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Foot orthoses for patellofemoral pain in adults
Abstract
Pain around the knee cap is a common problem. The pain may be brought on or made worse by day to day or sporting/exercise activities. Pain around the knee cap can have many different causes, such as the way the knee cap glides over the bones or because of knee overuse. Several different treatment options are available. Foot orthoses are specially moulded devices fitted into footwear. They are believed to be helpful because they might help improve the alignment of the leg bones. The aim of this review is to evaluate the effects of foot orthoses on knee pain and knee usage in adults with pain over the front of the knee. We aimed to compare foot orthoses against no treatment or flat insoles, or other treatments such as physiotherapy. We included two studies with a total of 210 participants in this review. Both trials were at some risk of bias because not enough care had been taken to ensure that groups received the same treatment other than the interventions being tested. One trial found some benefits from using foot orthoses over simple insoles at six weeks but not at one year. Participants wearing orthoses were, however, more likely to report minor adverse effects (e.g. rubbing, blistering) and discomfort compared with those wearing insoles. There were no important differences in knee pain and function in people given foot orthoses as well as physiotherapy when compared with people given physiotherapy only. Results for knee pain and function did not show important differences between foot orthoses versus physiotherapy. On the basis of the available evidence we do not recommend foot orthoses for adults with pain around the knee cap.
... 5 Active in sports for at least 120 minutes per week. 6 No engagement in regular sporting activities. This document is protected by international copyright laws. ...
... Scale (0 to 10; higher scores mean worse pain) 6 Follow-up: 12 months The mean pain in the control group ranged from 2.6 to 3.9 points 2 The mean pain during activity ...
... 4 Data were from VAS (0 to 10) and the McGill pain questionnaire (0 to 10). 5 In our assessment of the quality of the evidence for this outcome, we downgraded two levels for serious risk of bias (relating to lack of allocation concealment and lack of assessor blinding) and one level for imprecision (small sample size). 6 Data were from VAS (0 to 10) and VAS (0 to 200). Values were scaled to 0 to 10 (higher is worse). ...
Patellofemoral pain syndrome (PFPS) is a common knee problem characterised by retropatellar or peripatellar pain, which particularly affects adolescents and young adults. Exercise therapy is often prescribed.
To assess the effects of exercise therapy in people with PFPS.
Systematic review SETTING: All settings POPULATION: Adolescents and adults with PFPS METHODS: A search was performed in nine databases up to May 2014, including the Cochrane Register, MEDLINE and EMBASE. Randomised and quasi-randomised trials evaluating the effect of exercise therapy in adolescents and adults with PFPS were considered for inclusion. Two review authors independently selected trials, extracted data and assessed risk of bias.
In total, 31 trials including 1690 participants were included in this review, of which most were at high risk of performance bias and detection bias due to lack of blinding. The included studies provided evidence for: exercise therapy versus control; exercise therapy versus other conservative interventions (e.g. taping); and different exercises or exercise programmes. Pooled data favoured exercise therapy over control for pain during activity (short term MD -1.46 [-2.39, - 0.54]), usual pain (short term estimated MD -1.44 [-2.48,-0.39]), functional ability; (short term estimated MD 12.21 [6.44, 18.09] and long term recovery (RR 1.35 [0.99, 1.84]). Pooled data favoured hip and knee exercise over knee exercises alone for pain during activity (short-term MD -2.20 [3.80, -0.60]) and usual pain (short term MD-1.77 [-2.78,-0.76]).
This review 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 longterm recovery. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone.
Very low quality evidence but consistent evidence indicates that exercise therapy benefits patients with PFP. 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.
... Patellofemoral Pain Syndrome (PFPS) is a common knee disorder , with a typical pattern of symptoms characterised by anterior peripatella or retropatella knee pain (Heintjes et al., 2009; Collins et al., 2010; Hossain et al., 2011 ). Aggravating factors include activities or movements which either increase patellofemoral joint compression and/or produce mechanical forces in the surrounding soft tissue structures; for example: ascending/descending stairs, sitting with a flexed knee for prolonged periods, squatting, running, jumping or kneeling (Witvrouw et al., 2000; Crossley et al., 2002; Barton et al., 2008; Thijs et al., 2008; Tan et al., 2010). ...
... This impact may be especially debilitating as PFPS symptoms often reoccur, becoming chronic (Nimon et al., 1998; Stathopulu and Baildam, 2003; Collins et al., 2008; Boling et al., 2010). Whilst the aetiology of PFPS is debated, there is some consensus that its development may be secondary to a functional or structural mal-alignment at the patellofemoral joint, or of the lower extremity as a whole (Powers, 2003; Barton et al., 2008; Heintjes et al., 2009; Carry et al., 2010; Hossain et al., 2011). There may be multiple interacting factors which cause mal-alignment, such as muscle strength or timing issues, altered tissue extensibility or bony morphology (Powers, 2003; Barton et al., 2008; Heintjes et al., 2009; Bennell et al., 2010). ...
