.For VL, the distal edge of the distalelectrode was placed four fingerbreadthsfrom the superolateral edge of the patella(Delagi et al, 1975; page 192). Correctelectrode position was confirmed bypalpation during quadriceps contractionwith and without hip flexion to exclude therectus femoris (Cerny, 1995). For the VMO,the distal edge of the distal electrode wasEMG ProcedureEach set of electrodes was connected to a 4 kpre-amplifier, and following the advice ofOrtengren (1996) were taped to the skin toreduce movement-related artefacts. The gainfor each channel was x 1, and the signal (viathe telemetry belt) was calibrated on theoscilloscope of the base unit before everytest. The sampling frequency was 400 Hz.StandardisationTwo lines were drawn on each subject’s leg,one between the anterior superior iliacspine (ASIS) and the tibial tubercle toapproximate the line of rectus femoris, andthe other between the greater trochanterand the fibular head to approximate the lineof the iliotibial tract. These lines served tooutline VL. Finally, the halfway point of theASIS-tibial tubercle line was marked (fig 2).All tape was applied with the subject in nondominantside lying with a pillow betweenthe knees.Fixomull ApplicationThe same procedure was used for both theplacebo and active tape conditions. Threepieces of tape were cut to a length thatoverlapped the outlined VL transversely byabout 2 cm. All strips were applied across VLwithout tension or wrinkles. The distal edgeof the first piece was aligned with thehalfway mark on the ASIS-tibial tubercle line(fig 2).The second and third pieces were thenapplied proximal to their predecessors,overlapping them by half the width (fig 3).Active Leukotape ApplicationThree pieces of tape were cut to a lengththat failed to span the VL markings by about2 cm. The following procedure is from theinstructions McConnell gives on page 40 ofher 1995 course handbook: ‘Apply a piece oftape to the anterior thigh. Firmly pull thetape laterally and posteriorly while collectingPhysiotherapy April 2000/vol 86/no 4

Professional articles177the lateral thigh tissues with the other hand.Attach the tape to the posterolateral thigh ina horizontal direction.’The first piece was applied proximal to thedistal edge of the underlay to ensure therewas no direct skin contact (fig 4) The secondand third pieces were applied in the sameway, each overlapping its predecessor by halfthe width (fig 5). The desired effect was afurrow running down the VL.Placebo Leukotape ApplicationThis procedure mirrored that of the activetape with the exception that the placebotape was applied without tension andwithout movement of the tissues.Testing ProtocolFollowing the application of the appropriatecondition, each subject was asked to stand atthe top of the designated stairs, the samestairs being used throughout testing.Instructions given to each subject beforeeach descent were standardised as follows:■ Descend the stairs normally.■ Do not use the handrails.■ Step first with the non-dominant leg.■ Stand still on reaching the bottom of thestairs.■ A ‘3 – 2 – 1 – Go’ cue to start.No further communication occurred untilthe descent was completed to avoiduncontrolled extraneous variables.Each subject completed three descents foreach condition, after which any tape wasimmediately removed. Subjects rested for aminimum of five minutes before beingprepared for their next condition.Electrodes remained in place throughoutthe session.Treatment of Raw EMG TracesMYODAT 5 0 software was used to full-waverectify and envelope the raw EMG traces,rendering the data less susceptible to errorand more reliable than the raw traces(Boucher et al, 1992). The start and finish ofeach descent was identified and theintervening portion of data was used foranalysis.ResultsSPSS was used to calculate the mean electricalactivity for each muscle, per subject,per test, for each of the experimental conditions.By averaging three mean values persubject, per