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Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: A multicentre observational analysis
Abstract
Background
Patellofemoral pain (PFP) has traditionally been viewed as self-limiting, but recent studies show that a large proportion of patients report chronic knee pain at long-term follow-up. We identified those patients with an unfavourable recovery (‘moderate improvement’ to ‘worse than ever’ measured on a Likert scale) and examined whether there is an association between PFP and osteoarthritis (OA) at 5–8-year follow-up.
Methods
Long-term follow-up data were derived from 2 randomised controlled trials (n=179, n=131). Patient-reported measures were obtained at baseline. Pain severity (100 mm visual analogue scale (VAS)), function (Anterior Knee Pain Scale (AKPS)) and self-reported recovery were measured 5–8 years later, along with knee radiographs. Multivariate backward stepwise linear regression analyses were used to evaluate the prognostic ability of baseline pain duration, pain VAS and AKPS on outcomes of pain VAS and AKPS at 5–8 years.
Results
60 (19.3%) participants completed the questionnaires at 5–8-year follow-up (45 women, mean age at baseline 26 years) and 50 underwent knee radiographs. No differences were observed between responders and non-responders regarding baseline demographics, and 3-month and 12-month pain severity and recovery. 34 (57%) reported unfavourable recovery at 5–8 years. 48 out of 50 participants (98%) had no signs of radiographic knee OA. Multivariate models revealed that baseline PFP duration (>12 months; R²=0.22) and lower AKPS (R²=0.196) were significant predictors of poor prognosis at 5–8 years on measures of worst pain VAS and AKPS, respectively.
Summary and conclusion
More than half of participants with PFP reported an unfavourable recovery 5–8 years after recruitment, but did not have radiographic knee OA. Longer PFP duration and worse AKPS score at baseline predict poor PFP prognosis. Education of health practitioners and the general public will provide patients with more realistic expectations regarding prognosis.
... Current evidence-based treatment programs are less than optimal for producing positive, long-term outcomes, as over 50% of patients report unfavorable results 5e8 years after conservative treatments (Lankhorst et al., 2015). The longevity of this condition raises the concern of negative consequences across the entire lifespan for individuals suffering from PFP (Rathleff et al., 2015). ...
... Participants reported that health care professional did not take their knee pain seriously and viewed it as self-limiting. While PFP has previously been described as a selflimiting condition that will subside over time , pain and disability are common for multiple years after diagnosis (Lankhorst et al., 2015;Price et al., 2000). Undervaluing the pain experience is alarming, especially due to the high prevalence of PFP and a longer duration of symptoms being predictive of a poor prognosis (Lankhorst et al., 2015). ...
... While PFP has previously been described as a selflimiting condition that will subside over time , pain and disability are common for multiple years after diagnosis (Lankhorst et al., 2015;Price et al., 2000). Undervaluing the pain experience is alarming, especially due to the high prevalence of PFP and a longer duration of symptoms being predictive of a poor prognosis (Lankhorst et al., 2015). ...
Objective
Patellofemoral pain (PFP) is a common musculoskeletal condition, which has a negative effect on physical activity and function. Currently, it is unknown how and why individuals with PFP modify their physical activity. The purpose of this qualitative study was to explore the experience of knee pain on physical activity and everyday life in individuals experiencing PFP.
Design
Qualitative phenomenological interview study.
Setting
University.
Participants
Sixteen patients experiencing PFP.
Main outcome measures
Semi-structured interviews were used to explore the pain experience on physical activity and daily living.
Results
Patients with PFP attempted various strategies to remain physically active, such as identifying pain thresholds, activity modification, and pushing through their pain. Despite these various strategies to stay active, pain influenced their social life and patients demonstrated both fear avoidance beliefs and pain catastrophizing. Patients with PFP also reported barriers to seek care for their knee pain, such as negative past experiences with health care professionals and care not aligned with the best evidence available.
Conclusion
Clinicians treating PFP should be aware of biologic, psychological, and social aspects when evaluating and intervening with patients.
... 13 Although therapeutic interventions to reduce pain and counteract quadriceps inhibition in the short term are well documented, 10,14 the long-term outcomes of these interventions are not as effective. 15,16 For example, more than 90% of patients with AKP continued to experience pain 16 years after their diagnosis. 17 Researchers in 2 longitudinal studies demonstrated that higher severity and longer duration of AKP predisposed individuals to an increased risk of advanced injury (eg, knee osteoarthritis) and unfavorable sequelae (eg, poor quality of life). ...
... Furthermore, the authors 18 of a previous study reported that moderate-to-severe AKP resulted in quadriceps weakness, whereas mild pain did not. As support for this evidence, several investigators have described negative relationships of AKP severity 18,19 and duration 15,16,19 on quadriceps function 18,19 and self-reported function. 15,16 For instance, clinicians may assume that the rate of development of knee-joint injury due to quadriceps weakness 10 might be minimal for patients with a lower severity of pain, a shorter duration of pain, or both. ...
... As support for this evidence, several investigators have described negative relationships of AKP severity 18,19 and duration 15,16,19 on quadriceps function 18,19 and self-reported function. 15,16 For instance, clinicians may assume that the rate of development of knee-joint injury due to quadriceps weakness 10 might be minimal for patients with a lower severity of pain, a shorter duration of pain, or both. In clinical practice, patients with AKP are generally categorized into subgroups based on pain severity and duration (eg, 1.6 of 10 and 21.6 months, 20 4.4 of 10 and 48.6 months 21 ). ...
Context:
Little is known about how the combination of pain severity and duration affects quadriceps function and self-reported function in patients with anterior knee pain (AKP).
Objective:
To examine how severity (low [≤3 of 10] versus high [>3 of 10]) and duration (short [<2 years] versus long [>2 years]) of AKP affect quadriceps function and self-reported function.
Design:
Cross-sectional study.
Setting:
Laboratory.
Patients or Other Participants:
Sixty patients with AKP (mean pain severity = 4 of 10 on the numeric pain rating scale, mean pain duration = 38 months) and 48 healthy control individuals. Patients with AKP were categorized into 3 subdivisions based on pain: (1) severity (low versus high); (2) duration (short versus long); and (3) severity and duration (low and short versus low and long versus high and short versus high and long).
Main Outcome Measure(s):
Quadriceps maximal (maximal voluntary isometric contraction) and explosive (rate of torque development) strength, activation (central activation ratio), and endurance (average peak torque) and self-reported function (Lower Extremity Functional Scale score).
Results:
Compared with the healthy control group, (1) all AKP subgroups showed less quadriceps maximal strength (P < .005, d ≥ 0.78) and activation (P < .02, d ≥ 0.85), except for the AKP subgroup with low severity and short duration of pain (P > .32); (2) AKP subgroups with either high severity or long duration of pain showed less quadriceps explosive strength (P < .007, d ≥ 0.74) and endurance (P < .003, d ≥ 0.79), but when severity and duration were combined, only the AKP subgroup with high severity and long duration of pain showed less quadriceps explosive strength (P = .006, d = 1.09) and endurance (P = .0004, d = 1.21); and (3) all AKP subgroups showed less self-reported function (P < .0001, d ≥ 3.44).
Conclusions:
Clinicians should be aware of the combined effect of severity and duration of pain and incorporate both factors into clinical practice when rehabilitating patients with AKP.
... 1,2 Despite the high prevalence 3 of this condition across the general population and recreationally active populations, 4 it is a challenging condition to treat with poor long-term outcomes. 5 PFP is a chronic condition that negatively disrupts activities of daily living 6 and leads to decreased health related quality of life. 7 The primary symptom of PFP is retro-or peri-patellar pain during tasks that require knee flexion, such as running, stair climbing, squatting, and jumping. ...
... Pain has been suggested to influence PFP prognosis and predict patient success. 5 Decreased subjective function on the Anterior Knee Pain Scale, a common patient reported measure of disability, also predicts unfavorable recovery following PFP diagnosis. 5 Out of the 13-item questions on the scale, six different questions (including stair ambulation, squatting, running, and sitting) use pain as response choice. ...
... 5 Decreased subjective function on the Anterior Knee Pain Scale, a common patient reported measure of disability, also predicts unfavorable recovery following PFP diagnosis. 5 Out of the 13-item questions on the scale, six different questions (including stair ambulation, squatting, running, and sitting) use pain as response choice. This may suggest that increased pain across multiple tasks may play a more significant role on subjective function when assessed by the Anterior Knee Pain Scale. ...
Objectives
Patellofemoral pain (PFP) is a common lower extremity condition that results in pain during functional tasks. Currently, it is unknown the extent to which differences in pain levels exist in individuals with PFP compared to asymptomatic controls during functional task and if pain differ across various functional tasks. The purpose of this systematic review and meta-analysis is to evaluate pain levels between individuals with PFP and asymptomatic controls and compare pain severity across various functional tasks.
Design
Systematic review.
Methods
OVID, SPORTSDiscus, CINAHL, Web of Science and Embase were searched for studies that included PFP and asymptomatic controls with pain assessed during a functional task. Pooled pain scores mean with 95% confidence intervals were calculated between groups across 11 functional tasks. Standardized mean differences (SMD) were calculated based on Hedge's g effect sizes. Tasks whose SMD 95% confidence intervals were non-overlapping were considered significantly different.
Results
28 articles were included for data analysis. Pain was greater across 10 tasks (SMD = 1.52–6.08) in individuals with PFP compared to the asymptomatic controls with an average SMD of 2.45. Running and star excursion balance testing resulted in greater pain than walking. Limited evidence showed greater pain in sitting than seven other tasks.
Conclusions
Moderate evidence exists for greater pain levels in individuals with PFP compared to asymptomatic controls in functional tasks. Pain was greater during running and star excursion balance compared to walking. Clinicians should assess knee pain before and after functional tasks to improve our understanding of patient specific pain experiences.
... Similar to low back pain, recurrence of symptoms and chronic pain are common in individuals with PFP [10,11]. Unlike low back pain, where evidence supports a reduction in recurrence with early and appropriate physical therapy [9], it is unknown if the use and timing of physical therapy influences recurrence in patients with PFP. ...
... Healthcare use, physical therapy visits, total knee-related care (visits and costs), and total healthcare costs over the 2 years following the initial PFP diagnosis were higher in the delayed physical therapy group compared to the first or early physical therapy groups. Although previous literature has been heavily focused on the spine, these findings are complementary because patients with PFP follow similar trajectories of chronicity and recurrence [11,26]. The findings may assist with decisions about use and referral to physical therapy for PFP. ...
... This speaks to the importance of receiving appropriate interventions, including physical therapy. A quicker reduction of symptoms in patients with PFP leads to better outcomes in individuals in which the initial duration is shorter before receiving care [11,26]. Although we do not know the duration of the symptoms before individuals sought care, they could not have received any kneerelated care in the year prior to diagnosis to be included in the cohort. ...
Background
Early physical therapy has been shown to decrease downstream healthcare use, costs and recurrence rates in some musculoskeletal conditions, but it has not been investigated in individuals with patellofemoral pain. The purpose was to evaluate how the use and timing of physical therapy influenced downstream healthcare use, costs, and recurrence rates.
Methods
Seventy-four thousand four hundred eight individuals aged 18 to 50 diagnosed with patellofemoral pain between 2010 and 2011 in the Military Health System were categorized based on use and timing of physical therapy (first, early, or delayed). Healthcare use, costs, and recurrence rates were compared between the groups using descriptive statistics and a binary logit regression.
Results
The odds for receiving downstream healthcare use (i.e. imaging, prescription medications, and injections) were lowest in those who saw a physical therapist as the initial contact provider (physical therapy first), and highest in those who had delayed physical therapy (31–90 days after patellofemoral pain diagnosis). Knee-related costs for those receiving physical therapy were lowest in the physical therapy first group ($1,136, 95% CI $1,056, $1,217) and highest in the delayed physical therapy group ($2,283, 95% CI $2,192, $2,374). Recurrence rates were lowest in the physical therapy first group (AOR = 0.55, 95% CI 0.37, 0.79) and highest in the delayed physical therapy group (AOR = 1.78, 95% CI 1.36, 2.33).
Conclusions
For individuals with patellofemoral pain using physical therapy, timing is likely to influence outcomes. Healthcare use and costs and the odds of having a recurrence of knee pain were lower for patients who had physical therapy first or early compared to having delayed physical therapy.
... Síndrome dolorosa patelofemoral é um termo usado para descrever diversas afecções associadas à dor na região anterior do joelho (1) . É comum na prática médica e corresponde à causa mais frequente de dor no joelho em adolescentes e adultos jovens (1,2) . Sua origem é multifatorial, pois envolve maior ângulo de inclinação da patela, maior ângulo Q e do sulco troclear, e menor força de extensão do joelho e de abdução do quadril (2) . ...
... É comum na prática médica e corresponde à causa mais frequente de dor no joelho em adolescentes e adultos jovens (1,2) . Sua origem é multifatorial, pois envolve maior ângulo de inclinação da patela, maior ângulo Q e do sulco troclear, e menor força de extensão do joelho e de abdução do quadril (2) . ...
Introdução: Síndrome dolorosa patelofemoral é um termo usado para descrever diversas afecções associadas à dor na região anterior do joelho. Muito comum na prática médica, corresponde à causa mais comum de dor no joelho em adolescentes e adultos jovens, bem como pode estar associada a outros diagnósticos diferenciais. Objetivo: Relatar o caso de um paciente jovem com história de dor anterior no joelho durante cincoanos, evoluindo com piora lenta dos sintomas, até que se diagnosticou sinovite vilonodular pigmentada na região anterior do joelho. Relato do Caso: Paciente do sexo masculino, 22 anos, com história de dor no joelho esquerdo por cinco anos. Referiu ter passado por avaliação médica três vezes, nas quais recebeu o diagnóstico de dor de origem patelofemoral, e assim foi tratado, porém sem nunca ser submetido a uma ressonância magnética.Relatou que a limitação funcional foi aumentando junto com o volume ao redor do joelho. Prescreveu-se ressonância magnética do joelho esquerdo, que evidenciou formação nodular expansiva intra-articular localizada entre a gordura de Hoffa e a margem anterior da epífise tibial. O tratamento consistiu em artrotomia com via parapatelar medial para ressecção da lesão por via aberta. A lesão era de cor acastanhada, tinha consistênciafirme, media 8,0x5,0x4,0cm e apresentava características histopatológicas de sinovite vilonodular pigmentada. Um ano depois do procedimento, o paciente encontra-se assintomático, sem sinais clínicos sugestivos de recidiva da lesão e com boa função do joelho. Conclusão: Este caso enfatiza a importância dos exames de imagem em pacientes com dor na parte anterior do joelho. Apesar de a síndrome dolorosa patelofemoral ser a causamais comum de dor nessa articulação em pacientes jovens, outros diagnósticos diferenciais devem ser considerados, como a sinovite vilonodular pigmentada localizada, cujo diagnóstico e tratamento precoces permitem bons resultados funcionais e baixa taxa de recidiva.Palavras-chave: Sinovite pigmentada vilonodular, Síndrome da dor patelofemoral, Joelho ABSTRACT: Introduction: Patellofemoral pain syndrome is a term used to describe several conditions associated with anterior knee pain. This syndrome is very common in medical practice and is the most common cause of knee pain in adolescents and young adults. However, anterior knee pain may be associated with other differential diagnoses. Objective: To report a case of a patient with a 5-year history of anterior knee pain. It progressed with slow but gradual worsening of symptoms, until a diagnosis of pigmented villonodular synovitis located in the anterior region of the knee was made. Case report: Male patient, 22 years old, with a 5-year history of pain in the left knee. He mentioned that he had previously undergone medical evaluation three times, where he was diagnosed and treated for pain of patellofemoral origin, without ever having performed magnetic resonance imaging (MRI). He reports that the functional limitation was progressively increasing, along with the increase in volume around the knee. He was instructed to perform an MRI of the left knee, which showed an expansive, intra-articular nodular formation, located in the space between Hoffa’s fat and the anterior margin of the tibial epiphysis. Arthrotomy was performed with a medial parapatellar approach for resection of the lesion via an open approach. The resected lesion was brownish in color, firm in consistency, measuring 8.0x5.0x4.0 cm and had histopathological features of pigmented villonodular synovitis. One year after the operation he is asymptomatic, with no clinical signs suggestive of recurrence of the lesion, and with good knee function. Conclusion: This case emphasizes the importance of evaluation with imaging tests in patients with anterior knee pain. Although patellofemoral pain syndrome is the most common cause of knee pain in young patients, other differential diagnoses should be kept in mind, such as localized pigmented villonodular synovitis, whose early diagnosis and treatment allow good functional results, with a low recurrence rate.Keywords: Pigmented villonodular synovitis, Patellofemoral pain syndrome, Knee
... Knee disorders are very common [1][2][3][4] and are linked to prolonged recovery periods and higher reinjury rates [5][6][7][8]. Pain is reported to continue for 5-8 years after physical therapies for patellofemoral pain (PFP) in 1 of every 2 patients [5], while nearly 1 in 4 young athletic patients who sustain an anterior cruciate ligament (ACL) injury and return to high-risk sport will sustain another ACL injury at some point in their career [6]. ...