... Physiotherapy is the most common intervention in PFPS (Crossley et al., 2001; Heintjes et al., 2003), however, there is no clear consensus regarding the optimal components of a management programme. As a consequence, a wide variety of treatment techniques are employed by therapists including: quadriceps strengthening, vastus medialus obliques (VMO) muscle retraining, biofeedback, hip muscle strengthening, proximal strengthening, spinal manipulation, mobilisation, taping, knee supports, foot orthoses and stretching of the hamstrings, illiotial band, patella retinaculum or anterior hip (Crossley et al., 2002; Iverson et al., 2008; Heintjes et al., 2009; Earl and Hoch, 2011; Hossain et al., 2011; Callaghan and Selfe, 2012). In the absence of guidelines outlining the most favourable PFPS treatment options, physiotherapists should appraise their own management, utilising high quality, disease-specific, PFPS outcome measures to guide and evaluate patient care, so they may deliver efficacious treatment tailored to the individual (DoH, 2010; CSP, 2012; HCPC, 2013). ...
This systematic review investigated the measurement properties of disease-specific patient-reported outcome measures used in Patellofemoral Pain Syndrome. Two independent reviewers conducted a systematic search of key databases (MEDLINE, EMBASE, AMED, CINHAL+ and the Cochrane Library from inception to August 2013) to identify relevant studies. A third reviewer mediated in the event of disagreement. Methodological quality was evaluated using the validated COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) tool. Data synthesis across studies determined the level of evidence for each patient-reported outcome measure. The search strategy returned 2177 citations. Following the eligibility review phase, seven studies, evaluating twelve different patient-reported outcome measures, met inclusion criteria. A ‘moderate’ level of evidence supported the structural validity of several measures: the Flandry Questionnaire, Anterior Knee Pain Scale, Modified Functional Index Questionnaire, Eng and Pierrynowski Questionnaire and Visual Analogue Scales for ‘usual’ and ‘worst’ pain. In addition, there was a ‘Limited’ level of evidence supporting the test-retest reliability and validity (cross-cultural, hypothesis testing) of the Persian version of the Anterior Knee Pain Scale. Other measurement properties were evaluated with poor methodological quality, and many properties were not evaluated in any of the included papers. Current disease-specific outcome measures for Patellofemoral Pain Syndrome require further investigation. Future studies should evaluate all important measurement properties, utilising an appropriate framework such as COSMIN to guide study design, to facilitate optimal methodological quality.
... guided vs. unguided), frequency, dose and active component of the injections (though corticosteroid injections are more often reported in literature). Evidence base: The evidence for the effectiveness of aids and devices for pain and function included five guidelines [16,20,47,112,129], one clinical pathway [38], four Cochrane reviews [66,77,[130][131][132], two best evidence syntheses [58,133] and a meta-analysis [134]. The quality of reviews was moderate. ...
... The quality of reviews was moderate. Magnitude of effects: Either as stand-alone treatment or mostly in combination with other treatments, aids and devices for musculoskeletal pain have generally shown small effects (see supplementary S5 Table) on pain, function or work outcomes [16,20,38,58,66,77,[131][132][133]. Routine use of collars has not been found to confer any clinically significant benefits for neck pain [38,58,66,133]. ...
... The Knee 20 (2013) 595-599 A wide variety of treatment methods have been proposed for the treatment of AKP. Cochrane reviews addressing the efficacy of therapeutic ultrasound [21], exercise therapy [22], pharmacotherapy [23], and foot orthoses [24] for the treatment of AKP have found that evidence for the effectiveness of these interventions is limited and conflicting. Nevertheless, there is a growing body of evidence for the efficacy of biomechanical interventions focusing on foot center of pressure (COP) manipulation, agility and perturbation training when treating individuals with AKP [25][26][27][28][29]. ...
... The current retrospective study examined the outcome of continuous biomechanical treatment incorporating load reduction and repetitive perturbation stimuli for patients suffering from AKP. Currently, there is limited and conflicting evidence regarding the effectiveness of existing treatment methods [21][22][23][24]. The results of the current study demonstrated that objective gait parameters can be significantly influenced by this biomechanical intervention after 13 and 26 weeks of treatment. ...