condition, one figure wasFig 4: Application of first piece of Leukotape ®Fig 5: Application of three pieces of Leukotape ®obtained to represent the activity of eachmuscle. The modified data were used forthe descriptive and inferential analysis.Descriptive StatisticsTable 2 and figure 6 (overleaf) reveal a cleartrend in VL activity under each testcondition. Taking the no tape condition asthe baseline, there was an increase in activityafter application of the placebo tape, 421.89mv to 489.15 mv (an increase of 16%). Afterapplication of the active tape, VL activity fellfrom 42l.89 mv to 239.l8 mv (a decrease of43%). Possible implications are highlightedin the discussion.Table 3 and figure 6 indicate that thetrend in VMO activity mirrors that of VL.There was an increase in activity after theapplication of the placebo tape, 502.56 mvto 528.50 mv (an increase of 5%). Afterapplication of the active tape, VMO activityPhysiotherapy April 2000/vol 86/no 4

Professional articles179Table 3: Ranges of activity for VL and VMOCondition Mean Median SD Variance Range Percentile25th 50th 75thVastus lateralisNo tape 421.89 331.50 311.28 96894.11 1110.54 215.78 331.50- 508.23Placebo tape 419.15 370.13 426.70 182070.10 1811.02 223.04 370.13 594.84Active tape 239.18 188.29 159.32 25381.39 637.15 158.85 188.29 244.48Vastus medialis obliquusNo tape 502.56 377.67 396.47 157184.62 1719.26 312.92 377.67 627.67Placebo tape 528.50 370.16 396.29 157043.52 1705.38 320.63 370.16 687.13Active tape 415.20 371.18 209.45 43870.42 763.62 246.55 371.18 526.04Table 4: Inferential analysisInferential StatisticsThe data were subjected to a Friedman test,and as no post hoc test is associated with theFriedman, the data were subjected to furtherinvestigation with Wilcoxon tests (table 4).Descriptive statistics revealed that VL andVMO activity followed similar trends ofdifference between the conditions. With theaccepted probability level of α = 0.05, theFriedman test on VL indicated that one ofthe differences was significant. Wilcoxontests then established that the active tapecondition was responsible. It can beconcluded that application of McConnell'sVL inhibition taping technique didinhibit VL.With respect to VMO activity, theFriedman test was insignificant, but therewas a significant difference found by one ofthe Wilcoxon tests. However, if it is acceptedthat the no tape condition represented thebaseline activity level, the significantdifference was uncovered only after VMOactivity had been elevated under theinfluence of the placebo tape condition.Consequently, relevance of this result isquestionable.DiscussionThis study was conducted to investigate theeffects of McConnell's VL taping techniqueon VL and VMO activity. Results can besummarised thus:■ Activity of the VL and VMO increasedunder the placebo tape condition.Neither of these increases was statisticallysignificant.■ Activity of the VL and VMO decreasedunder the active tape condition. Thedecrease in VL activity was statisticallysignificant, but the decrease in VMOactivity was not.Muscle Condition Friedman test Wilcoxon testVL No tape vs placebo tape vs active tape P < 0.05 Not applicableVMO No tape vs placebo tape vs active tape P > 0.05 Not applicableVL No tape vs placebo tape Not applicable P > 0.05VL No tape vs active tape Not applicable P < 0.05VL Placebo tape vs active tape Not applicable P < 0.05VMO No tape vs placebo tape Not applicable P > 0.05VMO No tape vs active tape Not applicable P < 0.05VMO Placebo tape vs active tape Not applicable P < 0.05In view of the dearth of relevant literature,these results cannot be related to otherstudies.Increased VL activity under the placebotape condition is unsurprising given thecutaneous stimulation provided by the tape.Kandel et al (1991, page 586) confirm thatcutaneous stimulation can elicit reflexcontraction of the muscle underlying thearea of stimulation. Kandel et al (1991, page587) also identify an indirect effect. Theyreport