... Knee disorders are very common [1][2][3][4] and are linked to prolonged recovery periods and higher reinjury rates [5][6][7][8]. Pain is reported to continue for 5-8 years after physical therapies for patellofemoral pain (PFP) in 1 of every 2 patients [5], while nearly 1 in 4 young athletic patients who sustain an anterior cruciate ligament (ACL) injury and return to high-risk sport will sustain another ACL injury at some point in their career [6]. To improve secondary and tertiary prevention efforts, a greater understanding of the effects of knee disorders on trunk biomechanics is required given its influence on knee loading. ...
Background
The trunk is the foundation for transfer and dissipation of forces throughout the lower extremity kinetic chain. Individuals with knee disorders may employ trunk biomechanical adaptations to accommodate forces at the knee or compensate for muscle weakness. This systematic review aimed to synthesize the literature comparing trunk biomechanics between individuals with knee disorders and injury-free controls.
Methods
Five databases were searched from inception to January 2022. Observational studies comparing trunk kinematics or kinetics during weight-bearing tasks (e.g., stair negotiation, walking, running, landings) between individuals with knee disorders and controls were included. Meta-analyses for each knee disorder were performed. Outcome-level certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and evidence gap maps were created.
Results
A total of 81 studies investigating trunk biomechanics across six different knee disorders were included (i.e., knee osteoarthritis [OA], total knee arthroplasty [TKA], patellofemoral pain [PFP], patellar tendinopathy [PT], anterior cruciate ligament deficiency [ACLD], and anterior cruciate ligament reconstruction [ACLR]). Individuals with knee OA presented greater trunk flexion during squatting (SMD 0.88, 95% CI 0.58–1.18) and stepping tasks (SMD 0.56, 95% CI 0.13–.99); ipsilateral and contralateral trunk lean during walking (SMD 1.36; 95% CI 0.60–2.11) and sit-to-stand (SMD 1.49; 95% CI 0.90–2.08), respectively. Greater trunk flexion during landing tasks in individuals with PFP (SMD 0.56; 95% CI 0.01–1.12) or ACLR (SMD 0.48; 95% CI 0.21–.75) and greater ipsilateral trunk lean during single-leg squat in individuals with PFP (SMD 1.01; 95% CI 0.33–1.70) were also identified. No alterations in trunk kinematics of individuals with TKA were identified. Evidence gap maps outlined the lack of investigations for individuals with PT or ACLD, as well as for trunk kinetics across knee disorders.
Conclusion
Individuals with knee OA, PFP, or ACLR present with altered trunk kinematics in the sagittal and frontal planes. The findings of this review support the assessment of trunk biomechanics in these individuals in order to identify possible targets for rehabilitation and avoidance strategies.
Trial registration: PROSPERO registration number: CRD42019129257.
... However, 57% of people still report symptoms ve to eight years after diagnosis [4], indicating that current treatments are failing most patients. Unresolved patellofemoral pain is insidious due to the accompanying psychological distress, reduced quality of life [5] and increased likelihood of patellofemoral osteoarthritis [6]. ...
... Patellofemoral pain is prevalent in the general population [1] and can result in psychological distress [5] and precede the development of patellofemoral osteoarthritis [6]. Current treatments for patellofemoral pain are not effective for many patients, as evidenced by the high proportion that still report symptoms ve to eight years after diagnosis [4]. Patellofemoral joint loading has been implicated in patellofemoral pain [8] and may hasten disease progression in adults with patellofemoral osteoarthritis [10]. ...
Background
Patellofemoral pain is highly prevalent across the lifespan, and a significant proportion of people report unfavourable outcomes years after diagnosis. Previous research has implicated patellofemoral joint loading during gait in patellofemoral pain and its sequelae, patellofemoral osteoarthritis. Biomechanical foot-based interventions (e.g., footwear, insoles, orthotics, taping or bracing) can alter patellofemoral joint loads, making them a promising treatment option. This systematic review will summarise the evidence about the effect of biomechanical foot-based interventions on patellofemoral joint loads during gait in adults with and without patellofemoral pain and osteoarthritis.
Methods
MEDLINE (Ovid), the Cumulative Index to Nursing and Allied Health Literature CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), SPORTdiscus (EBSCO) and Embase (Ovid) will be searched. Our search strategy will include terms related to ‘patellofemoral joint’, ‘loads’ and ‘biomechanical foot-based interventions’. We will include studies published in the English language that assess the effect of biomechanical foot-based interventions on patellofemoral joint loads, quantified by patellofemoral joint pressure, patellofemoral joint reaction force and/or knee flexion moment. Two reviewers will independently screen titles and abstracts, complete full-text reviews, and extract data from included studies. Two reviewers will assess study quality using the Revised Cochrane Risk of Bias (RoB 2) tool or the Cochrane Risk Of Bias In Non-Randomized Studies – of Interventions (ROBINS-I) tool. We will provide a synthesis of the included studies’ characteristics and results. If three or more studies are sufficiently similar in population and intervention, we will pool the data to conduct a meta-analysis and report findings as standardised mean differences with 95% confidence intervals. If a meta-analysis cannot be performed, we will conduct a narrative synthesis of the results and produce forest plots for individual studies.
Discussion
This protocol outlines the methods of a systematic review that will determine the effect of biomechanical foot-based interventions on patellofemoral joint loads. Our findings will inform clinical practice by identifying biomechanical foot-based interventions that reduce or increase patellofemoral joint loads, which may aid the treatment of adults with patellofemoral pain and osteoarthritis.
Systematic review registry
Registered with PROSPERO on the 4th of May 2022 (CRD42022315207).
... Patellofemoral pain (PFP) is a common cause of knee pain in young adults, with an estimated annual prevalence of 22.7% in the general population. 1 The diagnosis is predominantly clinical, with most people with PFP reporting a non-traumatic onset of pain around or behind the patella exacerbated by activities that load the patellofemoral joint. 2 Symptoms are persistent, with one in two people continuing to experience pain 5À8 years after rehabilitation. 3 Despite PFP being traditionally linked with abnormal loading of the patellofemoral joint, 4À7 recent evidence indicate there is no direct relationship between pain and patellofemoral joint loading during stair ascent in women with PFP. 8 Other factors, including the presence of pressure hyperalgesia (i.e. "increased pain from a stimulus that normally provokes pain" 9 ), may play a greater role in the pain experience of people with PFP. ...
... It is possible that treatments targeting body fat reduction and increases in skeletal muscle mass may directly or indirectly influence the pressure hyperalgesia in those with PFP, having a positive impact on the poor long-term outcomes associated with the condition. 3,49 A recent study reported a link between weight loss and improvements in pressure hyperalgesia in people with knee pain who were obese and underwent bariatric surgery. 50 Additionally, reductions in self-reported knee pain following weight loss seems to be mediated by improvements in pressure hyperalgesia. ...
Background
Young adults with patellofemoral pain (PFP) have a high prevalence of overweight and obesity, which is associated with impaired lower limb function and muscle weakness. However, the impact of overweight and obesity in pain sensitivity has not been explored.
Objectives
We investigated the association between body fat, skeletal muscle mass, and body mass index (BMI) with pressure hyperalgesia and self-reported pain in young adults with PFP.
Methods
114 adults with PFP (24 ± 5 years old, 62% women) were recruited. Demographics and self-reported pain (current and worst knee pain intensity in the previous month - 0–100 mm visual analog scale) were recorded. Body fat and skeletal muscle mass were measured using bioelectrical impedance. Pressure hyperalgesia was measured using a handheld algometer (pressure pain threshold) at three sites: center of patella of the painful knee, ipsilateral tibialis anterior, and contralateral upper limb. The association between body fat, skeletal muscle mass, and BMI with pressure hyperalgesia and self-reported pain were investigated using partial correlations and hierarchical regression models (adjusted for sex, bilateral pain, and symptoms duration).
Results
Higher body fat and lower skeletal muscle mass were associated with local, spread, and widespread pressure hyperalgesia (ΔR²=0.09 to 0.17, p ≤ 0.001; ΔR²=0.14 to 0.26, p<0.001, respectively), and higher current self-reported pain (ΔR²=0.10, p<0.001; ΔR²=0.06, p = 0.007, respectively). Higher BMI was associated with higher current self-reported pain (ΔR²=0.10, p = 0.001), but not with any measures of pressure hyperalgesia (p>0.05).
Conclusion
Higher body fat and lower skeletal muscle mass help to explain local, spread, and widespread pressure hyperalgesia, and self-reported pain in people with PFP. BMI only helps to explain self-reported pain. These factors should be considered when assessing people with PFP and developing their management plan, but caution should be taken as the strength of association was generally low.
... Patellofemoral pain (PFP) is characterized by pain around or behind the knee cap that is present during activities such as negotiating stairs, squatting or running . It is associated with frequent use of pain killers, poorer quality of life, and negatively impacts participation in leisure time activities, work, and sport (Coburn et al., 2018;Lankhorst et al., 2016;Rathleff, 2016). ...
... Musculoskeletal Science and Practice xxx (xxxx) 102567 (Collins et al., 2018). Yet, more than 50% of participants adhering to active management interventions in clinical trials report unsatisfactory outcomes 2-5 years later (Lankhorst et al., 2016;Rathleff, 2016). A reason for this poor outcome might be that only approximately a third of prescribed exercise is performed (i.e., poor adherence with exercise programs) (Rathleff et al., 2015). ...
Objective
To identify challenges confronting patients and physiotherapists in managing patellofemoral pain by seeking their perspectives via generative activities involving critique, ideation and formulating shared visions for future treatments.
Design
Two Future Workshops, Reflexive Thematic Analysis.
Methods
We recruited 8 patients (median age 36 yrs, 4 women) who were experiencing patellofemoral pain and 10 physiotherapists (54 yrs, 8 women) who treated patients with the condition. Several vignette cases and design cards were constructed and included as tools for facilitating dialogue, throughout all three phases (each ∼40 min duration) of the workshops (i.e., critique, fantasy, implementation). Participants’ discussions were audio recorded, transcribed and thematically analyzed independently by four investigators until no additional themes emerged.
Results/findings: Four themes were identified; (i) challenges confronting patients, (ii) Learning to manage PFP, (iii) stakeholder accountability and (iv) development/use of portable applications (apps). Some challenges and strategies were related to family and social networks, financial costs, and psychological factors. Knowledge related to the condition, mental and physical impact of pain, exercises and physical activity. The physiotherapist's role in moderating accurate information was raised, as was that of the GP and personal trainer. Visions of future treatments centered about the inclusion of flexible modes of communication and cultivating mutual accountability. Social determinants and the invisible work of patients in managing their condition was apparent.
Conclusion
Enacting patient centered care was sought and recommended – requiring consideration of social contexts and flexible delivery. The physiotherapist was seen as a source of accurate information and a point of accountability.
... 1,2 Acute knee injuries often require surgical intervention, 3 and chronic knee injuries frequently persist, despite evidence-based management. 4,5 Consequently, knee injuries result in more time loss than injuries to other lower limb regions. 6 In the longer term, both acute and chronic knee injuries increase the risk of knee osteoarthritis and other knee-related symptoms, reducing quality of life. ...
... 10 Knee injuries have both a high incidence and severity (Stage 1). [1][2][3][4][5][6][7][8][9] Among potential risk factors, neuromuscular variables are particularly relevant to prevention, as they can be quantified using valid and reliable tests and modified through clinical intervention. For example, strength can be assessed by handheld dynamometry, 11 and can be enhanced by resistance training. ...
Objectives
Identify neuromuscular risk factors for non-contact knee injury, using a systematic review and meta-analysis, to inform the development of preventive strategies.
Methods
Medline, Web of Science and SCOPUS were searched from inception until November 2020. Prospective and nested case-control studies that analysed baseline neuromuscular characteristics as potential risk factors for subsequent non-contact knee injuries were included. Two reviewers independently appraised methodological quality using a modified Newcastle-Ottawa Scale. Meta-analysis was performed where appropriate, with standardised mean differences calculated for continuous scaled data.
Results
Seventeen studies were included, comprising baseline data from 5,584 participants and 415 non-contact knee injuries (heterogeneous incidence = 7.4%). Protocols and outcome measures differed across studies, limiting data pooling. Twenty-one neuromuscular variables were included in the meta-analysis. Three were identified as risk factors. For patellofemoral pain, among military recruits: reduced non-normalised quadriceps strength at 60 deg/s (SMD -0.66; 95% CI -0.99, -0.32); reduced quadriceps strength at 240 deg/s (normalised by body mass) (SMD -0.53; CI -0.87, -0.20). For PFP/ACL injury among female military recruits: reduced quadriceps strength at 60 deg/s (normalised by body mass) (SMD -0.50; CI -0.92, -0.08).
Conclusions
Quadriceps weakness is a risk factor for PFP among military recruits, and for PFP/ACL injury among female military recruits. However, the effect sizes are small, and the generalisability of these findings is limited. The effectiveness of quadriceps strengthening interventions for preventing PFP and ACL injury merits evaluation in prospective randomised trials.