... Most of the clinicians used biofeedback, patella taping, and foot orthoses as interventions for their patients . Cochrane reviews of the effectiveness of exercise therapy, patella taping, and orthotic devices in PFPS (Heintjes et al, 2003;Callaghan and Selfe, 2009;Hossain et al, 2010) reveal few properly designed studies and call for further research with special consideration being given to the design and reporting of trials. ...
... As in the Cochrane reviews (Heintjes et al, 2003;Callaghan and Selfe, 2009;Hossain et al, 2010), physiotherapists in NW identified the VAS as the primary patient reported outcome measure for pain. For secondary outcomes such as function, quality of life, and activity levels, physiotherapists know about, but rarely use, specific measures such as the Anterior Knee Pain Questionnaire (Kujala et al, 1993), the Modified Functional Index Questionnaire (Harrison et al, 1995), the SF-36 (Ware and Sherbourne, 1992) and the WOMAC OA Index (Bellamy et al, 1988). ...
Background/Aim
Little is known about how individual physiotherapists assess, treat and measure outcomes for patients with patellofemoral pain syndrome (PFPS) in the clinic. Previous research has revealed no gold standard methods. This study therefore set out to explore beliefs and practices of physiotherapists working in a non-academic health community in North Wales (NW).
Methods
Methodology involved a mixed-method approach. 4 quantitative questionnaire exploring how physiotherapists assess, treat, and measure outcomes in PFPS, was emailed to physiotherapists working in NW. Thirty responded (62.5%) and eleven were then interviewed (qualitative). Interviews were recorded, transcribed, and organised into categories. Number and frequency of the different assessments, treatments, and outcome measures were triangulated against the quantitative survey data. Findings were then synthesised.
Findings
Physiotherapists are aware of the different types of presentation of PFPS; however, individual clinical practice differs. Although the questionnaire reported a large number of outcome measures, interviews reported mainly only the visual analogue pain scale and subjective functional tasks. Moreover, physiotherapists treat function, not syndromes. Home exercises aim for simplicity and function rather than complex muscle group specific exercises. Peers were reported to be the most important source of knowledge and influence on their practice.
Conclusion
There is a need to develop an evidence-based assessment and outcome measurement protocol for routine clinical practice.
... After the application of the inclusion and exclusion criterion, 13 contemporary reviews (ie, since 2007) were identified. [24][25][26][27][28][29][30][31][32][33][34][35][36] Following quality assessment, six reviews [30][31][32][33][34][35] were deemed high quality with scores ranging from 20 to 26 (see table 2). The average quality score was 16.3 (out of 26). ...
... After the application of the inclusion and exclusion criterion, 13 contemporary reviews (ie, since 2007) were identified. [24][25][26][27][28][29][30][31][32][33][34][35][36] Following quality assessment, six reviews [30][31][32][33][34][35] were deemed high quality with scores ranging from 20 to 26 (see table 2). The average quality score was 16.3 (out of 26). ...
Patellofemoral pain (PFP) is both chronic and prevalent; it has complex aetiology and many conservative treatment options.
Develop a comprehensive contemporary guide to conservative management of PFP outlining key considerations for clinicians to follow.
Mixed methods.
We synthesised the findings from six high-quality systematic reviews to September 2013 with the opinions of 17 experts obtained via semistructured interviews. Experts had at least 5 years clinical experience with PFP as a specialist focus, were actively involved in PFP research and contributed to specialist international meetings. The interviews covered clinical reasoning, perception of current evidence and research priorities.
Multimodal intervention including exercise to strengthen the gluteal and quadriceps musculature, manual therapy and taping possessed the strongest evidence. Evidence also supports use of foot orthoses and acupuncture. Interview transcript analysis identified 23 themes and 58 subthemes. Four key over-arching principles to ensure effective management included-(1) PFP is a multifactorial condition requiring an individually tailored multimodal approach. (2) Immediate pain relief should be a priority to gain patient trust. (3) Patient empowerment by emphasising active over passive interventions is important. (4) Good patient education and activity modification is essential. Future research priorities include identifying risk factors, testing effective prevention, developing education strategies, evaluating the influence of psychosocial factors on treatment outcomes and how to address them, evaluating the efficacy of movement pattern retraining and improving clinicians' assessment skills to facilitate optimal individual prescription.
Effective management of PFP requires consideration of a number of proven conservative interventions. An individually tailored multimodal intervention programme including gluteal and quadriceps strengthening, patellar taping and an emphasis on education and activity modification should be prescribed for patients with PFP. We provide a 'Best Practice Guide to Conservative Management of Patellofemoral Pain' outlining key considerations.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
... U ntil now, the evidence on the effectiveness of different conservative therapies (eg, exercise, tape, orthoses) to reduce pain and improve function in those with patellofemoral pain (PFP) has been limited. 6,11,15,17,29 There is consensus that a multimodal physical therapy program that includes exercise therapy is the preferred treatment for PFP. 36 ...