that cutaneous stimulation reducesthe threshold of the motor neurones in theunderlying muscle, thereby making themeasier to excite and motor units easier torecruit. Both these mechanisms wouldmanifest themselves as increased electricalactivity within the muscle, hence theelevated EMG.Explanation for increased VMO activityunder the placebo tape is less apparent. Thelack of cutaneous stimulation renders theabove mechanisms irrelevant. It could bethat increased VMO activity represents areaction to increased activity of the VL. Thisis suggestive of an inherent capacity tocounter the creation of muscle imbalancewithin the quadriceps, which raises theintriguing question of why this mechanismthen fails, as it appears to in PFPS. Thedebate regarding quadriceps imbalancebeing a primary or secondary occurrence inPFPS was identified in the introduction. ThePhysiotherapy April 2000/vol 86/no 4

180apparent ability of the VMO to respond toan increase in VL activity in asymptomaticindividuals could indicate that quadricepsimbalance requires some factor(s) toprecede it, thereby supporting the secondaryfeature theory.It was proposed that stimulation of thetype IV nociceptors could have a directinhibitory effect on the VL. Following theapplication of the active tape, there wasimmediate decrease in VL activity asdetected by the EMG. This suggests that theproposed mechanism may well have beenemployed, ie the inhibition of the alphamotor neurones for the VL via the C-fibreafferents and local inhibitory interneurones.Although this circuit appears feasible, asinvolvement of higher centres or othermechanisms is unknown, its influencecannot be assumed.The explanation for the VMO response isagain less clear. It can be approached fromtwo ways: why VMO activity did not increase,and why it actually decreased. Twomechanisms, which could increase VMOactivity, were proposed in the introduction:■ The biomechanical/physiological mechanisminvolved adaptive tissue changes. Assubjects in this study were asymptomatic,their VMOs were unlikely to be elongatedand therefore had little potential toshorten and increase cross-bridgeformation. Such tissue changes would alsorequire several days to become apparent.Thus, the possible involvement of thismechanism was not addressed by thisstudy, and cannot therefore be dismissed.The neurological mechanism wasaddressed and it can be concluded that itis unlikely to feature in increasing VMOactivity, certainly in asymptomaticsubjects. If the C-fibre afferents from theVL had formed an excitatory circuit withthe alpha motor neurones of the VMO,EMG would have reflected increasedelectrical activity in the VMO, which didnot happen.■ The VMO response is indicative of aninherent capacity to react to the activitylevel of VL. Boucher et al (1992) foundthat the VMO:VL ratio was disrupted inPFPS, but in asymptomatic individuals,although activity levels of both muscleschanged during knee movement, theratio stayed constant. Therefore, assubjects in this study were asymptomatic,it is possible that the fall in VMO activityrepresented an attempt to keep theVMO:VL balance in equilibrium. It canalso be explained as a reaction to thereduced load placed on the VMO. Byinhibiting the VL, the VMO had lesslateral force to resist which would requirefewer motor units to be recruited. Thiswould manifest itself as decreasedelectrical activity, which reflects theEMG recordings from this study.Limitations and RecommendationsThe design of this study did have someweaknesses, such as failing to control thespeed of each stair descent. Although suchcontrol would have reduced the normality ofthe activity, speed is a variable that caninfluence muscle activity (MacIntyre andRobertson, 1992). This lack of control mayhave influenced results. There was a lack ofstandardisation of the resting intervalsbetween individual tests and betweenexperimental conditions. Nevertheless,the minimum resting interval betweenconditions and the