... Patellofemoral pain is a highly prevalent condition affecting young people through to older adults, including both active and sedentary populations. 1 Clinical guidelines recommend exercise, and education on load, self-management strategies and the nature of patellofemoral pain, as the cornerstones of patellofemoral pain treatment. 2-4 However, 57% of people still report symptoms 5-8 years following diagnosis, 5 showing that current treatment is suboptimal for this non-self-limiting condition. The persistent nature of patellofemoral pain symptoms, the poor long-term prognosis and limited evidence on effective treatment options, means patients may also be at an increased risk of developing patellofemoral osteoarthritis compared with ...
Objective
To evaluate the effects of biomechanical foot-based interventions (eg, footwear, insoles, taping and bracing on the foot) on patellofemoral loads during walking, running or walking and running combined in adults with and without patellofemoral pain or osteoarthritis.
Design
Systematic review with meta-analysis.
Data sources
MEDLINE, CINAHL, SPORTdiscus, Embase and CENTRAL.
Eligibility criteria for selecting studies
English-language studies that assessed effects of biomechanical foot-based interventions on peak patellofemoral joint loads, quantified by patellofemoral joint pressure, reaction force or knee flexion moment during gait, in people with or without patellofemoral pain or osteoarthritis.
Results
We identified 22 footwear and 11 insole studies (participant n=578). Pooled analyses indicated low-certainty evidence that minimalist footwear leads to a small reduction in peak patellofemoral joint loads compared with conventional footwear during running only (standardised mean difference (SMD) (95% CI) = −0.40 (–0.68 to –0.11)). Low-certainty evidence indicated that medial support insoles do not alter patellofemoral joint loads during walking (SMD (95% CI) = −0.08 (–0.42 to 0.27)) or running (SMD (95% CI) = 0.11 (–0.17 to 0.39)). Very low-certainty evidence indicated rocker-soled shoes have no effect on patellofemoral joint loads during walking and running combined (SMD (95% CI) = 0.37) (−0.06 to 0.79)).
Conclusion
Minimalist footwear may reduce peak patellofemoral joint loads slightly compared with conventional footwear during running only. Medial support insoles may not alter patellofemoral joint loads during walking or running and the evidence is very uncertain about the effect of rocker-soled shoes during walking and running combined. Clinicians aiming to reduce patellofemoral joint loads during running in people with patellofemoral pain or osteoarthritis may consider minimalist footwear.
... At long-term follow-up, approximately half of atraumatic knee pain patients report persistent pain and reduced function. (9)(10)(11) Recurrence is also common after running injuries affecting the knee (12) and a prior history of injury is a recognized risk factor for running injuries in both civilian and military populations. (13)(14)(15) Optimal treatment strategies for overuse knee injuries in are needed to avoid subsequent injury, restore running ability, and return to duty as quickly as possible. ...
Introduction
Running is the most common cardiovascular exercise in the military. However, there is a high incidence of running-related overuse injuries that reduces military readiness. Gait retraining is a common intervention to treat running-related injuries, but the high cost of equipment and lack of clinician expertise and availability reduces utilization. Gait retraining intervention in a telehealth format might improve feasibility. The purpose of this randomized clinical trial is to determine the effectiveness of a telehealth gait retraining intervention on pain, self-reported function, and biomechanical risk factors for injury in Service Members who present to a Military Health System physical therapy clinic with an overuse knee injury.
Methods
This is a parallel, two-arm, single-blind randomized clinical trial. The two independent variables are intervention (2 levels: telehealth gait retraining intervention with standard of care or only standard of care) and time (3 levels: baseline, 10-weeks or post-intervention, 14-weeks). The primary dependent variables are: 1. worst reported pain during and after running as measured on a visual analog scale; and 2. foot strike pattern during running. Secondary outcomes include worst non-knee pain during running, worst overall knee pain, self-reported function (University of Wisconsin Running Injury and Recovery Index, Single Assessment Numerical Evaluation, Anterior Knee Pain Scale), and running biomechanics (step rate, step length, ground contact time, peak knee adduction angle, peak hip adduction angle, average vertical loading rate, instantaneous vertical loading rate, knee stiffness, and peak rearfoot inversion moment).
Discussion
The effectiveness of a telehealth gait retraining intervention to reduce pain and modify foot strike pattern is not known. The results of this study may help determine the effectiveness and feasibility of a telehealth gait retraining intervention to reduce pain, change foot strike, improve function, and improve running gait biomechanics.
Trial registration
ClinicalTrials.gov, NCT04269473. Registered 05 February 2020, http://clinicaltrials.gov/NCT04269473.
... 5 Although multimodal treatments have been developed for PFPS, 57% of the patients reported negative results after 5-8 years and the need for alternative methods was emphasized. 6 The number of studies directly evaluating the effectiveness of education in PFPS is limited. Even though increasing emphasis has recently been placed on studies on patient education, the available evidence is quite insufficient. ...
... 6 While most patients with PFP seek medical care, 8 over 60% are not satisfied with their knee function within 3 months of concluding treatment. 15 Numerous studies targeting hip abductor strength produce minimal improvements, 16 and hip strength gains are lost within months of concluding treatment. 16 17 The lack of strength changes after hip-focused strengthening interventions suggests that there may be additional meaningful factors of neuromuscular function in adults with PFP. ...
Patellofemoral pain (PFP) is a chronic condition that presents with patellar pain during various daily and recreational activities. Individuals with PFP have a wide range of impairments that result in long-term disability and reduced quality of life. Current interventions target hip muscle weakness with strength-based exercises, but recurrence rates are as high as 90%. A single feasibility study demonstrated success with power-based exercises; however, there is limited evidence evaluating pain or self-reported function in larger cohorts, and no study has assessed recurrence rates. This protocol details a study evaluating a strength-based rehabilitation programme compared with a strength-based programme incorporating power-based exercises in individuals with PFP. This single-blinded randomised controlled trial will evaluate 88 participants with PFP, aged 18–40 years old. Participants will be recruited from three universities, the surrounding community and sports medicine clinics. Participants will receive three telemedicine rehabilitation sessions a week for 6 weeks. The rehabilitation programme will consist of either strength-based exercises or a combination of power and strength-based exercises. Pain, subjective function and recurrence rates will be assessed at baseline, immediately after the intervention and at four follow-up time points: 6-month, 12-month, 18-month and 24-month postintervention. We will also assess neuromuscular function of the hips and global rating of change at each postintervention time point. Trial registration number NCT05403944 .
... Long-term pain is reported to continue in one of every two patients even after treatment (3,23). Symptom severity may remain unchanged or increase in 50% of affected individuals (24,25). As such, a similar prospective pattern would also be expected for physical and non-physical features given their previously reported cross-sectional association with PFP. ...
Background:
This is a protocol for a prospective longitudinal study that aims to investigate: (1) group-by-time changes over a minimum of 15 months follow-up in patellofemoral pain (PFP) symptoms, biomechanical, muscle function, pain processing, and psychological features; (2) the extent to which changes in biomechanical, muscle function, pain processing, and psychological features are associated with changes in self-reported pain, physical performance measures, self-reported function, health-related quality of life (HRQOL), and physical activity level.
Methods:
Individuals with PFP (n = 144) and control individuals (n = 85) without PFP were assessed at baseline. Outcomes assessed included: 3D kinematics and kinetics during single leg squat, step-down and single leg hop; maximal torque and rate of torque development of hip abductors and knee extensors/flexors; force steadiness of hip abductors and knee extensors; anterior and lateral trunk endurance; pressure pain thresholds at the center of patella and contralateral shoulder; kinesiophobia (Tampa Scale for Kinesiophobia); pain catastrophizing (Pain Catastrophizing Scale); worst self-reported pain (Visual Analogue Scale); physical performance measures (Single Leg Hop Test and Forward Step-Down Test); self-reported function (Anterior Knee Pain Scale); HRQOL (Medical Outcome Short-Form 36), and physical activity level (Baecke's Questionnaire). Follow-up assessments will be identical to the baseline and will be performed after a minimum of 15 months. Generalized linear mixed model (GLMM) will be used to investigate group-by-time differences. Linear regression models will be used to determine the extent to which changes in biomechanical, muscle function, pain processing, and psychological features are associated with changes in self-reported pain, physical performance measures, self-reported function, HRQOL, and physical activity level.
Discussion:
Physical and non-physical features have been previously associated with PFP. However, the present study will be the first to investigate their integrated evolution as part of the natural history of PFP and its progression. In doing so, we will be able to determine their behavior in the long-term, as well as how they prospectively associate with each other and with clinical outcomes. Ultimately, this will provide a greater understanding of predictors of long-term outcome and possible targets for interventions.
... In the absence of other pathologies, anterior knee pain that is exacerbated by activities such as sitting, squatting, ascending and descending stairs, jumping, or running is identified as PFPS (Witvrouw et al., 2014). According to recent studies, this syndrome is not regarded as a simple selflimiting disease, and it has been reported that more than 50% of PFPS suffer from advanced chronic pain (Lankhorst et al., 2016;Rathleff et al., 2016;Wyndow et al., 2016). Concerns over the long-term consequences of anterior knee pain in adolescence and young adulthood include a predisposition to patellofemoral osteoarthritis in later life (Utting, Davies, and Newman, 2005). ...
Purpose:
The aims of this study were to evaluate the diagnostic accuracy of common physical examination and functional evaluation tests, and to determine a set of tests with the highest diagnostic accuracy for diagnosing patellofemoral pain syndrome (PFPS) in patients with anterior knee pain.
Methods:
Based on careful evaluation of clinical findings and imaging methods by orthopedic physicians, 162 patients with anterior knee pain were classified into two groups of PFPS and non-PFPS. The physical examination and functional tests were performed by two physiotherapists. The accuracy of these measures was determined by calculating sensitivity, specificity, area under the receiver operating characteristic (ROC) curve (AUC), likelihood ratio (LR), and predictive value (PV).
Results:
Our results showed the most sensitive tests in identifying patients with PFPS were as follows: eccentric step test [0.82 (95%CI: 0.72-0.89)]; palpation test [0.81(95%CI: 0.70-0.88)]; and prolonged sitting [0.73 (95%CI: 0.62-0.82)]. The palpation test, patellar tilt test, eccentric step test, navicular drop test, squatting, and stair descending tests had an acceptable accuracy (AUC ≥ 70). The strongest combination of the physical examination and functional tests included pain severity between 3 and 10 during stair descending test and pain severity between 6 and 10 during prolonged sitting test. This combination showed a positive LR of 19.47 (95% CI: 6.36-59.65) and a posttest probability of 95%.
Conclusion:
Our findings provide evidence for the good accuracy of the palpation test, patellar tilt test, eccentric step test, navicular drop test, squatting, and stair descending and prolonged sitting tests for diagnosing PFPS. Also, the combination of stair descending test and prolonged sitting test could be very useful for ruling in PFPS patients.
... Growing evidence supports that exercise therapy protocols are effective rehabilitation for people with PFP [5][6][7][8]. However, pain and function improvements have been reported not to be sustained in the long term [6,9,10]. This indicates that the current protocols may not comprehend all required functional factors to provide a full and consistent recovery for that population. ...
Background
Growing evidence supports that exercise therapy is effective for patellofemoral pain (PFP) rehabilitation. Nevertheless, the improvements have been reported not to be sustained in the long term, suggesting that the current protocols may not comprehend all required functional factors to provide a consistent recovery. A potential neglected factor in treatment protocols for PFP is postural control. However, it is unclear whether this population presents balance impairments or the influence of postural control on pain and function during rehabilitation programmes.
Objective
To investigate whether (Q1) balance is impaired in people with PFP compared to controls, (Q2) conservative interventions are effective to improve balance in people with PFP, and (Q3) balance exercises are effective to improve pain and function in people with PFP.
Data sources
Medline, Embase, CINAHL, SPORTDiscus, Web of Science and Cochrane Library, supplemented by hand searching of reference lists, citations and relevant systematic reviews in the field.
Methods
A systematic review with meta-analysis was conducted according to the Cochrane recommendations and reported according to the PRISMA statement recommendations. We included cross-sectional studies comparing balance between people with and without PFP; and randomised controlled trials verifying the effect of conservative intervention on balance and the effect of balance intervention on pain and function in people with PFP. The risk of bias was assessed using the Epidemiological Appraisal Instrument for cross-sectional studies and the Physiotherapy Evidence Database scale for randomised controlled trials.
Results
From 15,436 records, 57 studies (Q1 = 28, Q2 = 23, Q3 = 14) met the eligibility criteria. Meta-analyses indicated that people with PFP have worse anteroposterior (very low grade evidence, standardised mean difference [SMD] = 1.03, 95% CI 0.40–1.66) and mediolateral (moderate grade evidence, SMD = 0.87, 95% CI 0.31–1.42) balance compared to controls. Moderate grade evidence indicated that overall balance is not affected in people with PFP (SMD = 0.38, 95% CI − 0.05–0.82). Low to very low grade evidence indicates that interventions are ineffective for mediolateral (SMD = 0.01, 95% CI − 0.51–0.53) and overall (SMD = 0.49, 95% CI − 0.14–1.11) balance improvements, and low grade evidence indicates that interventions are effective to improve anteroposterior balance (SMD = 0.64, 95% CI 0.04–1.23). Moderate to low grade evidence indicated that balance interventions are effective to reduce pain (SMD = 0.82, 95% CI 0.26–1.38) and improve function (SMD = 0.44, 95% CI 0.09–0.80) when measured using questionnaires; and very low grade evidence indicated no efficacy for function measured via functional tests (SMD = 0.73, 95% CI − 0.16–1.61).
Conclusion
People with PFP likely present balance deficits compared to asymptomatic people. There was insufficient evidence to support the efficacy of interventions to improve or modify balance in people with PFP. Also, there was insufficient evidence to support the efficacy of balance exercises to improve pain and function in people with PFP.
Trial Registration The present systematic review was registered in PROSPERO (CRD42018091717).
... Otros estudios sobre la historia natural del SDPF indican que el dolor puede prolongarse sobre los 12 meses hasta 20 años (7)(8)(9). La persistencia de este síntoma se ha relacionado con una activación alterada de los nociceptores periféricos y con trastornos del sistema somatosensorial, lo cual es significativamente perjudicial para la salud mental y la funcionalidad física, logrando que los pacientes restrinjan su participación en diversas actividades (10)(11)(12) e incrementen las posibilidades de adquirir otras enfermedades (8). ...