... U ntil now, the evidence on the effectiveness of different conservative therapies (eg, exercise, tape, orthoses) to reduce pain and improve function in those with patellofemoral pain (PFP) has been limited. 6,11,15,17,29 There is consensus that a multimodal physical therapy program that includes exercise therapy is the preferred treatment for PFP. 36 In the short term, exercise therapy seems to be more effective than a "wait and see" approach. ...
Study design:
Secondary exploratory analysis of a randomized controlled trial comparing supervised exercise therapy to usual care in patients with patellofemoral pain (PFP).
Objective:
To explore which patients with PFP are more likely to benefit from exercise therapy.
Background:
Patellofemoral pain is a common condition for which exercise therapy is effective in reducing pain and improving function. However, not all patients benefit from exercise therapy.
Methods:
The present study explored patient characteristics that might interact with treatment effects of PFP in 131 patients treated with usual care or exercise therapy. These characteristics were tested for interaction with treatment in a regression analysis. The primary outcomes were function and pain on activity at a 3-month follow-up.
Results:
None of the tested variables had a significant interaction with treatment. A positive trend was seen for females with PFP: they were more likely to report higher function scores with exercise therapy than with usual care compared to males with PFP (β = 12.1; 95% confidence interval: 0.23, 24.0; P = .05). A positive trend was seen for patients with a longer duration of complaints (greater than 6 months); they were more likely to report higher function scores and to have less pain on activity with exercise therapy than with usual care compared to those with a shorter duration of complaints (β = 12.3; 95% confidence interval: -0.08, 24.7; P = .05 and β = -1.74; 95% confidence interval: -3.90, 0.43; P = .12, respectively).
Conclusion:
Two factors, sex and duration of complaints, may have a predictive value for response to exercise therapy at 3-month follow-up. Due to the exploratory design of the study, future research should confirm this tendency.
... Evidence review: Three systematic reviews (including six RCTs) and eight additional RCTs were included ('very low GRADE') [1,2,6,9,19,20,23,33,40,48,51]. ...
Purpose
The purpose of this study was to develop a multidisciplinary guideline for patellofemoral pain (PFP) and patellar tendinopathy (PT) to facilitate clinical decision‐making in primary and secondary care.
Methods
A multidisciplinary expert panel identified questions in clinical decision‐making. Based on a systematic literature search, the strength of the scientific evidence was determined according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method and the weight assigned to the considerations by the expert panel together determined the strength of the recommendations.
Results
After confirming PFP or PT as a clinical diagnosis, patients should start with exercise therapy. Additional conservative treatments are indicated only when exercise therapy does not result in clinically relevant changes after six (PFP) or 12 (PT) weeks. Pain medications should be reserved for cases of severe pain. The additional value of imaging assessments for PT is limited. Open surgery is reserved for very specific cases of nonresponders to exercise therapy and those requiring additional conservative treatments. Although the certainty of evidence regarding exercise therapy for PFP and PT had to be downgraded (‘very low GRADE’ and ‘low GRADE’), the expert panel advocates its use as the primary treatment strategy. The panel further formulated weaker recommendations regarding additional conservative treatments, pain medications, imaging assessments and open surgery (‘very low GRADE’ to ‘low GRADE’ assessment or absence of scientific evidence).
Conclusion
This guideline recommends starting with exercise therapy for PFP and PT. The recommendations facilitate clinical decision‐making, and thereby optimizing treatment and preventing unnecessary burdens, risks and costs to patients and society.
Level of Evidence
Level V, clinical practice guideline.
... 53 Absence of effect in the second trial 56 may result from the short 2-week intervention period, with a previous Cochrane review of two studies involving 210 participants reporting that foot orthoses resulted in better improvements in patellofemoral pain among the general population compared with flat orthoses at 6 weeks. 81 Future research should aim to determine whether certain subgroups of runners (eg, those with certain foot mechanics) benefit more than others from the prescription of foot orthoses, the effects of customised orthoses versus prefabricated orthoses, and the effects of combining foot orthoses with other interventions (ie, therapeutic exercise) and include medium-term to long-term follow-ups. ...
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
... Indeed, most researchers advocate conservative treatment for patellofemoral pain, and a range of different therapeutic and orthopaedic mechanisms have been explored, including exercise therapy, taping, bracing, insoles, soft-tissue manipulation, and acupuncture [12]. However, recent Cochrane reviews indicate that there is still insufficient clarity about the effectiveness of current conservative treatment modalities [13][14][15], likely owing to the heterogeneous nature of patellofemoral pain presentation and aetiology [16]. ...