counterbalancing of thetesting order may have ensured that theseweaknesses were not materially detrimentalto this study.The size and nature of the sample haveimplications for what can be inferred fromthe findings of this study. The sample beingsmall and convenient limits the populationto which the results can be confidentlyapplied.This taping technique is designed toaddress the problem of quadricepsimbalance. Voight and Weider (1991) foundthat VL contractions were faster andstronger in PFPS, implying that somethingwithin or controlling the muscle hadchanged. As the aetiology of this muscleimbalance is not understood, it cannot beassumed that the quadriceps ofasymptomatic subjects will respond in thesame way as those of symptomaticindividuals. Consequently these experimentsneed to be carried out on people with PFPSto increase their clinical relevance.EMG measurements are accepted as anappropriate assessment of muscle activity(Kumar and Mital, 1996). However, there issome debate about the sensitivity of surfaceelectrodes and their potential forcontamination by cross talk. The authorbelieves that as the activity level changesfor VMO and VL differed, the surfaceelectrodes used in this study were sensitiveenough to distinguish between the twomuscles. Whether they were able toPhysiotherapy April 2000/vol 86/no 4

Professional articles181differentiate between VMO and vastusmedialis longus is uncertain. Although theVMO electrodes could have been detectingthe activity of vastus medialis as a whole, thedocumented placement of these electrodesmay have ensured that VMO provided themajor contribution to the EMG recordings.Accordingly, it is appropriate to accept theserecordings as reflective of VMO activity.It is possible that there was inconsistencyin application of the tape, especially as thetension and pressure were not standardised.This inconsistency may explain why somesubjects did not show VL inhibition afterapplication of the active tape. Although theoverall decrease in VL activity was highlysignificant, influence of this variable cannotbe determined.Sample size and poor external validitymean that extreme caution must be usedwhen making recommendations from thisstudy. However, the results do suggest thatthis taping technique has the potential to bebeneficial in correction or prevention ofquadriceps imbalance. Irrespective ofwhether this technique facilitates VMOactivity, it may have a role in intervention forquadriceps imbalance. Provided VL activityis reduced more than any decrease in theVMO, the imbalance is still being redressed.In order to evaluate the adaptive shorteningtheory proposed as a mechanism by whichVL inhibition could in fact facilitate VMO,future studies should be of sufficientduration for such changes to occur.If this technique had a similar effect on VLactivity in a patient population, it may bethat a case can be made for using it in mostquadriceps rehabilitation, either as aprophylactic or a correctional measure formuscle imbalance. If so, this technique has ahuge advantage over McConnell's patellartaping techniques. Cerny (1995), andFitzgerald and McClure (1995) are amongthose who have identified poor inter-raterand intra-rater reliability in the assessmentof patellar position, which has implicationsfor selection of the appropriate realignmenttechnique. As the VL technique requiresonly the identification of VMO insufficiency,it appears reasonable to expect that it wouldbe associated with higher inter-rater andintra-rater reliability, thereby increasing theappropriateness of selection technique andthe chances of a successful outcome.A major recommendation resulting fromthis study is that a comprehensive review ofquadriceps rehabilitation is needed. Asdiscussed previously, the principle behindmost quadriceps programmes is general restrengthening.However, as Harms-Ringdahl(1993) acknowledges, muscle imbalancemay pose a more potent threat to jointfunction and protection than simplemuscle