El síndrome doloroso patelofemoral (SDPF) es una condición musculoesquelética frecuente que se manifiesta con dolor retro y peripatelar. El fortalecimiento muscular de cadera y rodilla (FCR) ha sido propuesto como un tratamiento apropiado para el SDPF. Es precisa una revisión que compare los resultados del FCR con otras intervenciones utilizando evidencia científica actual. Objetivo. Evaluar la efectividad del FCR en pacientes con SDPF. Materiales y métodos. La revisión sistemática (RS) y metaanálisis (MA) siguieron las directrices PRISMA. El cribaje y selección de estudios se realizó mediante el programa Rayyan. Nueve artículos fueron incluidos y evaluados con la escala PEDro y la herramienta Riesgo de Sesgo de Cochrane. El MA se realizó en la aplicación Jamovi. Las variables utilizadas fueron dolor, funcionalidad y fuerza muscular. Resultados. El MA demostró que el FCR fue superior en la disminución del dolor (2.30 [1.18, 3.42] 95%IC) (1.76 [0.70, 2.81] 95%IC) y el incremento de la funcionalidad (14.30 [7.49, 21.11] 95%IC) (8.66 [3.08, 14.23] 95%IC) comparado con los grupos sin intervención (NI) y los del fortalecimiento de rodilla (FR), respectivamente; mientras que la adición de intervenciones al fortalecimiento de cadera y rodilla (FCR+) demostró mayores beneficios en la funcionalidad (-5.71[-8.32, -3.10] 95%IC) al compararse con el FCR. Así mismo, el análisis cualitativo de la variable fuerza muscular estableció que el FCR obtuvo mejores resultados que los grupos de FR y FCR+ ejercicios de control motor. Conclusiones. El FCR es una intervención efectiva en la reducción del dolor, el incremento de la funcionalidad y fuerza muscular en pacientes con SDPF.
... Patellofemoral pain (PFP) is a chronic musculoskeletal disorder affecting people from adolescence into older adulthood (Rathleff et al., 2015). PFP prevalence can be as high as 35.7% in athletes , with long-term pain in one of every two patients reported to continue for 5-8 years after physical therapies for PFP (Lankhorst et al., 2016). The characteristic anterior knee pain is typically exacerbated by activities that have higher loading demands on the patellofemoral joint (PFJ) such as stair negotiation, stepping down, and running (Bazett-Jones et al., 2013;Briani et al., 2018). ...
The exacerbation of patellofemoral pain (PFP) may lead to compensatory trunk and lower limb movement patterns in order to minimize patellofemoral joint loading. However, joint kinematics are often analysed in isolation, which limits the understanding of how the underlying segments were coordinated to produce limb postures and load distribution across the limb. In this study we used a dynamical systems approach to investigate how women with PFP coordinate trunk, hip, and knee motion and distribute hip-knee moment demands following symptom exacerbation. Coordination patterns and coordination variability of the trunk, hip, and knee from 61 women with PFP were obtained during stair descent, ascent, and step down tasks, before and after a pain exacerbation protocol. Hip-knee extensor moment impulse ratio was also calculated. Following the exacerbation of PFP, women utilized knee dominant coordination patterns less often (p=0.039-0.027; d=0.51-0.53), while coordination patterns with the trunk leaning forward were utilized more during stair negotiation (p=0.043-<0.001; d=0.52-0.96). Although no significant differences in hip-knee coordination patterns were found, there was an increase in the hip-knee impulse ratio during stair negotiation (p=0.014-<0.001; d=0.27-0.36). These findings seem to display a movement strategy utilized by women with PFP in order to distribute more load to the hip joint and less to the knee joint, possibly in an attempt to avoid/manage pain.
... A systematic review on this topic noted that reproduction of retropatellar pain during squatting and a hypomobile patellar tilt test were the most accurate diagnostic tests for PFPS [4]. Symptoms associated with PFPS have the potential to become chronic and more than half of individuals with PFPS report unfavorable recovery 5 to 8 years after symptom onset even without radiographic evidence of osteoarthritis [5]. Despite the prevalence and challenges for recovery in patients with PFPS, physical therapy (PT) interventions demonstrate potential to improve symptoms and function in individuals with PFPS [6][7][8]. ...
... The annual prevalence in the general population is around 22.7% (Smith et al., 2018). Although PFP was previously considered a self-limiting condition, recent studies have shown that symptoms can persist for years (Collins et al., 2013;Lankhorst et al., 2016;Rathleff et al., 2016). ...
Background
No studies have evaluated whether interventions used by Brazilian physiotherapists for the treatment of patellofemoral pain (PFP) are in line with the best existing scientific evidence.
Objectives
Identify the interventions most commonly used by Brazilian physiotherapists for the rehabilitation of PFP and determine whether characteristics of physiotherapists and knowledge regarding evidence-based practice (EBP) influence the choice of interventions.
Design
Cross-sectional web-based survey.
Methods
Brazilian physiotherapists who treat patients with PFP participated in the study. Characteristics of the participants, information regarding EBP and interventions used in the treatment of PFP were collected through an online questionnaire. Descriptive analysis of the data was performed. Logistic regression analysis was employed to investigate associations between the interventions and both the characteristics of the physiotherapists and their knowledge regarding EBP.
Results
One hundred and ninety-four physiotherapists completed the questionnaire, 97.4% of whom reported using combined hip and quadriceps strengthening exercises, whereas only 25.3% reported using foot orthoses. A significant number of physiotherapists also reported using interventions that are not recommended (such as patellar mobilization, lumbar, hip and knee mobilization/manipulation and biophysical agents). Physiotherapists with a master's or doctoral degree and those who were aware of clinical practice guidelines were respectively 2.57-fold and 3.81-fold more likely to use recommended interventions.
Conclusion
Most Brazilian physiotherapists choose interventions that are in line with current scientific evidence. However, a significant number also use interventions that are not recommended for the treatment of PFP.
... Furthermore, a long-term study on 22 patients has reported that 91% of the patients diagnosed with PFP in childhood continue to experience knee pain for up to 18 years after the initial diagnosis (Stathopulu and Baildam, 2003), while another study has established that 57% patients continue to have significant symptoms (i.e. severe pain and functional impairments) up to 8 years after the initial diagnosis (Lankhorst et al., 2016). Additional evidence showing that approximately one quarter of PFP patients eventually stop participating in sports activities (Rathleff, Rasmussen, and Olesen, 2012) highlights the need for designing, implementing and evaluating effective therapeutic exercise programs for this condition. ...
OBJECTIVE: The aim of this study was to explore patients’ experience of patellofemoral pain (PFP), in order to help improve the mutual understanding between the patient and the physiotherapist and consequently enhance the efficacy of treatment.
METHODS: A qualitative study design with focus groups was used to explore patient experience prior to the implementation of the therapeutic exercise program, during its duration, and up to twelve months after its conclusion.
RESULTS: Patients provided a detailed description of their lifestyle prior to the enrollment in the therapeutic exercise program, their experience of the therapeutic exercise program and the behavioral changes that remained after its conclusion. Three main themes emerged from our data: 1) PFP characteristics and the impact of PFP on daily life; 2) experience with the therapeutic exercise program; and 3) changes in PFP and daily behaviors following the therapeutic exercise program.
CONCLUSION: Our findings suggest that a targeted therapeutic exercise program effectively reduces short- and long-term PFP and enhance overall well-being. Further research is needed to investigate the effects of different therapeutic exercise programs with a focus on the role of self-motivation.
... LangzeitFollowups zeigen, dass nur ein Drittel der Patienten ein Jahr nach der Diagnose trotz Therapie schmerzfrei ist (8). Negative prog nostische Faktoren sind hierbei eine lange Dauer der Erkrankung (> 2 Monate) sowie eine ausge prägte Schmerzintensität und Funktionseinschrän kung vor Therapiebeginn (8,9). Dies deutet darauf hin, dass die Therapie zeitnah beginnen sollte. ...
Patient*innen mit patellofemoralen Schmerzen kommen häufig zur Physiotherapie. Die Langzeitprognose ist eher schlecht, vor allem, wenn die Therapie nicht rechtzeitig beginnt. An einem Fallbeispiel wird aufgezeigt, worauf es ankommt und welchen Mehrwert die instrumentelle Bewegungsanalyse bringen kann.
... [4][5][6][7][8] For most patients, PFP consists of a chronic musculoskeletal condition with periods of remission of symptoms. 9 Long-term cohort studies [9][10][11] showed that most individuals with idiopathic knee pain or PFP have persistent symptoms several years after the onset of condition. This recurrence of PFP has been associated with the development of knee osteoarthritis, with subjects undergoing total knee arthroplasty often reporting history of PFP during adolescence. ...
Background:
Patellofemoral pain (PFP) is typically accompanied by changes in movement pattern. However, it is unclear if these changes persist in the remission phase of symptoms. Investigating movement patterns in individuals in remission phase of PFP may help to further guide the rehabilitation process and to understand whether changes are due to high levels of pain or related to other factors.
Purpose:
To compare 3D kinematics during walking and the single leg squat (SLS) between individuals with history of PFP in remission phase and a control group without history of lower limb injuries and PFP.
Study design:
Cross-sectional case-control study.
Methods:
Individuals with onset of PFP for at least one year and in phase of remission of symptoms (experimental group [EG]; n=13, 30±8 years) were compared to a control group (CG, n=13, 28±7 years). A 10-camera motion analysis system (Vicon-Nexus®) was used to record 3D ankle, knee, hip and trunk angles during walking and SLS.
Results:
The EG presented less ankle dorsiflexion, knee and hip flexion during the stance phase of walking compared to the CG (p=0.005, large effect size ηp2 = 0.141). During the SLS, no between-group differences were observed for the ankle, knee and hip angles at the peak of knee flexion (p>0.05). A trend for increased trunk range of movement in the EG compared to the CG was observed (p=0.075, medium effect size ηp2 = 0.127).
Conclusion:
The results of this study indicate less movement in the sagittal plane during walking, and a trend towards more movement of the trunk during SLS in the EG compared to the CG. The participants of the EG had minimal symptoms, to the point of not classifying them as pathological. However, the between-group differences suggest that even in the remission phase, kinematic differences persist for some reason and may contribute to the recurring pain in PFP individuals.
Level of evidence:
Level 3.
... 5,[8][9][10][11] While classically described as a self-limited condition, AKP can become a devastatingly persistent and recurrent chronic problem. [12][13][14][15] Relatively few patients with AKP ultimately require surgery, with multimodal nonoperative treatment including physical therapy remaining the mainstay of treatment for a vast majority. As such, familiarity of practitioners with appropriate evidence-based rehabilitation plans is paramount to successful treatment of patients experiencing AKP. ...
Anterior knee pain represents one of the most common athletic knee conditions and arguably also one of the most complex. The patellofemoral joint is at the center of several forces, and alterations in any of these force vectors due to muscular imbalance, soft-tissue tightness or laxity, and altered functional movement patterns can all combine to create a painful anterior knee. While typically anterior knee pain is not a surgical entity, the orthopaedic surgeon with an understanding of these biomechanical intricacies is best positioned to provide comprehensive evidence-based care for the patient with anterior knee pain.
Level of Evidence
V, expert opinion.
... 8 Currently, the cornerstone of conservative treatment includes therapeutic exercises that target GMed and GMax activation. 16 Although hip-focused strength interventions are successful in the short term, they do not have conclusive evidence supporting success >1 year after the conclusion of treatment 17,18 and do not improve frontal plane kinematics during squatting and running tasks. 19,20 Prospective studies have reported that hip weakness is not a risk factor for individuals who develop PFP and may be a consequence of injury. ...
Context:
Lesser hip muscle strength is commonly observed in females with patellofemoral pain (PFP) compared with females without PFP and is associated with poor subjective function and single-leg squat (SLS) biomechanics. Hip muscle weakness is theorized to be related to PFP, suggesting centrally mediated muscle inhibition may influence the observed weakness. The central activation ratio (CAR) is a common metric used to quantify muscle inhibition via burst superimposition. However, gluteal inhibition has yet to be evaluated using this approach in females with PFP. The study objectives are to (1) describe gluteal activation in the context of subjective function, hip strength, and squatting biomechanics and (2) examine the relationship of gluteal activation with subjective function and squatting biomechanics in females with PFP.
Design:
Cross-sectional.
Methods:
Seven females with PFP (age = 22.8 [3.6] y; mass = 69.4 [18.0] kg; height = 1.67 [0.05] m, duration of pain = 6-96 mo) completed this study. Subjective function was assessed with the Anterior Knee Pain Scale, while fear-avoidance beliefs were assessed with the Fear-Avoidance Belief Questionnaire physical activity and work subscales. Biomechanical function was assessed with peak hip and knee angles and moments in the sagittal and frontal planes during SLS. Gluteus medius (GMed) and gluteus maximus (GMax) activation were assessed with the CAR. Descriptive statistics were calculated, and relationships between variables were assessed with Spearman rho correlations.
Results:
The CAR of GMed and GMax was 90.5% (8.1%) and 84.0% (6.3%), respectively. Lesser GMed CAR was strongly associated with greater hip adduction during SLS (ρ = -.775, P = .02) and greater fear-avoidance beliefs-physical activity subscale (ρ = -.764, P = .018).
Conclusion:
We found a wide range in GMed and GMax activation across females with PFP. Lesser GMed activation was associated with greater hip adduction during SLS and fear of physical activity, suggesting that gluteal inhibition should be assessed in patients with PFP.
... Patellofemoral pain (PFP) is characterized by retropatellar and/or peripatellar pain that is aggravated during activities that increase patellofemoral joint loading (e.g., squatting and ascending/descending stairs) [1], with an annual prevalence in the general population of around 22.7% [2]. Although PFP was previously considered as a self-limiting condition, recent studies suggest that alterations and symptoms may persist for several years [3][4][5]. Chronic pain associated with PFP has a negative impact on an individual´s level of physical activity and quality of life, interfering with work, activities of daily living, and physical exercise [5][6][7]. ...
Background
Strong evidence supports the proximal combined with quadriceps strengthening for patellofemoral pain (PFP) rehabilitation. However, most reported rehabilitation programs do not follow specific exercise prescription recommendations or do not provide adequate details for replication in clinical practice. Furthermore, people with PFP have power deficits in hip and knee muscles and it remains unknown whether the addition of power exercises would result in superior or more consistent outcomes. Therefore, this study is designed to verify whether the benefits of a rehabilitation program addressing proximal and knee muscles comprising power and strength exercises are greater than those of a program consisting of strength exercises only.
Method
This study will be a randomized controlled trial that will be conducted at university facilities. A minimum of 74 people with PFP between the ages of 18 and 45 years will be included. The experimental group will engage in a 12-week resistance training program focusing on proximal and knee muscles using power and strength exercises. The control group will engage in a 12-week resistance training program focusing on proximal and knee muscles using strength exercises only. Primary outcomes will be pain intensity and physical function; and secondary outcomes will be kinesiophobia, self-reported improvement, quality of life, peak hip and knee torque, and hip and knee rate of force development. The primary outcomes will be evaluated at baseline, and after 6 weeks, 12 weeks, 3 months, 6 months, and 1 year. The secondary outcomes will be evaluated at baseline and immediately after the interventions. Therapists and participants will not be blinded to group allocation.
Discussion
This randomized clinical trial will investigate if adding power exercises to a progressive resistance training may lead to more consistent outcomes for PFP rehabilitation. The study will provide additional knowledge to support rehabilitation programs for people with PFP.
Trial registration
ClinicalTrials.gov NCT 03985254. Registered on 26 August 2019.
... Research aimed at managing PFP is primarily quantitative (Smith et al., 2018a), with randomised control trials of varying methodological quality (Kedroff et al., 2019) recommending addressing the biomechanical impairments associated with PFP (Vicenzino et al., 2019). Despite the strength of this research PFP has a poor prognosis, with >50% of people reporting persistent pain five years post-treatment (Lankhorst et al., 2016). ...