PURPOSE: This study aimed to explore the efficacy of U.S. Montmorency tart cherry
in treating recreationally active individuals with patellofemoral pain.
METHODS: Twenty-four recreationally active participants with patellofemoral pain
were randomly separated into either placebo (males N = 8, females N = 4, age = 43.30
± 7.86 yrs, mass = 72.10 ± 17.89 kg, stature = 171.16 ± 10.17, BMI = 24.31 ± 3.75
kg/m 2 , symptom duration = 30.18 ± 10.90) or Montmorency tart cherry (males N = 9,
females N = 3, age = 41.75 ± 7.52 yrs, mass = 76.96 ± 16.64 kg, stature = 173.05 ±
7.63, BMI = 25.53 ± 4.03 kg/m 2 , symptom duration = 29.73 ± 11.88) groups. Both
groups ingested 60 mL of either Montmorency tart cherry concentrate or taste matched
placebo daily for 6-weeks. Measures of self-reported pain (KOOS PF), psychological
wellbeing (COOP WONCA) and sleep quality (PSQI) alongside blood biomarkers (Creactive protein, uric acid, TNF alpha, creatinine and total antioxidant capacity) and
knee biomechanics were quantified at baseline and 6-weeks. Differences between
groups were examined using linear mixed effects models.
RESULTS: There was 1 withdrawal in the cherry and 0 in the placebo group and no
adverse events were noted in either condition. The placebo condition exhibited
significant improvements (baseline = 67.90±16.18 & 6-weeks = 78.04±14.83) in KOOS
PF scores compared to the tart cherry group (baseline = 67.28±12.55& 6-weeks =
67.55±20.61). No other statistically significant observations were observed.
CONCLUSION: Tart cherry supplementation as specifically ingested in the current
investigation, does not appear to be effective in mediating improvements in
patellofemoral pain symptoms in recreationally active individuals.
... Open access the ability to perform activities of daily living and occupational tasks and reducing participation in physical activity. 5 6 Focusing on the rehabilitation of this population, some systematic reviews have evaluated the effectiveness of several adjunctive treatments combined with exercise therapy [7][8][9][10][11][12][13][14][15][16][17][18][19][20] and/or multimodal physiotherapy programmes. 7-12 14-16 20 These adjunctive treatments include patellar taping, 7-12 14 knee 10 12 14 and foot 8 10 14-16 orthoses, electromyography biofeedback, 8 14 17 dry needling 19 and neuromuscular electrical stimulation. ...
Introduction
Patellofemoral pain (PFP) is a chronic condition that affects up to 25% of the general population and has a negative impact on functionality and quality of life due to the high levels of pain experienced by these patients. In order to improve pain and function, rehabilitation programmes that combine adjunctive treatments with exercise therapy are often used in research and clinical settings. However, despite the variety of adjunctive treatments available, their effectiveness when compared with exercise therapy has yet to be elucidated. Thus, the aim of this study is to evaluate the effectiveness of adjunctive treatments plus exercise therapy versus exercise therapy, and determine the relative efficacy of different types of adjunctive treatments plus exercise therapy for individuals with PFP.
Methods and analysis
A systematic review and network meta-analysis will be conducted based on the Cochrane Collaboration recommendations and reported in line with Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. We will search Embase, PubMed (MEDLINE), CENTRAL, CINAHL, PEDro, SPORTDiscus, Web of Science and OpenGrey. It will be included randomised controlled trials that compared adjunctive treatment plus exercise therapy to placebo adjunctive treatment plus exercise therapy or exercise therapy. The outcomes of interest will be pain and function, with no restrictions on language, setting or year of publication. Study selection will be performed by two independent reviewers, based on the eligibility criteria. Risk of bias will be assessed using the Physiotherapy Evidence Database scale and the evidence summarised via the Grading of Recommendation, Assessment, Development and Evaluation approach. A Bayesian network meta-analysis will be performed to compare the efficacy of different adjunctive treatments plus exercise therapy. Consistency between direct and indirect comparisons will be assessed.
Ethics and dissemination
No ethical statement will be required for this systematic review and meta-analysis. The findings will be published in a relevant international peer-reviewed journal and presented at conferences.
PROSPERO registration number
CRD42020197081.
... Aids and devices such as orthoses, braces, prostheses, cervical collars, and other support devices, either alone or in combination with other treatments for musculoskeletal pain, have generally shown small effects on pain, function, or performance [33]. Routine use of cervical collars has been found to provide any clinically significant benefit for neck pain, which can be attributed to marginal pain relief (short-term) and propensity to rest and inactivity, and thus prolong disability. ...