weakness. Traditional quadricepsprogrammes do not account for thedifferent functions and training needs of thecomponents, so how they can restoreoptimal quadriceps interaction is unclear.ConclusionIt seems that McConnell's VL inhibitiontaping technique has the potential to be ofconsiderable clinical value. This study foundthat application of this technique didsignificantly decrease VL activity. VMOactivity also fell but not by a statisticallysignificant amount. This suggests thatactivity levels of the component quadricepscan be manipulated with respect to eachother, which has implications for lower limbrehabilitation, especially where quadricepsimbalance is present or may develop. Toapply these results safely to a clinicalcontext, research involving symptomaticindividuals is needed.ReferencesAhmed, A M, Shi, S, Hyder, A, and Chan, K H(1988). ‘The effect of quadriceps tensioncharacteristics on the patellar tracking pattern’,Proceedings of the Orthopaedic Research Society 34thAnnual Meeting, Atlanta, Georgia, page 280.Antich, T J, and Brewster, C E (1986).‘Modification of quadriceps femoris muscleexercises during knee rehabilitation’, PhysicalTherapy, 66, 8, 1246-51.Arroll, A, Ellis-Pegler, F, Edwards, A and Sutcliffe,G (1997). ‘Patellofemoral pain syndrome’,American Journal of Sports Medicine, 25, 2, 207-212.Bockrath, K, Wooden, C, Worrell, T,Ingersoll, C D, and Farr, J (1993). ‘Effects ofpatellar taping on patellar position and perceivedpain’, Medicine and Science in Sports and Exercise,25, 9, 989-992.Bose, K, Kanagasuntheram, R and Osman, M B H(1980). ‘Vastus medialis obliquus: An anatomicaland physiological study’, Orthopaedics, 3, 9,880-883.Boucher, J P, King, M A, LeFebvre, R andPepin, A (1992). ‘Quadriceps femoris muscleactivity in patellofemoral pain syndrome’,American Journal of Sports Medicine, 20, 5, 527-532.Physiotherapy April 2000/vol 86/no 4

182Cerny, K (1995). ‘Vastus medialis obliquus/vastuslateralis muscle activity ratios for selectedexercises in persons with and withoutpatellofemoral pain syndrome’, Physical Therapy,75, 8, 672-683.Crome, P, Pattison, P, Kelly, P, Sommerville, Kand Richardson, C (1987). ‘The effect of patellartaping on the activation of vastus medialisobliquus in subjects with retro-patellar pain -A pilot study’, Proceedings of the World Confederationfor Physical Therapy, Sydney, Australia,pages 939-943.Delagi, E F, Perotto, A, Iazzetti, J andMorrison, D (1975). Anatomic Guide for theElectromyographer, Charles C Thomas,Illinois.DeLorme, T L (1945). ‘Restoration of musclepower by heavy resistance exercise’, Journal ofBone and Joint Surgery, 27, 645-647.Devereaux, MD and Lachman, SM (1984).‘Patellofemoral arthralgia in athletes attending asporting injury clinic’, British Journal of SportsMedicine, 18, 1, 18-21.Finestone, A, Radin, E L, Lev, B, Shlamkovitch,N, Weiner, M and Milgrom, C (1993). ‘Treatmentof overuse patellofemoral pain’, ClinicalOrthopaedics and Related Research, 293, 208-210.Fitzgerald, G K, and McClure, P W (1995).‘Reliability of measurements obtained with fourtests for patellofemoral alignment’, PhysicalTherapy, 75, 2, 84-90.Fulkerson, J P, and Hungerford, D S (1990).Disorders of the Patellofemoral Joint, Williams andWilkins, Baltimore, 2nd edn.Gerrard, B (1989). ‘The patellofemoral painsyndrome: A clinical trial of the McConnellprogramme’, Australian Journal of Physiotherapy,35, 2, 71-80.Harms-Ringdahl, K (1993). Muscle Strength,Churchill Livingstone, Edinburgh.Herrington, L, and Payton, C J (1997). ‘Effects ofcorrective taping of the patella on patients withpatellofemoral pain’, Physiotherapy, 83, 11,566-571.Hicks, C M (1995). Research for Physiotherapists:Project Design and Analysis, Churchill Livingstone,Edinburgh, 2nd edn.Hilyard, A (1990). ‘Recent developments in themanagement of patellofemoral pain: TheMcConnell programme’, Physiotherapy, 76, 9,559-565.Kandel, E R, Schwartz, J H, and Jessell, T M(1991). Principles of Neural Science, Prentice-Hall,New Jersey, USA, 3rd edn.Karst, G M and Jewett, P D (1993).