Background
Patellofemoral pain (PFP) is common and long-term treatment outcomes are unsatisfactory. Qualitative exploration of diagnosis and management from the perspective of people with PFP is lacking.
Objectives
To inform care and improve intervention delivery by exploring the experience of people with patellofemoral pain (PFP) regarding diagnosis and management.
Design
Qualitative study with semi-structured interviews.
Method
Online recruiting yielded a convenience sample of participants with PFP for semi-structured interviews. Interviews were recorded, transcribed verbatim and analysed using thematic analysis until theoretical saturation by multiple investigators to determine themes and sub-themes.
Results
12 participants were interviewed, with three themes identified; the value of diagnosis, the need for tailored (individualised) care, and the role of education. Participants viewed a diagnosis as essential to guide management, yet this was rarely provided, causing uncertainty about pain mechanisms; “it's nice to be told what it is that's wrong”. Interventions needed to be tailored to the individual as not all participants responded in the same way to treatment(s) or had the same needs; “everyone copes and reacts differently”. Finally, participants viewed education as essential to empower them to understand and manage the condition; “if I'd have been given more information, I think I'd know how to deal with it more”.
Conclusions
The overarching narrative from three themes was a desire for clearly communicated personalised care that meets individual needs. People with PFP desire a diagnosis to explain their pain, tailored interventions, and appropriate education to optimise their experience and outcomes.
... Although short-term treatment for PFP is promising, long-term outcomes are less successful. [4][5][6][7][8][9] Individuals with PFP for greater than 12 months have worse pain 5-8 years later, 4 and a 7-year follow-up of those with chronic PFP found that approximately 30% had persistent complaints. 9 Prolonged PFP can decrease physical activity 7,10,11 and may increase the risk of developing patellofemoral osteoarthritis. ...
Altered gait variability occurs in those with patellofemoral pain and may be relevant to pain progression. We examined gait kinematic and coordination variability between individuals with acute and chronic patellofemoral pain and healthy controls. Eighty-three patellofemoral pain runners (37 men and 46 women) and 142 healthy controls (52 men and 90 women) ran on a treadmill while 3-dimensional lower limb kinematic data were collected. Patellofemoral pain runners were split into acute (n = 22) and chronic (n = 61) subgroups based on pain duration (< and ≥3 mo, respectively). Approximate entropy assessed continuous hip, knee, and ankle kinematic variability. Vector coding calculated coordination variability for select joint couplings. Variability measures were compared between groups using 1-way analysis of variance and post hoc comparisons with Cohen d effect sizes. The chronic patellofemoral pain subgroup displayed higher frontal plane knee kinematic variability compared with controls ( P = .0004, d = 0.550). No statistically significant effects for any coordination variability couplings were identified. Minimal differences in gait variability were detected between those with acute and chronic patellofemoral pain and healthy controls.
... Alarmingly, the results of long term follow up studies have reported that the majority of individuals with PFP still suffered from pain four to eight years later despite initially receiving treatment and education (Noehren, Pohl, Sanchez, Cunningham, & Lattermann, 2012;Souza & Powers, 2009;Stathopulu & Baildam, 2003). Such findings underline that PFP is not self-limiting and the gold standard strategy for managing PFP is yet to be identified (Lankhorst et al., 2016). It also indicates that the majority of patients with PFP do not respond to treatment and might be at risk of developing chronic pain (Yosmaoglu et al., 2019). ...
Objectives
Guidelines for a comprehensive rehabilitation programme for patellofemoral pain (PFP) have been developed by international experts. The aim of this study was to analyse the effect of such a rehabilitative exercise programme on pain, function, kinesiophobia, running biomechanics, quadriceps strength and quadriceps muscle inhibition in individuals with PFP.
Design
Observational study.
Setting
Clinical environment.
Participants
Twenty-seven participants with PFP.
Main outcome measures
Symptoms [numeric pain rating scale (NPRS)and the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS)], function measured by using the KUJALA scale and KOOS, kinesiophobia measured by using the Tampa scale, three-dimensional biomechanical running data, quadriceps isometric, concentric and eccentric strength and arthrogenic muscle inhibition (AMI) were acquired before and after the six-week exercise programme.
Results
Although pain did not significantly improve all patients were pain-free after the six-week exercise programme (NPRS: p = 0.074). Function, kinesiophobia and quadriceps AMI improved significantly after the six-week exercise programme (KUJALA: p = 0.001, KOOS: p = 0.0001, Tampa: p = 0.017, AMI: p = 0.018). Running biomechanics during stance phase did not change after the exercise intervention. Quadriceps strength was not different after the six-week exercise programme (isometric: p = 0.992, concentric: p = 0.075, eccentric: p = 0.351).
Conclusion
The results of this study demonstrate that the current exercise recommendations can improve function and kinesiophobia and reduce pain and AMI in individuals with PFP. There is a need for reconsideration of the current exercise guidelines in stronger individuals with PFP.
... The high rates of injury reoccurrence in many contact and noncontact sports suggests that athletes are susceptible to re-injury during their rehabilitation and following return-to-play. For example, those with a history of tibia stress injury have a six times greater risk of injury reoccurrence following return to activity [210], and similarly, .50% of people who report patellofemoral pain experience symptom reoccurrence after treatment and returning to activity [211]. Rehabilitation programs following sport-related injuries often involve interventions within clinical settings, as well as following guidance in home-based exercises or advice. ...
This chapter is concerned with the use of wearable devices for disabled and extreme sports. These sporting disciplines offer unique challenges for sports scientists and engineers. Disabled athletes often rely on and utilize more specialist equipment than able-bodied athletes. Wearable devices could be particularly useful for monitoring athlete-equipment interactions in disability sport, with a view to improving comfort and performance, while increasing accessibility and reducing injury risks. Equipment also tends to be key for so called “extreme” sports, such as skiing, snowboarding, mountain biking, bicycle motocross, rock climbing, surfing, and white-water kayaking. These sports are often practiced outdoors in remote and challenging environments, with athletes placing heavy demands on themselves and their equipment. Extreme sports also encompass disability sports, like sit skiing and adaptive mountain biking, and the popularity and diversity of such activities is likely to increase with improvements in technology and training, as well as with the support of organizations like the High Fives Foundation (highfivesfoundation.org) and Disability Snowsport, United Kingdom (disabilitysnowsport.org.uk). Within this chapter in these two sporting contexts, wearable devices are broadly associated with those that can be used to monitor the kinetics and kinematics of an athlete and their equipment. This chapter will first consider image-based alternatives and then focus on wearable sensors, in three main sections covering, (1) sports wearables, (2) disability sport and the use of wearables, and (3) extreme sport and the use of wearables, as well as making recommendations for the future.
Patellofemoral pain is a prevalent condition among physically active individuals.
Background
Psychological barriers due to anterior knee pain (AKP) and anterior cruciate ligament reconstruction (ACLR) may have a direct impact on an individual’s return to physical activity. A comprehensive understanding of these psychological barriers in individuals with AKP and ACLR may help clinicians to develop and implement better treatment strategies to address deficits that may exist in these individuals.
Hypothesis/Purpose
The primary purpose of this study was to evaluate fear-avoidance, kinesiophobia, and pain catastrophizing in individuals with AKP and ACLR compared with healthy individuals. The secondary purpose was to directly compare psychological characteristics between the AKP and ACLR groups. It was hypothesized that 1) individuals with AKP and ACLR would self-report worse psychosocial function than healthy individuals and 2) the extent of the psychosocial impairments between the two knee pathologies would be similar.
Study Design
Cross-sectional study.
Methods
Eighty-three participants (28 AKP, 26 ACLR, and 29 healthy individuals) were analyzed in this study. Fear avoidance belief questionnaire (FABQ) with the physical activity (FABQ-PA) and sport (FABQ-S) subscales, Tampa scale of Kinesiophobia (TSK-11) and pain catastrophizing scale (PCS) assessed psychological characteristics. Kruskal-Wallis tests were used to compare the FABQ-PA, FABQ-S, TSK-11, and PCS scores across the three groups. Mann-Whitney U tests were performed to determine where group differences occurred. Effect sizes (ES) were calculated with the Mann-Whitney U z-score divided by the square root of the sample size.
Results
Individuals with AKP or ACLR had significantly worse psychological barriers compared to the healthy individuals for all questionnaires (FABQ-PA, FABQ-S, TSK-11, and PCS) (p<0.001, ES>0.86). There were no differences between the AKP and ACLR groups (p≥0.67), with a medium ES (-0.33) in the FABQ-S between AKP and ACLR groups.
Conclusion
Greater psychological scores indicate impaired psychological readiness to perform physical activity. Clinicians should be aware of fear-related beliefs following knee-related injuries and are encouraged to measure psychological factors during the rehabilitation process.
Level of Evidence
2
Background
Patellofemoral pain is highly prevalent across the lifespan, and a significant proportion of people report unfavourable outcomes years after diagnosis. Previous research has implicated patellofemoral joint loading during gait in patellofemoral pain and its sequelae, patellofemoral osteoarthritis. Biomechanical foot-based interventions (e.g., footwear, insoles, orthotics, taping or bracing) can alter patellofemoral joint loads by reducing motions at the foot that increase compression between the patella and underlying femur via coupling mechanisms, making them a promising treatment option. This systematic review will summarise the evidence about the effect of biomechanical foot-based interventions on patellofemoral joint loads during gait in adults with and without patellofemoral pain and osteoarthritis.
Methods
MEDLINE (Ovid), the Cumulative Index to Nursing and Allied Health Literature CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), SPORTdiscus (EBSCO) and Embase (Ovid) will be searched. Our search strategy will include terms related to ‘patellofemoral joint’, ‘loads’ and ‘biomechanical foot-based interventions’. We will include studies published in the English language that assess the effect of biomechanical foot-based interventions on patellofemoral joint loads, quantified by patellofemoral joint pressure, patellofemoral joint reaction force and/or knee flexion moment. Two reviewers will independently screen titles and abstracts, complete full-text reviews, and extract data from included studies. Two reviewers will assess study quality using the Revised Cochrane Risk of Bias (RoB 2) tool or the Cochrane Risk Of Bias In Non-Randomized Studies – of Interventions (ROBINS-I) tool. We will provide a synthesis of the included studies’ characteristics and results. If three or more studies are sufficiently similar in population and intervention, we will pool the data to conduct a meta-analysis and report findings as standardised mean differences with 95% confidence intervals. If a meta-analysis cannot be performed, we will conduct a narrative synthesis of the results and produce forest plots for individual studies.
Discussion
This protocol outlines the methods of a systematic review that will determine the effect of biomechanical foot-based interventions on patellofemoral joint loads. Our findings will inform clinical practice by identifying biomechanical foot-based interventions that reduce or increase patellofemoral joint loads, which may aid the treatment of adults with patellofemoral pain and osteoarthritis.
Trial registration
Registered with PROSPERO on the 4th of May 2022 (CRD42022315207).
Riassunto
Questo articolo sotto forma di parere di esperti mira a fornire un aggiornamento sulle attuali conoscenze su una patologia che causa dolore anteriore al ginocchio: la sindrome femoro-rotulea. Sono elencati elementi di epidemiologia ed eziologia al fine di comprendere meglio il contesto di questa gestione. Sono dettagliati i mezzi diagnostici allo scopo di poter realizzare diagnosi differenziali che consentano di escludere altre patologie. Con l’obiettivo di migliorare la prognosi formulata dai clinici, sono proposti classificazioni e sottogruppi di patologia. Analogamente, è affrontata una dimensione psicosociale attraverso l’importanza dell’esame soggettivo e l’inclusione nel ragionamento clinico dei fattori non biomeccanici. Sono sviluppati diversi tipi di trattamento, ponderati in base al livello di evidenza nella letteratura scientifica, per rispondere al meglio ai risultati dell’esame.
Resumen
Este artículo, en forma de opinión de expertos, tiene como objetivo revisar los conocimientos actuales de una enfermedad que causa dolor anterior en la rodilla: el síndrome femoropatelar. Se presenta un inventario de elementos epidemiológicos y etiológicos, a fin de entender mejor el contexto de los tratamientos. Se detallan los medios diagnósticos destinados a llevar a cabo el diagnóstico diferencial y excluir otras enfermedades. Con el objetivo de mejorar el pronóstico que establecen los clínicos, se proponen clasificaciones y subagrupaciones de la enfermedad. Del mismo modo, se aborda la dimensión psicosocial a través de la importancia de la exploración subjetiva y la consideración de factores no biomecánicos en el razonamiento clínico. Se desarrollan diferentes tipos de tratamiento, ponderados por su nivel de evidencia en la literatura científica, con el fin de responder de la mejor manera posible a los resultados de la exploración.
Objectives
Determine criterion validity and intra/inter-rater reliability of 2-dimensional (2D) knee frontal plane projection angle (kFPPA), hip frontal plane projection angle (hFPPA), and dynamic valgus index (DVI) during forward step-downs in those with patellofemoral pain (PFP).
Design
Cross-sectional.
Setting
University research laboratory.
Participants
39 participants with PFP (34.18 ± 7.41years, 170± .1 cm, 81.03 ± 19.36 kg, duration of pain: 68.67 ± 85.08months, anterior knee pain scale: 80.49 ± 7.87, visual analog scale:2.08 ± 2.02)
Main outcome measures
Average 3D hip and knee sagittal, frontal, and transverse joint angles and 2D kFPPA, hFPPA, and DVI at maximum knee flexion were variables of interest. 3D DVI was calculated as the sum of hip and knee frontal and transverse angles. 2D kFPPA, hFPPA, and DVI were calculated by two raters independently on two occasions.
Results
Intra- and inter-rater reliability of all 2D angles were excellent. kFPPA was moderately correlated to 3D knee transverse angles. hFPPA was moderately correlated to 3D hip frontal and transverse angles and largely correlated to 3D DVI. 2D DVI was moderately correlated to hip transverse angles.
Conclusion
kFPPA, hFPPA, and DVI are reliable. hFPPA may be reflective of 3D hip and knee frontal and transverse motion during forward step-downs in those with PFP.
Objective:
To assess the content validity and feasibility of patient-reported outcome measures (PROMs) used to assess pain and function in adults and adolescents with patellofemoral pain (PFP).
Design:
Systematic review.
Literature search:
We searched the databases PubMed, CINAHL, Scopus, SPORTDiscus, and the Cochrane Library from inception to January 6, 2022.
Study selection criteria:
We included studies that described the development or evaluation of the content validity of English-language PROMs for PFP as well as their translations and cultural adaptations to different languages.
Data synthesis:
Using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology, we determined overall ratings and quality of evidence for the relevance, comprehensiveness, and comprehensibility of PROMs. We extracted data related to feasibility for clinical use (eg, administration time and scoring ease).
Results:
Forty-three studies for 33 PROMs were included. The overall quality of most studies was "inadequate" due to failure to engage stakeholders and/or ensure adherence to rigorous qualitative research procedures. Of all PROMs evaluated, the Knee injury and Osteoarthritis Outcome Score - Patellofemoral subscale (KOOS-PF), was the only PROM with "sufficient" content validity components. Quality of evidence for content validity of the KOOS-PF was low. Most PROMs were rated feasible for clinical and research purposes.