Results: By reviewing 50 references, we presented the principles of treatment of musculoskeletal disorders. For many patients, clinical treatment decisions are often focused on a specific region of the body without much recourse to the potential impact of prognostic factors or other coexisting pain problems. It is difficult to obtain a more holistic view because examinations and systematic examinations usually focus on the specific site of musculoskeletal pain, comparing only two or three treatment options. Conclusion: Exercise therapy is beneficial for pain, function, and quality of life. Current research evidence shows significant positive effects in exercise programs on pain, function, quality of life, and work-related results in the short and long term for all manifestations of musculoskeletal pain (compared to subjects without exercise). Manual therapy has little or no clinically relevant effect on pain intensity, functional status, global improvement or return to work in patients with acute, subacute or chronic back pain with or without sciatica. TENS was no more effective in reducing placebo pain in chronic back pain, neck pain, shoulder pain, knee pain, and chronic musculoskeletal pain in general. Ultrasound and shock wave therapy do not significantly improve the clinical outcomes of acute and chronic lower back pain.
... Combining exercise with foot orthotics is likely more beneficial than either treatment alone. Semi-rigid foot orthotics absorb shock and provide medial longitudinal arch support, correcting dynamic valgus due to flatfoot and rearfoot eversion [127,128]. ...
Muscle injuries are the most common injuries in professional athletes forced to high-intensity sprinting efforts. Due to a high recurrence rate and possible consequences for elite athletes, it is one of the most challenging tasks for a sports medicine team to prepare a professional athlete to return to performance. This results in an ongoing search for new treatments to improve and accelerate muscle healing. In this chapter, we describe the principle of muscle healing and discuss the contemporary biological therapies with the available scientific evidence on their efficacy and safety.
... Combining exercise with foot orthotics is likely more beneficial than either treatment alone. Semi-rigid foot orthotics absorb shock and provide medial longitudinal arch support, correcting dynamic valgus due to flatfoot and rearfoot eversion [127,128]. ...
Acute and chronic hamstring injuries are common in athletics. Acute injuries account for 17.1% of all injuries. Chronic injuries (proximal hamstring tendinopathy) are seen less frequently, however, but true incidences are unknown. Acute injuries occur at the (from most frequent to less frequent) musculotendinous junction (MTJ), the intramuscular tendon and the free tendons (partial- or full-thickness injury). Proximal hamstring tendinopathy occurs in the proximal hamstring free tendons. Diagnosis of these injuries is mostly clinical but can be supported by imaging such as magnetic resonance imaging or ultrasound. Treatment for partial-thickness MTJ acute hamstring injuries is informed by 14 RCTs. For proximal hamstring tendinopathy and partial- or full-thickness free tendon injuries, there is little evidence to guide treatment. Cornerstone of treatment is physiotherapy-based interventions with progressive (eccentric) loading and activity modification, combined with expectation management. Surgery is usually reserved for full-thickness free tendon injuries. Other treatments such as platelet-rich plasma injections, corticosteroid injections and non-steroidal anti-inflammatory medication have little supportive evidence and should be avoided.
... PFPS is mainly treated non-surgically, with surgery usually being reserved for severe cases that failed to respond to non-surgical treatment [7]. While one Cochrane review found physiotherapy aimed at quadriceps strengthening to be an effective therapeutic approach [8], other modalities such as patellar taping [9], foot orthoses [10], and anti-inflammatory medications [7] were not found to be beneficial for long-term symptom relief. In contrast, other investigators have found that 40% of the patients treated by physiotherapy reported that their symptoms had persisted 1 year following treatment [11]. ...
Purpose
Patellofemoral pain syndrome (PFPS) is a common pathology usually presenting with anterior or retropatellar pain. It is associated with a relative imbalance between the vastus medialis oblique (VMO) and the vastus lateralis (VL) muscles. This can lead to considerable morbidity and reduced quality of life (QOL). This study aims to assess the long-term functional outcome of PFPS treated with VL muscle botulinum toxin A (BoNT-A) injection.
Materials and methods
A retrospective review was performed on 26 consecutive patients (31 knees) with a mean age of 50.1 years (± 19.7 years) who were treated with BoNT-A injections to the VL muscle followed by physiotherapy between 2008 and 2015. Pre- and post-treatment pain levels (numerical rating scale, NRS), QOL (SF-6D), and functional scores (Kujala and Lysholm questionnaires) were measured. Demographics, physical therapy compliance, previous surgeries, perioperative complications, and patient satisfaction levels were collected.