‘Electromyographic analysis of exercise proposedfor differential activation of medial and lateralquadriceps femoris muscle components’, PhysicalTherapy, 73, 5, 286-299.Knight, K L (1985). ‘Quadriceps strengtheningwith the DAPRE technique: Case studies withneurological implications’, Medicine and Science inSports and Exercise, 17, 6, 646-650.Kowall, M G, Kolk, G, Nuber, G W, Cassisi, J Eand Stern, S H (1996). ‘Patellar taping in thetreatment of patellofemoral pain’, AmericanJournal of Sports Medicine, 24, 1, 61-66.Kumar, S and Mital, A (1996). Electromyographyand Ergonomics, T J Press.Lieb, F J, and Perry, J (1968). ‘Quadricepsfunction: An anatomical study using amputatedlimbs’, Journal of Bone and Joint Surgery, 50, 8,1535-48.Macintyre, D and Robertson, G E (1992).‘Quadriceps muscle activity in women runnerswith and without patellofemoral pain syndrome’,Archives of Physical and Medical Rehabilitation, 73,January, 10-14.McConnell, J (1986). ‘The management ofchondromalacia patellae: A long term solution’,Australian Journal of Physiotherapy, 32, 4, 215-223.McConnell, J (1987a). ‘Patella alignment andquadriceps strength’, Proceedings of the MTAAConference, November.McConnell, J (1987b). ‘Training the vastusmedialis obliquus in the management ofpatellofemoral pain’, Proceedings of the 10thInternational Congress of the World Confederation forPhysical Therapy, May, Sydney, Australia.McConnell, J (1995). The McConnell PatellofemoralTreatment Plan - Course Handbook, McConnellInstitute, London.McConnell, J (1996). ‘Management ofpatellofemoral problems’, Manual Therapy, 1, 60-66.Nicoll, E A (1943), ‘Principles of exercise, BritishMedical Journal, 1, 747-750.Ortengren, K J (l996). ‘Noise and artefacts’ in:Kumar, S and Mital, A (eds) Electromyography andErgonomics, T J Press.Polgar, S and Thomas, S A (l995). Introduction toResearch in the Health Sciences, ChurchillLivingstone, Edinburgh, 3rd edn.Richardson, C A (1985). ‘The role of the kneemusculature in high speed oscillating movementsof the knee: Implications for the conservativetreatment of retropatellar pain’, Proceedings of theMTAA 4th Biennial Conference, Brisbane, Australia,pages 59-70.Roberts, J M (1989). ‘The effects of taping onpatellofemoral alignment: A radiological pilotstudy’, Proceedings of the MTAA Conference,Adelaide, Australia, pages 146-151.Robson, C (1996). Real World Research, BlackwellScientific Publications, Oxford.Shelton, G L (1992). ‘Conservative managementof patellofemoral dysfunction’, Primary Care, 19,2, 331-350.Physiotherapy April 2000/vol 86/no 4

Professional articles183Voight, M L and Weider, D L (1991).‘Comparative reflex response times of vastusmedialis obliquus and vastus lateralis in normalsubjects and subjects with extensor mechanismdysfunction’, American Journal of Sports Medicine,19, 2, 131-137.Witvrouw, E, Sneyers, C, Lysens, R, Victor, J andBellemans, J (1996). ‘Reflex response times ofvastus medialis obliquus and vastus lateralis innormal subjects and subjects with patellofemoralpain syndrome’, Journal of Orthopaedic and SportsPhysical Therapy, 24, 3, 160-165.Worrell, T W, Connelly, S, and Hilvert, J (1995).‘VMO: VL ratios and torque comparisons at fourangles of knee flexion’, Journal of SportRehabilitation, 4, 4, 264-271.Key Points■ There is a need for physiotherapists tore-examine their approach to quadricepsrehabilitation and muscle specificity.■ It is possible to inhibit the activity of thevastus lateralis.■ Vastus medius obliquus and vastuslateralis imbalance may be addressedmore effectively by inhibition of the VLbefore VMO rehabilitation.CPSTitle: (eg Mr Ms Miss Dr)First NameSurnameCSP membership numberOld addressCHANGINGADDRESS?Why not use this formto send us the details?Please use CAPITAL LETTERSand send it to:The Membership DepartmentCSP, 14 Bedford RowLondon WC1R 4EDNew addressPost codeDate of moveSignaturePhysiotherapy April 2000/vol 86/no 4