Q Angle and Exercise

Women typically have larger Q-angles than men.  You may have analysed women’s Q-angles without being conscious of it, or perhaps without even knowing what a Q-angle is.  Maybe you noticed that while walking or running, a female’s knees seemed to look caved in.  They may not look as strong or physically stable as most men carrying out the same activities.

The “Q” (Quadriceps) angle is the angle defined by two lines: the first being from the anterior superior iliac spine (ASIS), or the pointy side-part of your hip to the center of the patella (knee cap); and the second being from the patella to the tibial tuberosity (bump at the top of the shin bone).  Here’s a visual:

Q-angles vary between sexes, but when the angle becomes excessive in either, the likelihood of knee problems shoots up dramatically. Having Q-angles in females greater than 15 °, and Q-angles in males greater than 20 ° is typically when issues arise.  Some major changes in knee and leg functioning become a concern.  Anteversion (forward tilt) of the shin bone is common, while constant lateral pulling of the patella is always apparent.  Foot pronation, also referred to as “flat foot” is also more common with a greater Q-angle.  Less visible differences such as medial rotation of the tibia and femur are also characteristic of greater Q-angles.

A whole slew of peri-patella problems arise when Q angles are >15 ° in females and >20 ° in males.  ACL tears become much more prominent, wearing away of the meniscal cartilage becomes more of an issue, and there is threat of patella subluxation (partial dislcocation) as well as full dislocation due to constant lateral pulling from the quadriceps muscles. Pain just above the knee-cap, referred to as patellofemoral pain is extremely common as well.

There are many concerns surrounding the knee and lower leg with high Q-angles, and these problems can easily spread throughout the kinetic chain, disguising themselves as hip or back issues.

You may ask, so what? Everyone’s built differently and we’re all prone to various injuries…some are more pigeon toed or bow-legged than others for example.  People with greater Q-angles may never experience substantial pain but I feel this is because they choose to lead a sedentary lifestyle.  If you never push your body or even attempt to be active, Q-angle issues will never be given the opportunity to elicit themselves as a problem. The main issue arises when those with greater Q-angles are physically active.

 Implications of exercise

The Q-angle is important to consider because knees are a constant source of pain in many sports – we can’t ignore such a blatant abnormality in the body.

Take running as an example.  Most people are encouraged to run; it’s such a primal movement and everyone should be able to do it right? However, such a standard modality of exercise can have adverse effects.  With such a visible problem we can tell the body isn’t functioning ideally. To steal a phrase from Mike Robertson, “Stacked joints are happy joints”. If you look at a body with an excessive Q-angle, the hip, knee, and ankle are not stacked on top of each other.  With slight valgus (inwards collapse) of the knee, a lot of stress is put on and around the knee.

It’s Not Always About Correctable Form

As trainers we like to think we’re superheros; that we can take someone who can’t squat and have them squatting with a barbell 8 weeks later.  This isn’t always the case, as with excessive Q-angles.  There is a deviation in how the lower body is formed, and because of this, certain exercises can exacerbate the problem (i.e. running, squatting, deadlifting)

 Excessive Q-angle is a special scenario

Having a greater than normal Q-angle is special because of one reason in particular.  At first glance you look at someone with a high Q-angle: they have wide hips and their knees are concave.  You’d think this would be labelled as a structural difference – a deformity that lies in bone formation and is impossible to change. However, this isn’t the case.  A good example of a ‘real’ structural difference is individual’s who have Down’s Syndrome.  They typically have what’s called atlanto-axial instability, where there is an unstable articulation between the atlas and axis (the top two vertebrae).  As a result, any physical activity programming for individuals with Down’s Syndrome has to be very particular with regards to physical contact.

An excessive Q angle is not entirely structural, but should be described as mechanical, in that it can be altered through movement and facilitation/activation of certain muscles and joints.

 So How Do We Rectify This?

All excessive Q-angles will not be 100% remedied; however, we do know that certain actions will help groove beneficial movements in the body that can over time alter Q-angles. In order to help fix the problem we need to look at commonalities such as medial rotation of the tibia and femur, “flat-foot” due to pronation etc. After recognizing similarities and concurrent issues with excessive Q-angles, we need to look at how to reverse these.

The gluteus maximus is a lateral rotator of the femur, so strengthening and engaging this gluteal muscle is a good idea as it will shift the femur into a more natural position, decreasing Q-angle.

In addition, orthotics have been shown to help.  One study concluded that insertion of full length, flexible orthotics helped decreased Q-angles in 39 out of 40 male participants with excessive Q angles. However, our main concern with orthotics is retention – will the results remain after having the orthotics removed? More research must be done.

Research looking into the effects of isometric quadriceps activation (IQA) following quadriceps exercise has shown to be beneficial in reducing Q angles in females.  However, much more research, and even more importantly, a standardized test (i.e. patient standing, in supine position for measurement etc.) for determining Q-angles must be established.

References:

Lathinghouse, L. H., (2000). Effects of Isometric Quadriceps Activationon the Q-angle in Women Before and After Exercise. Journal of Orthopaedic & Sports Physical Therapy. (4): pages 211-216.

Kuhn, R., Yochum, T. R., Cherry, A. R., Rodgers, S. S., (2002). Immediate Changes in the quadriceps femoris angle after insertion of an orthopaedic device. Journal of Manipulative and Physiological Therapeutics.  (25): 7, pages 465-470.

Smith, T. O., Hunt, N. J., Donell, S. T., (2008). The reliability and valididty of the Q-angle: a systematic review. Knee Traumatology Arthroscopy. (16): pages 1068-1079.

http://www.easyvigour.net.nz/fitness/h_gluteus_max_leg.htm

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