Results
The mean follow-up time was 58.8 ± 36.4 months. There were significant improvements in all the examined domains. The average pain score (NRS) decreased from 7.6 to 3.2 ( P < 0.01), and the Kujala, Lysholm, and SF-6D scores improved from 58.9 to 82.7 ( P < 0.001), 56.2 to 83.2 ( P < 0.001), and 0.6 to 0.8 ( P < 0.001), respectively. Similar delta improvement was achieved irrespective of gender, age, compliance to post-treatment physical therapy, or coexisting osteoarthritis. Patients who presented with a worse pre-treatment clinical status achieved greater improvement. Prior to BoNT-A intervention, 16 patients (18 knees) were scheduled for surgery, of whom 12 (75%, 13 knees) did not require further surgical intervention at the last follow-up.
Conclusions
A single intervention of BoNT-A injections to the VL muscle combined with physiotherapy is beneficial for the treatment of patients with persistent PFPS.
Level III evidence
Retrospective cohort study.
... Combining exercise with foot orthotics is likely more beneficial than either treatment alone. Semi-rigid foot orthotics absorb shock and provide medial longitudinal arch support, correcting dynamic valgus due to flatfoot and rearfoot eversion [127,128]. ...
Stress fractures of the foot and ankle in athletes represent a challenging problem for the orthopedic surgeon, as they are associated with high rates of reoccurrence and long-lasting absence from daily sport activities. In elite sports, stress fractures most commonly occur in the lower extremity.
... Combining exercise with foot orthotics is likely more beneficial than either treatment alone. Semi-rigid foot orthotics absorb shock and provide medial longitudinal arch support, correcting dynamic valgus due to flatfoot and rearfoot eversion [127,128]. ...
Ankle sprains and instability are among the most common musculoskeletal disorders in track and field athletes. They are associated with pain, loss of function, inability to sport, and loss of performance. Adequate diagnosis and treatment of ankle sprains will minimize the risk of long-term consequences including chronic instability and cartilage degeneration. The current chapter serves as a comprehensive overview of the most important aspects of diagnosis and treatment of lateral ankle sprains and instability with a special consideration for this type of injury in track and field athletes.
... Participants wore thermoplastic or EVA FOs for at least 4 h a day, following a previous protocol (Hossain et al., 2011). Participants were given the option whether or not to wear the FOs in physical activities other than walking. ...
Altering plantar load using foot orthoses (FOs) may alter the mechanical work required of internal structures and change the size of muscle and connective tissues. Skin sensitivity might also change as a result of altering mechanoreceptor stimulation. This study investigated the effects of FOs on foot soft tissue morphology and skin sensitivity over three months of use. Forty-one healthy participants wore prefabricated FOs (n = 23) or no insert (n = 18) for three months. The FOs were prescribed specific to each participant, using criteria of a change in peak pressure of 8% in the medial arch (pressure increase) and medial heel (pressure decrease). Ultrasound images were recorded pre- and post-FOs use to derive cross-sectional area and thickness of: abductor hallucis, flexor hallucis brevis, flexor digitorum brevis and the Achilles tendon at the insertion and mid-portion. Plantar fascia thickness was measured at the insertion and midfoot. The minimal detectable difference was established in piloting (n = 7). Skin sensitivity was measured with monofilaments at the dorsum (between the hallux and second toe), medial and lateral heel, medial and lateral arch and the 1st metatarsal head. The FOs increased peak pressure by 15% in the medial arch and reduced it by 21% in the medial heel. None of the changes in soft tissue measurements was greater than the minimal detectable difference and there were no effects of group and time. Skin sensitivity decreased over time at the 1st metatarsal head for both groups, but there was no group effect. Using FOs over three months did not change the foot tissues nor skin sensitivity. This study challenges the notion that FOs make muscles smaller.
... A systematic evaluation that included 11 clinical studies showed that foot orthoses can reduce pain and improve function in the short as well as the long term, but foot orthoses have only a slight effect on lower limb kinematics and muscle activation, and the relationship between the biomechanical effects of orthoses and pain remains unclear (Ahlhelm et al. 2015). In addition, a comparison of the effects of flat shoes and foot orthoses found that although wearing a foot orthosis for 6 weeks improved pain in patients with PFP, there was no significant difference in rehabilitation outcomes between the two at one year follow-up and there were more adverse effects such as chafing and blistering in the foot orthosis group (Hossain et al. 2011). It is worth noting that foot orthoses combined with foot-targeted exercise methods can achieve better results than knee exercise therapy alone (Mølgaard et al. 2018). ...