Conclusion:
Most PROMs used to measure pain and function in patients with PFP have inadequate content validity. The KOOS-PF had the highest overall content validity. We recommend the KOOS-PF for evaluating pain and function (in research and clinical practice) in adults and adolescents with PFP.
Objective
To evaluate the effectiveness of interventions to prevent and manage knee injuries in runners.
Design
Systematic review and meta-analysis.
Data sources
MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus up to May 2022.
Eligibility criteria for selecting studies
Randomised controlled trials (RCTs) with a primary aim of evaluating the effectiveness of intervention(s) to prevent or manage running-related knee injury.
Results
Thirty RCTs (18 prevention, 12 management) analysed multiple interventions in novice and recreational running populations. Low-certainty evidence (one trial, 320 participants) indicated that running technique retraining (to land softer) reduced the risk of knee injury compared with control treadmill running (risk ratio (RR) 0.32, 95% CI 0.16 to 0.63). Very low-certainty to low-certainty evidence from 17 other prevention trials (participant range: 24 –3287) indicated that various footwear options, multicomponent exercise therapy, graduated running programmes and online and in person injury prevention education programmes did not influence knee injury risk (RR range: 0.55–1.06). In runners with patellofemoral pain, very low-certainty to low-certainty evidence indicated that running technique retraining strategies, medial-wedged foot orthoses, multicomponent exercise therapy and osteopathic manipulation can reduce knee pain in the short-term (standardised mean difference range: −4.96 to −0.90).
Conclusion
There is low-certainty evidence that running technique retraining to land softer may reduce knee injury risk by two-thirds. Very low-certainty to low-certainty evidence suggests that running-related patellofemoral pain may be effectively managed through a variety of active (eg, running technique retraining, multicomponent exercise therapy) and passive interventions (eg, foot orthoses, osteopathic manipulation).
PROSPERO registration number
CRD42020150630
Objective:
To determine the effects of non-surgical treatments on pain and function in people with patellofemoral pain (PFP).
Design:
Systematic review with meta-analysis.
Literature search:
We searched Medline, Web of Science, and Scopus to May 2022 for interventional randomised controlled trials (RCTs) in people with PFP.
Study selection criteria:
We included RCTs that were scored >7 on the PEDro scale.
Data synthesis:
We extracted homogenous pain and function data at short- (<3 months), medium- (>3 to <12 months) and long-term (>12 months) follow up. Interventions demonstrated primary efficacy if outcomes were superior to sham, placebo, or wait-and-see control. Interventions demonstrated secondary efficacy if outcomes were superior to an intervention with primary efficacy.
Results:
We included 65 RCTs. Four interventions demonstrated short-term primary efficacy: knee-targeted exercise therapy for pain (SMD 1.16, 95% CI 0.66, 1.66) and function (SMD 1.19, 95% CI 0.51, 1.88), combined interventions for pain (SMD 0.79, 95% CI 0.26, 1.29) and function (SMD 0.98, 95% CI 0.47, 1.49), foot orthoses for global rating of change (OR 4.31, 95% CI 1.48, 12.56), and lower-quadrant manual therapy for pain (SMD 2.30, 95% CI 1.60, 3.00). Two interventions demonstrated short-term secondary efficacy compared to knee-targeted exercise therapy: hip-and-knee-targeted exercise therapy for pain (SMD 1.02, 95% CI 0.58,1.46) and function (SMD 1.03, 95% CI 0.61, 1.45), and knee-targeted exercise therapy and perineural dextrose injection for pain (SMD 1.34, 95% CI 0.72, 1.95) and function (SMD 1.21, 95% CI 0.60, 1.82).
Conclusion:
Six interventions had positive effects at three-months for people with PFP, with no intervention adequately tested beyond this timepoint.
Background
International guidelines recommend educational intervention to treat knee osteoarthritis. However, they do not specify the type of intervention and the effectiveness of group educational intervention for knee pain is unclear.
Objectives
We aimed to examine the effectiveness of group educational interventions for people over 50 years old with knee pain compared with a control group.
Design
A systematic review and meta-analysis of randomized controlled trials (RCTs).
Method
We searched Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature and screened for RCTs involving participants over 50 years old that reported the effects of group education on knee pain. We performed meta-analyses and evaluated the methodological quality and evidence quality using the Physiotherapy Evidence Database scale and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, respectively.
Results
The search retrieved 1,177 studies. Seven RCTs were ultimately included, four of which were subjected to meta-analysis, showing standardized mean differences of −0.22 (95% confidence interval [CI]: −0.42 to −0.02, n = 423; I² = 0% GRADE: low). All studies included in the meta-analysis involved exercise without individualized instruction in addition to group educational intervention.
Conclusions
Group education, when delivered in addition to exercises, significantly reduces knee pain in people over 50 years old.
Background
Patellofemoral pain (PFP) is common, with a poor long-term prognosis. There is a lack of clarity about the clinical reasoning of recognised inter-disciplinary experts.
Objectives
To help identify best practice by exploring the clinical reasoning of a range of experts that regularly diagnose and treat PFP.
Design
Qualitative study with semi-structured interviews.
Method
Recruitment resulted in a convenience sample for semi-structured interviews, which were recorded and transcribed verbatim. Data were analysed until theoretical saturation, as determined by multiple investigators.
Findings
Interviews with 19 clinical experts (15 men, 4 women; mean experience 18.6 years ± 8.6) from four broad professions yielded four themes. Firstly, the assessment and diagnosis process should include a thorough history and examination to rule in PFP. Secondly, information provision should aim to increase patients’ understanding, aid in controlling symptoms, and facilitate behaviour change. Thirdly, active rehabilitation, which was a salient theme and included advocacy of combined hip and knee exercise that is adapted to the individual. Finally, treatment adjuncts, which can be used selectively to modify symptoms, may include running retraining, taping, or foot orthoses.
Conclusions
PFP should be diagnosed clinically, and tailored treatment programmes should be prescribed for people with PFP. Exercise was considered the most effective treatment and underlying psychological factors should be addressed to improve prognosis.
Context:
Lower-extremity musculoskeletal injury is commonly associated with poor movement patterns at the trunk, hip, and knee. Efforts have been focused on identifying poor lower-extremity movement using clinically friendly movement assessments, such as rubrics and 2D measures. Assessments used clinically or for research should have acceptable measurement properties, such as reliability and validity. However, the literature on reliability and validity of movement assessments to analyze jump landings has not been summarized.
Objective:
To systematically review measurement properties of rubrics and 2D measurements that aim to classify movement quality during jump landings.
Evidence acquisition:
The search strategy was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The search was performed in PubMed, SPORTDiscus, and Web of Science databases. The COnsensus-based Standards for the selection of health Measurement INstruments multiphase procedure was used to extract relevant data, evaluate methodological quality of each study, score the results of each movement assessment, and synthesize the evidence.
Evidence synthesis:
Twenty-two studies were included after applying eligibility criteria. Reliability and construct validity of the landing error scoring system were acceptable. Criterion validity of 2D knee flexion angle and medial knee displacement is acceptable. Reliability of 2D knee ankle separation ratio and knee frontal plane projection angle are acceptable.
Conclusion:
The landing error scoring system is a valid way to determine poor movement quality and injury risk. Measures of 2D knee flexion angle and medial knee displacement are valid alternatives for 3D knee flexion angle and knee abduction moment, respectively. Knee ankle separation ratio and knee frontal plane projection angle are reliable but lack validity justifying their clinical use.
Context:
Poor lower-extremity biomechanics are predictive of increased risk of injury. Clinicians analyze the single-leg squat (SLS) and step-down (SD) with rubrics and 2D assessments to identify these poor lower-extremity biomechanics. However, evidence on measurement properties of movement assessment tools is not strongly outlined. Measurement properties must be established before movement assessment tools are recommended for clinical use.
Objective:
The purpose of this study was to systematically review the evidence on measurement properties of rubrics and 2D assessments used to analyze an SLS and SD.
Evidence acquisition:
The search strategy was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The search was performed in PubMed, SPORTDiscus, and Web of Science databases. The COnsensus-based Standards for the selection of health Measurement INstruments multiphase procedure was used to extract relevant data, evaluate methodological quality of each study, score the results of each movement assessment, and synthesize the evidence.
Evidence synthesis:
A total of 44 studies were included after applying eligibility criteria. Reliability and construct validity of knee frontal plane projection angle was acceptable, but criterion validity was unacceptable. Reliability of the Chmielewski rubric was unacceptable. Content validity of the knee-medial-foot and pelvic drop rubrics was acceptable. The remaining rubrics and 2D measurements had inconclusive or conflicting results regarding reliability and validity.
Conclusions:
Knee frontal plane projection angle is reliable for analyzing the SLS and SD; however, it does not serve as a substitute for 3D motion analysis. The Chmielewski rubric is not recommended for assessing the SLS or SD as it may be unreliable. Most movement assessment tools yield indeterminate results. Within the literature, standardized names, procedures, and reporting of movement assessment tool reliability and validity are inconsistent.
Background
Local neuromuscular deficits have been reported in people with patellofemoral pain. We synthesised the neuromuscular characteristics associated with patellofemoral pain to help identify interventional targets and potential mechanisms.
Methods
Five databases were searched for local neuromuscular characteristics in case-control studies. Electromyography, flexibility, muscle performance and cross-sectional area data were derived from functional or isolated task investigations and synthesised accordingly. An evidence gap map was constructed.
Findings
Sixty-seven studies were included. In functional tasks, electromyographic investigations showed moderate evidence of small effect for vastus medialis onset-delays relative to vastus lateralis (0.44 [0.03, 0.85]) during stepping/stair negotiation tasks, and higher biceps femoris mean excitation amplitudes (0.55 [0.06, 1.04]) in single-leg triple-hop test. In isolated tasks, we found moderate evidence of medium effect for lower Hoffman-reflex amplitude of vastus medialis (−1.12 [−1.56, −0.67]). Muscle performance investigations showed; strong evidence with medium and small effects for lower extensors concentric (−0.61 [−0.81, −0.40]) and eccentric (−0.56 [−0.79, −0.33]) strength, and moderate evidence of medium effect of lower isometric (−0.64 [−0.87, −0.41]) strength, moderate evidence with small effect for rate of force development to 30% (−0.55[−0.89, −0.21]), 60% (−0.57[−0.90, −0.25]) and medium effect to 90% (−0.76[−1.43, −0.10]) of maximum voluntary contraction, and small effect for lower flexors concentric strength (−0.46 [−0.74, −0.19]) and extensors total work (−0.48 [−0.90, −0.07]). Flexibility investigations showed tighter hamstrings (−0.57 [−0.99, −0.14]).
Interpretation
Differences within quadriceps and hamstrings motor-control, hamstrings tightness, and quadriceps and hamstrings weakness are associated with patellofemoral pain, and can be used to guide investigations of treatment effects.
Objectives
To compare trunk muscle endurance among females and males with and without patellofemoral pain (PFP), and to investigate the correlations between trunk muscle endurance and performance of the single leg hop test (SLHT) and forward step-down test (FSDT).
Design
Cross-sectional.
Setting
Laboratory-based study.
Participants
110 females and 38 males with PFP, 61 females and 31males without PFP.
Main outcome measures
Anterior and lateral trunk muscle endurance were assessed with the prone and bilateral side-bridge tests, respectively. Performance during the SLHT and FSDT was also assessed.
Results
Lower anterior and lateral trunk muscle endurance were identified in females (p < .001; d = −0.74 to −0.86), but not in males (p ≥ .806; d = −0.04 to 0.05) with PFP as compared to sex-matched controls. Moderate to large, positive correlations between anterior and lateral trunk muscle endurance with performance in the SLHT and FSDT were identified in females (r = .27 to .50; p < .004) and males (r = 0.27 to 0.59; p < .031) with PFP and females without PFP (r = 0.26 to 0.40; p < .044).
Conclusion
Our findings highlight that assessing trunk muscle endurance is advised in females with PFP. Trunk muscle endurance of individuals with PFP may have a role in the performance of hopping and stepping down tasks.
Patellofemoral pain is a common complaint in athletes, with twice the incidence in females as compared to males. The pathogenesis of patellofemoral pain is multifactorial and can be impacted by anatomic and biomechanical abnormalities, altered neuromuscular recruitment, strength deficits, altered pain-processing mechanisms, and psychologic factors. Successful treatment is often achieved by nonoperative means, utilizing a multimodal approach individualized to the specific risk factors identified for each person, including exercise therapy, kinematic retraining, taping, bracing, orthotic use, and patient education. Appropriately indicated surgeries for patellofemoral pain primarily aim to address soft tissue and bony malalignment or focal cartilage defects.
Background:
Routine knee radiographs are discouraged for individuals with non-traumatic knee pain, but they are often still ordered despite limited evidence for their value in guiding treatment choices. Radiograph utilization may delay the use of physical therapy, which has been associated with improved outcomes and lower long-term costs.
Objective:
To examine the relationship between obtaining knee radiographs for patients with patellofemoral pain (PFP) and the timing of physical therapy, and the association between ordering radiographs for patients who use physical therapy and the likelihood of knee pain recurrence.
Study design:
Retrospective cohort.
Setting:
United States Military Health System civilian and military clinics.
Patients:
23,332 individuals aged 18 to 50 diagnosed with PFP between 2010 and 2011 in the United States Military Health System who received physical therapy.
Interventions:
Physical therapy provided to individuals who did or did not receive an initial radiograph.
Main outcome measures:
Timing of physical therapy and recurrence of knee pain were compared between groups (with and without initial radiographs).
Results:
If radiographs were used, the odds of initiating physical therapy (aOR = 0.78; 95% CI 0.64 to 0.94) within 30 days of the initial diagnosis were significantly lower. The mean days from diagnosis to initiating physical therapy was 12.1 (95% CI 9.1 to 16.1) if patients had radiographs versus 6.9 (95% CI 5.2 to 9.1) without. The odds of knee pain recurrence were no greater if radiographs were used (aOR = 1.01; 95% CI 0.83 to 1.22).
Conclusions:
Receiving knee radiographs as part of initial care for PFP was associated with delayed initiation of physical therapy, but there was no association between early knee radiographs and recurrence of knee pain. Routine use of radiographs for PFP is not warranted, and can potentially delay appropriate treatment. This article is protected by copyright. All rights reserved.
Context:
Patellofemoral pain (PFP) is prevalent and challenging to manage. Most people with PFP are unsatisfied with their knee function 6-months following treatment, and report ongoing pain up to 16-years after diagnosis. Confidence and knowledge to provide evidence-based care to people with PFP amongst Athletic Trainers (ATs) is currently unknown.
Objective:
Investigate confidence and knowledge of ATs for the treatment, diagnosis, risk factors, and prognosis with current evidence for PFP.
Design:
Cross-sectional study.
Setting:
Online survey. Patient or Other Participants: A random sample of 3000 ATs were invited to participate; 261 completed the survey (10% participation rate, 88% completion rate).
Main outcome measures(s):
AT demographics, confidence in PFP management, and knowledge related to diagnosis, risk factors, prognosis and treatment were surveyed. Chi-squared analyses assessed responses related to confidence and knowledge to manage PFP. ATs beliefs about evidence was compared to current evidence available (i.e. consensus statements, position statements, systematic reviews).
Results:
91% of ATs surveyed were confident that their management of PFP aligns with current evidence, but only 59% were confident in identifying risk factors for PFP development. 91-92% of ATs responded that quadriceps and hip muscle weakness were risk factor for PFP, which aligns with current evidence for quadriceps but not hip muscle weakness. 93-97% of AT responses related to therapeutic exercise aligned with current evidence. However, 35-48% of responses supported the use of passive treatments, such as electrophysical agents and ultrasound, which do not align with current evidence.
Conclusion:
Most ATs are aware of supporting evidence for therapeutic exercise in PFP management and are confident providing it, providing a strong foundation for evidence-based care. However, varying awareness of evidence related to risk factors and passive treatments for PFP highlights a need for professional development initiatives to better align AT knowledge with current evidence.
BACKGROUND:
Patellofemoral pain syndrome (PFPS) is a common knee problem, which particularly affects adolescents and young adults. PFPS, which is characterised by retropatellar (behind the kneecap) or peripatellar (around the kneecap) pain, is often referred to as anterior knee pain. The pain mostly occurs when load is put on the knee extensor mechanism when climbing stairs, squatting, running, cycling or sitting with flexed knees. Exercise therapy is often prescribed for this condition.
OBJECTIVES:
To assess the effects (benefits and harms) of exercise therapy aimed at reducing knee pain and improving knee function for people with patellofemoral pain syndrome.
SEARCH METHODS:
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 4), MEDLINE (1946 to May 2014), EMBASE (1980 to 2014 Week 20), PEDro (to June 2014), CINAHL (1982 to May 2014) and AMED (1985 to May 2014), trial registers (to June 2014) and conference abstracts.
SELECTION CRITERIA:
Randomised and quasi-randomised trials evaluating the effect of exercise therapy on pain, function and recovery in adolescents and adults with patellofemoral pain syndrome. We included comparisons of exercise therapy versus control (e.g. no treatment) or versus another non-surgical therapy; or of different exercises or exercise programmes.
DATA COLLECTION AND ANALYSIS:
Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. Where appropriate, we pooled data using either fixed-effect or random-effects methods. We selected the following seven outcomes for summarising the available evidence: pain during activity (short-term: ≤ 3 months); usual pain (short-term); pain during activity (long-term: > 3 months); usual pain (long-term); functional ability (short-term); functional ability (long-term); and recovery (long-term).
MAIN RESULTS:
In total, 31 heterogeneous trials including 1690 participants with patellofemoral pain are included in this review. There was considerable between-study variation in patient characteristics (e.g. activity level) and diagnostic criteria for study inclusion (e.g. minimum duration of symptoms) and exercise therapy. Eight trials, six of which were quasi-randomised, were at high risk of selection bias. We assessed most trials as being at high risk of performance bias and detection bias, which resulted from lack of blinding.The included studies, some of which contributed to more than one comparison, provided evidence for the following comparisons: exercise therapy versus control (10 trials); exercise therapy versus other conservative interventions (e.g. taping; eight trials evaluating different interventions); and different exercises or exercise programmes. The latter group comprised: supervised versus home exercises (two trials); closed kinetic chain (KC) versus open KC exercises (four trials); variants of closed KC exercises (two trials making different comparisons); other comparisons of other types of KC or miscellaneous exercises (five trials evaluating different interventions); hip and knee versus knee exercises (seven trials); hip versus knee exercises (two studies); and high- versus low-intensity exercises (one study). There were no trials testing exercise medium (land versus water) or duration of exercises. Where available, the evidence for each of seven main outcomes for all comparisons was of very low quality, generally due to serious flaws in design and small numbers of participants. This means that we are very unsure about the estimates. The evidence for the two largest comparisons is summarised here. Exercise versus control. Pooled data from five studies (375 participants) for pain during activity (short-term) favoured exercise therapy: mean difference (MD) -1.46, 95% confidence interval (CI) -2.39 to -0.54. The CI included the minimal clinically important difference (MCID) of 1.3 (scale 0 to 10), indicating the possibility of a clinically important reduction in pain. The same finding applied for usual pain (short-term; two studies, 41 participants), pain during activity (long-term; two studies, 180 participants) and usual pain (long-term; one study, 94 participants). Pooled data from seven studies (483 participants) for functional ability (short-term) also favoured exercise therapy; standardised mean difference (SMD) 1.10, 95% CI 0.58 to 1.63. Re-expressed in terms of the Anterior Knee Pain Score (AKPS; 0 to 100), this result (estimated MD 12.21 higher, 95% CI 6.44 to 18.09 higher) included the MCID of 10.0, indicating the possibility of a clinically important improvement in function. The same finding applied for functional ability (long-term; three studies, 274 participants). Pooled data (two studies, 166 participants) indicated that, based on the 'recovery' of 250 per 1000 in the control group, 88 more (95% CI 2 fewer to 210 more) participants per 1000 recovered in the long term (12 months) as a result of exercise therapy. Hip plus knee versus knee exercises. Pooled data from three studies (104 participants) for pain during activity (short-term) favoured hip and knee exercise: MD -2.20, 95% CI -3.80 to -0.60; the CI included a clinically important effect. The same applied for usual pain (short-term; two studies, 46 participants). One study (49 participants) found a clinically important reduction in pain during activity (long-term) for hip and knee exercise. Although tending to favour hip and knee exercises, the evidence for functional ability (short-term; four studies, 174 participants; and long-term; two studies, 78 participants) and recovery (one study, 29 participants) did not show that either approach was superior.
AUTHORS' CONCLUSIONS:
This review has found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery. However, there is insufficient evidence to determine the best form of exercise therapy and it is unknown whether this result would apply to all people with PFPS. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone.Further randomised trials are warranted but in order to optimise research effort and engender the large multicentre randomised trials that are required to inform practice, these should be preceded by research that aims to identify priority questions and attain agreement and, where practical, standardisation regarding diagnostic criteria and measurement of outcome.
PMID:
25603546
[PubMed - as supplied by publisher]
Objective
The patellofemoral joint (PFJ) is important in early detection of knee osteoarthritis (OA). Little is known about the relationship between specific clinical findings and PFJ MRI features. The objective was to examine the relationship between (early) clinical findings and PFJ MRI features in females (45-60 years) without knee OA (PFJ or tibiofemoral joint (TFJ) OA) based on a recently suggested MRI definition.
Methods
MRIs of knees of women of a sub-study of the Rotterdam Study were scored with semi-quantitative scoring. Specific patellar tests were performed on physical examination. Current knee pain and history of patellar knee pain were reported. Binomial logistic generalized estimated equations were used to determine the association between clinical findings of OA and PFJ MRI features. All associations were adjusted for age, BMI and TFJ MRI features.
Results
In 888 women (1776 knees, mean age: 55.1years and mean BMI: 27.0kg/m2) we found significant associations between crepitus and all PFJ MRI features (Odds ratios (OR) range: 2.61-5.49). A history of patellar pain was significantly associated with almost all PFJ MRI features (ORcartilage: 1.95; ORcysts: 1.86; ORbone marrow lesions: 1.83), except for osteophytes. No significant associations were found between the clinical findings and TFJ MRI features.
Conclusion
Crepitus and history of patellar pain are clinical findings that indicate PFJ lesions seen on MRI. These tests could help to indicate signs of PFJ OA. Follow-up data needs to confirm whether these tests have an additional diagnostic value for early knee OA in PFJ or TFJ.
Patellofemoral pain (PFP) is often seen in physically active individuals and may account for 25-40% of all knee problems seen in a sports injury clinic.1 ,2 Patellofemoral-related problems occur more frequently in women than in men.3 PFP is characterised by diffuse pain over the anterior aspect of the knee and aggravated by activities that increase patellofemoral joint (PFJ) compressive forces, such as squatting, ascending and descending stairs and prolonged sitting, as well as repetitive activities such as running. It, therefore, has a debilitating effect on sufferers’ daily lives by reducing their ability to perform sporting and work-related activities pain free. Dye has described PFP as an orthopaedic enigma, and it is one of the most challenging pathologies to manage.4 Alarmingly, a high number of individuals with PFP have recurrent or chronic pain.5 While physiotherapy interventions for PFP have proven effective compared with sham treatments, treatment results can be disappointing in a proportion of patients. This variability in treatment results may be due to the fact that the underlying factors that contribute to the development of PFP are not being addressed, or are not the same for all patients with PFP. The mission of the 3rd International Patellofemoral Research Retreat was to improve our understanding concerning the factors that contribute to the development and consequently to the treatment of PFP. The 3rd International Patellofemoral Research Retreat was held in Vancouver, Canada, in September 2013, for 3 days: from 18 September to 21 September. After peer-review for scientific merit and relevance to the retreat, 58 abstracts were accepted for the retreat (39 podiums, 8 posters and 11 thematic posters). The podium and poster presentations were grouped into three categories: (1) natural history of PFP and local factors that influence PFP, (2) trunk and distal factors that influence PFP and …
Background
Knee pain is common during adolescence. Adolescents and their parents may think that knee pain is benign and self-limiting and therefore avoid seeking medical care. However, long-term prognosis of knee pain is not favourable and treatment seems to offer greater reductions in pain compared to a "wait-and-see" approach. The purpose of this study was to describe the determinants of care-seeking behaviour among adolescents with current knee pain and investigate what types of treatment are initiated.
Methods
An online questionnaire was forwarded to 2,846 adolescents aged 15--19 in four upper secondary schools. The questionnaire contained questions on age, gender, height, weight, currently painful body regions, frequency of knee pain, health-related quality of life measured by the EuroQol 5-dimensions, sports participation and if they had sought medical care. Adolescents who reported current knee pain at least monthly or more frequently were telephoned. The adolescents were asked about pain duration, onset of knee pain (traumatic or insidious) and if they were currently being treated for their knee pain.
Results
504 adolescents currently reported at least monthly knee pain. 59% of these had sought medical care and 18% were currently under medical treatment . A longer pain duration and higher pain severity increased the odds of seeking medical care. Females with traumatic onset of knee pain were more likely to have sought medical care than females with insidious onset of knee pain. Females with traumatic onset of knee pain and increased pain severity were more likely to be undergoing medical treatment. The most frequently reported treatments were the combination of exercises and orthotics (68% of those undergoing medical treatment).
Conclusion
Females with insidious onset of knee pain do not seek medical care as often as those with traumatic onset and adolescents of both genders with insidious onset are less likely to be under medical treatment. These findings are important as knee pain with insidious onset has similar consequences as knee pain with traumatic onset regarding pain severity, pain duration and reductions in health-related quality of life.
Patellofemoral Pain Syndrome (PFPS) can be considered as a
clinical entity evolving during adolescence and young adult
age.Though the complaints may be self-limiting and follow a
benign course there are claims that exercise therapy may be
beneficial for patients with patellofemoral pain syndrome.
The aim of this thesis is to study the clinical effects and costeffectiveness
of exercise therapy for patellofemoral pain
syndrome. In this thesis the results of a clinical trial on exercise
therapy for PFPS as well as the results of a systematic literature
review are presented. Furthermore the effectiveness of exercise
therapy is studied in relation to other conservative strategies.
Additional to these studies data are presented concerning the
current strategies for PFPS and for other non-traumatic knee
complaints in general practice.
Objectives Describe proportions of individuals with patellofemoral pain (PFP) with an unfavourable recovery over 12 months; identify clinical predictors of poor recovery at 3 and 12 months; and determine baseline values of predictors that identify those with poor 12-month prognosis.
Methods An observational analysis utilised data from 310 individuals with PFP enrolled in two randomised clinical trials. Thirteen baseline variables (participant, PFP, study characteristics) were investigated for their prognostic ability. Pain, function and global recovery were measured at 3 and 12 months. Multivariate backward stepwise regression analyses (treatment-adjusted, p<0.10) were performed for each follow-up measure. Receiver operator characteristic curves identified cut-points associated with unfavourable recovery at 12 months.
Results 55% and 40% of participants had an unfavourable recovery at 3 and 12 months, respectively. Longer baseline pain duration was significantly associated with poor 3-month and 12-month recovery on measures of pain severity (β 11.36 to 24.94), Anterior Knee Pain (AKP) Scale (−4.44 to −11.33) and global recovery (OR: 2.32 to 6.11). Greater baseline pain severity and lower AKP Scale score were significantly associated with poor recovery on multiple measures (p<0.05). Baseline duration >2 months and AKP Scale score <70/100 were associated with unfavourable 12-month recovery.
Conclusions A substantial number of individuals with PFP have an unfavourable recovery over 12 months, irrespective of intervention. Knee pain duration >2 months is the most consistent prognostic indicator, followed by AKP Scale score <70. Sports medicine practitioners should utilise interventions with known efficacy in reducing PFP, and promote early intervention to maximise prognosis.
Trial registration Australian study: Australian Clinical Trials Registry (ACTRN012605000463673), ClinicalTrials.gov (NCT00118521); Dutch study: International Standard Randomised Controlled Trial Number Register (ISRCTN83938749)
This review systematically summarises factors associated with patellofemoral pain syndrome (PFPS). A systematic literature search was conducted. Studies including ≥20 patients with PFPS that examined ≥1 possible factor associated with PFPS were included. A meta-analysis was performed, clinical heterogeneous data were analysed descriptively. The 47 included studies examined 523 variables, eight were pooled. Pooled data showed a larger Q-angle, sulcus angle and patellar tilt angle (weighted mean differences (WMD) 2.08; 95% CI 0.64, 3.63 and 1.66; 95% CI 0.44, 2.77 and 4.34; 95% CI 1.16 to 7.52, respectively), less hip abduction strength, lower knee extension peak torque and less hip external rotation strength (WMD -3.30; 95% CI -5.60, -1.00 and -37.47; 95% CI -71.75, -3.20 and -1.43; 95% CI -2.71 to -0.16, respectively) in PFPS patients compared to controls. Foot arch height index and congruence angle were not associated with PFPS. Six out of eight pooled variables are associated with PFPS, other factors associated with PFPS were based on single studies. Further research is required.
Patellofemoral joint osteoarthritis (OA) is common and leads to pain and disability. However, current classification criteria do not distinguish between patellofemoral and tibiofemoral joint OA. The objective of this study was to provide empirical evidence of the clinical features of patellofemoral joint OA (PFJOA) and to explore the potential for making a confident clinical diagnosis in the community setting.
This was a population-based cross-sectional study of 745 adults aged ≥50 years with knee pain. Information on risk factors and clinical signs and symptoms was gathered by a self-complete questionnaire, and standardised clinical interview and examination. Three radiographic views of the knee were obtained (weight-bearing semi-flexed posteroanterior, supine skyline and lateral) and individuals were classified into four subsets (no radiographic OA, isolated PFJOA, isolated tibiofemoral joint OA, combined patellofemoral/tibiofemoral joint OA) according to two different cut-offs: 'any OA' and 'moderate to severe OA'. A series of binary logistic and multinomial regression functions were performed to compare the clinical features of each subset and their ability in combination to discriminate PFJOA from other subsets.
Distinctive clinical features of moderate to severe isolated PFJOA included a history of dramatic swelling, valgus deformity, markedly reduced quadriceps strength, and pain on patellofemoral joint compression. Mild isolated PFJOA was barely distinguished from no radiographic OA (AUC 0.71, 95% CI 0.66, 0.76) with only difficulty descending stairs and coarse crepitus marginally informative over age, sex and body mass index. Other cardinal signs of knee OA - the presence of effusion, bony enlargement, reduced flexion range of movement, mediolateral instability and varus deformity - were indicators of tibiofemoral joint OA.
Early isolated PFJOA is clinically manifest in symptoms and self-reported functional limitation but has fewer clear clinical signs. More advanced disease is indicated by a small number of simple-to-assess signs and the relative absence of classic signs of knee OA, which are predominantly manifestations of tibiofemoral joint OA. Confident diagnosis of even more advanced PFJOA may be limited in the community setting.
Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain.
A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL® and Pre-CINAHL®, PEDro, PubMed, SportDiscus®, Web of Science®, BIOSIS Previews®, and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models.
Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Metaanalysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI 0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD −0.21, 95% CI −0.64, 0.21; 8–12 weeks: SMD −0.22, 95% CI −0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control).
Findings suggest that, in implementing evidence-based practice for the nonsurgical management of anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required.
To compare data based on touch screen to data based on traditional paper versions of questionnaires frequently used to examine patient reported outcomes in knee osteoarthritis patients and to examine the impact of patient characteristics on this comparison
Participants were recruited from an ongoing trial (http://ClinicalTrials.Gov Identifier: NCT00655941). 20 female participants, mean age 67 (SD 7), completed KOOS, VAS pain, function and patient global, SF-36, Physical Activity Scale, painDETECT, and the ADL Taxonomy. Patients were randomly assigned to one of two subgroups, completing either the paper or touch screen version first. Mean, mean differences (95% CI), median, median differences and Intraclass Correlation Coefficients (ICCs) were calculated for all questionnaires.
ICCs between data based on computerized and paper versions ranged from 0.86 to 0.99. Analysis revealed a statistically significant difference between versions of the ADL Taxonomy, but not for the remaining questionnaires. Age, computer experience or education-level had no significant impact on the results. The computerized questionnaires were reported to be easier to use.
The computerized questionnaires gave comparable results to answers given on paper. Patient characteristics did not influence results and implementation was feasible.
Patellofemoral osteoarthritis (PFOA) is a common form of knee OA in middle and older age, but its relation to PF disorders and symptoms earlier in life is unclear. Our aim was to conduct a systematic review to investigate the strength of evidence for an association between anterior knee pain (AKP) in younger adults and subsequent PFOA.
The search strategy included electronic databases (Pubmed, EMBASE, AMED, CINAHL, Cochrane, PEDro, SportDiscus: inception to December 2009), reference lists of potentially eligible studies and selected reviews. Full text articles in any language, - identified via English titles and abstracts, were included if they were retrospective or prospective in design and contained quantitative data regarding structural changes indicative of PFOA, incident to original idiopathic AKP. Eligibility criteria were applied to titles, abstracts and full-texts by two independent reviewers. Data extraction included study location, design, date, sampling procedure, sample characteristics, AKP/PFOA definitions, follow-up duration and rate, and main findings. Foreign language articles were translated into English prior to examination.
Seven articles satisfied eligibility (5 English, 2 German). Only one case-control study directly investigated a link between PFOA and prior AKP, providing level 3b evidence in favour of an association (OR 4.4; 95%CI 1.8, 10.6). Rough estimates of the annual risk of PFOA from the remaining six small, uncontrolled, observational studies (mean follow-up range: 5.7 to 23 years) ranged from 0% to 3.4%. This was not the primary aim of these studies, and limitations in design and methodology mean this data should be interpreted with caution.
There is a paucity of high-quality evidence reporting a link between AKP and PFOA. Further, well-designed cohort studies may be able to fill this evidence gap.
Patellofemoral pain syndrome (PFP) is a common musculoskeletal condition that has a tendency to become chronic and problematic in a proportion of affected individuals. The objective of this study was to identify prognostic factors that may have clinical utility in predicting poor outcome on measures of pain and function in individuals with PFP.
A prospective follow-up study was conducted of 179 participants in a randomised clinical trial. Nine baseline factors (age, gender, body mass index, arch height, duration of knee pain, worst pain visual analogue scale, Kujala Patellofemoral Score (KPS), functional index questionnaire (FIQ), step down repetitions) were investigated for their prognostic ability on outcome assessed at six, 12 and 52 weeks (worst pain, KPS and FIQ). Factors with significant univariate associations were entered into multivariate linear regression models to identify a group of factors independently associated with poor outcome.
Long symptom duration was the most consistent predictor of poor outcome over 52 weeks rated on the KPS and the FIQ (beta-0.07, 95% confidence interval -0.1 to -0.03, p < 0.000; and -0.02, -0.03 to -0.01, p < 0.000, respectively). Worse KPS at baseline was predictive of outcome at six, 12 and 52 weeks. Gender, body mass index and arch height were generally not associated with outcome (univariate analysis), while age, worst pain, FIQ and step downs were excluded during multivariate analyses.
Patients presenting with PFP of long duration who score worse on the KPS have a poorer prognosis, irrespective of age, gender and morphometry. These results suggest that strategies aimed at preventing chronicity of more severe PFP may optimise prognosis.
To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome.
Open label randomised controlled trial.
General practice and sport physician practice.
Patients with a new episode of patellofemoral pain syndrome recruited by their general practitioner or sport physician.
The intervention group received a standardised exercise programme for 6 weeks tailored to individual performance and supervised by a physical therapist, and were instructed to practise the tailored exercises at home for 3 months. The control group were assigned usual care, which comprised a "wait and see" approach of rest during periods of pain and refraining from pain provoking activities. Both the intervention group and the control group received written information about patellofemoral pain syndrome and general instructions for home exercises.
The primary outcomes were self reported recovery (7 point Likert scale), pain at rest and pain on activity (0-10 point numerical rating scale), and function (0-100 point Kujala patellofemoral score) at 3 months and 12 months follow-up.
A total of 131 participants were included in the study: 65 in the intervention group and 66 in the control group. After 3 months, the intervention group showed better outcomes than the control group with regard to pain at rest (adjusted difference -1.07, 95% confidence interval -1.92 to -0.22; effect size 0.47), pain on activity (-1.00, -1.91 to -0.08; 0.45), and function (4.92, 0.14 to 9.72; 0.34). At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain (adjusted difference in pain at rest -1.29, -2.16 to -0.42; effect size 0.56; pain on activity -1.19, -2.22 to -0.16; effect size 0.54), but not function (4.52, -0.73 to 9.76). A higher proportion of patients in the exercise group than in the control group reported recovery (41.9% v 35.0% at 3 months and 62.1% v 50.8% at 12 months), although the differences in self reported recovery between the two groups were not statistically significant. Predefined subgroup analyses revealed that patients recruited by sport physicians (n=30) did not benefit from the intervention, whereas those recruited by general practitioners (n=101) showed significant and clinically relevant differences in pain and function in favour of the intervention group.
Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice. Exercise therapy did not produce a significant difference in the rate of self reported recovery.
ISRCTN83938749.
Since the introduction of Cohen's kappa as a chance-adjusted measure of agreement between two observers, several "paradoxes" in its interpretation have been pointed out. The difficulties occur because kappa not only measures agreement but is also affected in complex ways by the presence of bias between observers and by the distributions of data across the categories that are used ("prevalence"). In this paper, new indices that provide independent measures of bias and prevalence, as well as of observed agreement, are defined and a simple formula is derived that expresses kappa in terms of these three indices. When comparisons are made between agreement studies it can be misleading to report kappa values alone, and it is recommended that researchers also include quantitative indicators of bias and prevalence.
There is broad consensus that good outcome measures are needed to distinguish interventions that are effective from those that are not. This task requires standardized, patient-centered measures that can be administered at a low cost. We developed a questionnaire to assess short- and long-term patient-relevant outcomes following knee injury, based on the WOMAC Osteoarthritis Index, a literature review, an expert panel, and a pilot study. The Knee injury and Osteoarthritis Outcome Score (KOOS) is self-administered and assesses five outcomes: pain, symptoms, activities of daily living, sport and recreation function, and knee-related quality of life. In this clinical study, the KOOS proved reliable, responsive to surgery and physical therapy, and valid for patients undergoing anterior cruciate ligament reconstruction. The KOOS meets basic criteria of outcome measures and can be used to evaluate the course of knee injury and treatment outcome.
There is no clear consensus in the literature concerning the terminology, aetiology and treatment for pain in the anterior part of the knee. The term 'anterior knee pain' is suggested to encompass all pain-related problems. By excluding anterior knee pain due to intra-articular pathology, peripatellar tendinitis or bursitis, plica syndromes, Sinding Larsen's disease, Osgood Schlatter's disease, neuromas and other rarely occurring pathologies, it is suggested that remaining patients with a clinical presentation of anterior knee pain could be diagnosed with patello-femoral pain syndrome (PFPS). Three major contributing factors of PFPS are discussed: (i) malalignment of the lower extremity and/or the patella; (ii) muscular imbalance of the lower extremity; and (iii) overactivity. The significance of lower extremity alignment factors and pathological limits needs further investigation. It is possible that the definitions used for malalignment should be re-evaluated, as the scientific support is very weak for determining when alignment is normal and when there is malalignment. Consequently, pathological limits must be clarified, along with evaluation of risk factors for acquiring PFPS. Muscle tightness and muscular imbalance of the lower extremity muscles with decreased strength due to hypotrophy or inhibition have been suggested, but remain unclear as potential causes of PFPS. Decreased knee extensor strength is a common finding in patients with PFPS. Various patterns of weaknesses have been reported, with selective weakness in eccentric muscle strength, within the quadriceps muscle and in terminal knee extension. The significance of muscle function in a closed versus open kinetic chain has been discussed, but is far from well investigated. It is clear that further studies are necessary in order to establish the significance of various strength deficits and muscular imbalances, and to clarify whether a specific disturbance in muscular activation is a cause or an effect (or both) of PFPS. The most common symptoms in patients with PFPS are pain during and after physical activity, during bodyweight loading of the lower extremities in walking up/down stairs and squatting, and in sitting with the knees flexed. However, the source of patellofemoral pain in patients with PFPS cannot be sufficiently explained. There are several types of clinical manifestation of pain, and therefore a differentiated documentation of the patient's pain symptoms is necessary. The connection between strength, pain and inhibition, as well as between personality and pain, needs further investigation. Many different treatment protocols are described in the literature and recent studies advocate a comprehensive treatment approach allowing for an individual and specifically designed treatment. Surgical treatment is rarely indicated. It is strongly suggested that, when presenting studies on PFPS, a detailed description should be provided of the diagnosis, inclusion and exclusion criteria of the patients should be specified along with a detailed methodology, and the conclusions drawn should be compared with those of other studies in the published literature. As this is not the case in most studies on PFPS found in the literature, it is only possible to make general comparisons. In order to further develop treatment models for PFPS we advocate prospective, randomised, controlled, long term studies using validated outcome measures. However, there is a strong need for basic research on the nature and aetiology of PFPS in order to better understand this mysterious syndrome.
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects (benefits and harms) of exercise therapy aimed at reducing knee pain and improving knee function for people with patellofemoral pain syndrome.
Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain. A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL (R) and Pre-CINAHL (R), PEDro, PubMed, SportDiscus (R), Web of Science (R), BIOSIS Previews (R), and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models. Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Meta-analysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI -0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD -0.21, 95% CI -0.64, 0.21; 8-12 weeks: SMD -0.22, 95% CI 0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control). Findings suggest that, in implementing evidence-based practice for the nonsurgical management of anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required.
Background: Patellofemoral pain syndrome is a highly prevalent musculoskeletal overuse condition that has a significant impact on participation in daily and physical activities. A recent systematic review highlighted the lack of high quality evidence from randomised controlled trials for the conservative management of patellofemoral pain syndrome. Although foot orthoses are a commonly used intervention for patellofemoral pain syndrome, only two pilot studies with short term follow up have been conducted into their clinical efficacy. Methods/design: A randomised single-blinded clinical trial will be conducted to investigate the clinical efficacy and cost effectiveness of foot orthoses in the management of patellofemoral pain syndrome. One hundred and seventy-six participants aged 18–40 with anterior or retropatellar knee pain of non-traumatic origin and at least six weeks duration will be recruited from the greater Brisbane area in Queensland, Australia through print, radio and television advertising. Suitable participants will be randomly allocated to receive either foot orthoses, flat insoles, physiotherapy or a combined intervention of foot orthoses and physiotherapy, and will attend six visits with a physiotherapist over a 6 week period. Outcome will be measured at 6, 12 and 52 weeks using primary outcome measures of usual and worst pain visual analogue scale, patient perceived treatment effect, perceived global effect, the Functional Index Questionnaire, and the Anterior Knee Pain Scale. Secondary outcome measures will include the Lower Extremity Functional Scale, McGill Pain Questionnaire, 36-Item Short-Form Health Survey, Hospital Anxiety and Depression Scale, Patient-Specific Functional Scale, Physical Activity Level in the Previous Week, pressure pain threshold and physical measures of step and squat tests. Cost-effectiveness analysis will be based on treatment effectiveness against resource usage recorded in treatment logs and self-reported diaries. Discussion: The randomised clinical trial will utilise high-quality methodologies in accordance with CONSORT guidelines, in order to contribute to the limited knowledge base regarding the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome, and provide practitioners with high-quality evidence upon which to base clinical decisions.
Background:
Proximal muscle rehabilitation is commonly prescribed to address muscle strength and function deficits in individuals with patellofemoral pain (PFP). This review (1) evaluates the efficacy of proximal musculature rehabilitation for patients with PFP; (2) compares the efficacy of various rehabilitation protocols; and (3) identifies potential biomechanical mechanisms of effect in order to optimise outcomes from proximal rehabilitation in this problematic patient group.
Methods:
Web of Knowledge, CINAHL, EMBASE and Medline databases were searched in December 2014 for randomised clinical trials and cohort studies evaluating proximal rehabilitation for PFP. Quality assessment was performed by two independent reviewers. Effect size calculations using standard mean differences and 95% CIs were calculated for each comparison.
Results:
14 studies were identified, seven of high quality. Strong evidence indicated proximal combined with quadriceps rehabilitation decreased pain and improved function in the short term, with moderate evidence for medium-term outcomes. Moderate evidence indicated that proximal when compared with quadriceps rehabilitation decreased pain in the short-term and medium-term, and improved function in the medium term. Limited evidence indicated proximal combined with quadriceps rehabilitation decreased pain more than quadriceps rehabilitation in the long term. Very limited short-term mechanistic evidence indicated proximal rehabilitation compared with no intervention decreased pain, improved function, increased isometric hip strength and decreased knee valgum variability while running.
Conclusions:
A robust body of work shows proximal rehabilitation for PFP should be included in conservative management. Importantly, greater pain reduction and improved function at 1 year highlight the long-term value of proximal combined with quadriceps rehabilitation for PFP.