... Nearly 40% of those with PFP continue to experience symptoms after 2 years, which is associated with frequent use of pain killers, lowering of physical activity levels and low quality of life. 4 5 Many different treatments are used in clinical practice to help patients with PFP. 6 While there are several systematic reviews evaluating treatments for PFP, [7][8][9] the comparative effectiveness of all available treatments has never been examined. This makes deciding on the most appropriate treatment challenging and may explain the variation in clinical practice. ...
Abstract
Objective To investigate the comparative effectiveness of all treatments for patellofemoral pain (PFP).
Design Living systematic review with network meta-analysis (NMA).
Data sources Sensitive search in seven databases, three grey literature resources and four trial registers.
Eligibility criteria Randomised controlled trials evaluating any treatment for PFP with outcomes ‘any improvement’, and pain intensity.
Data extraction Two reviewers independently extracted data and assessed risk of bias with Risk of Bias Tool V.2. We used Grading of Recommendations, Assessment, Development and Evaluation to appraise the strength of the evidence.
Primary outcome measure ‘Any improvement’ measured with a Global Rating of Change Scale.
Results Twenty-two trials (with forty-eight treatment arms) were included, of which approximately 10 (45%) were at high risk of bias for the primary outcome. Most comparisons had a low to very low strength of the evidence. All treatments were better than wait and see for any improvement at 3 months (education (OR 9.6, 95% credible interval (CrI): 2.2 to 48.8); exercise (OR 13.0, 95% CrI: 2.4 to 83.5); education+orthosis (OR 16.5, 95% CrI: 4.9 to 65.8); education+exercise+patellar taping/mobilisations (OR 25.2, 95% CrI: 5.7 to 130.3) and education+exercise+patellar taping/mobilisations+orthosis (OR 38.8, 95% CrI: 7.3 to 236.9)). Education+exercise+patellar taping/mobilisations, with (OR 4.0, 95% CrI: 1.5 to 11.8) or without orthosis (OR 2.6, 95% CrI: 1.7 to 4.2), were superior to education alone. At 12 months, education or education+any combination yielded similar improvement rates.
Summary/conclusion Education combined with a physical treatment (exercise, orthoses or patellar taping/mobilisation) is most likely to be effective at 3 months. At 12 months, education appears comparable to education with a physical treatment. There was insufficient evidence to recommend a specific type of physical treatment over another. All treatments in our NMA were superior to wait and see at 3 months, and we recommend avoiding a wait-and-see approach.
PROSPERO registeration number CRD42018079502.
... Therefore, the intervention program included CKC strengthening exercises and foot orthoses. 4,23 Table 2 shows the details of each of the specific targeted intervention programs. ...
Background
Targeted intervention for subgroups is a promising approach for the management of patellofemoral pain.
Hypothesis
Treatment designed according to subgroups will improve clinical outcomes in patients unresponsive to multimodal treatment.
Study Design
Prospective crossover intervention.
Level of Evidence
Level 3.
Methods
Patients with patellofemoral pain (PFP; n = 61; mean age, 27 ± 9 years) were enrolled. Patients with PFP received standard multimodal treatment 3 times a week for 6 weeks. Patients not responding to multimodal treatment were then classified into 1 of 3 subgroups (strong, weak and tight, and weak and pronated foot) using 6 simple clinical tests. They were subsequently administered 6 further weeks of targeted intervention, designed according to subgroup characteristics. Visual analog scale (VAS), perception of recovery scale (PRS), 5-Level European Quality 5 Dimensions (EQ-5D-5L), and self-reported version of the Leeds Assessment of Neuropathic Symptoms and Signs scale (S-LANSS) were used to assess pain, knee function, and quality of life before and after the interventions.
Results
In total, 34% (n = 21) of patients demonstrated recovery after multimodal treatment. However, over 70% (n = 29/40) of nonresponders demonstrated recovery after targeted treatment. The VAS, PRS, S-LANSS, and EQ-5D-5L scores improved significantly after targeted intervention compared with after multimodal treatment ( P < 0.001). The VAS score at rest was significantly lower in the “weak and pronated foot” and the “weak and tight” subgroups ( P = 0.011 and P = 0.008, respectively). Posttreatment pain intensity on activity was significantly lower in the “strong” subgroup ( P = 0.006).
Conclusion
Targeted treatment designed according to subgroup characteristics improves clinical outcomes in patients unresponsive to multimodal treatment.
Clinical Relevance
Targeted intervention could be easily implemented after 6 simple clinical assessment tests to subgroup patients into 1 of 3 subgroups (strong, weak and tight, and weak and pronated foot). Targeted interventions applied according to the characteristics of these subgroups have more beneficial treatment effects than a current multimodal treatment program.
... The latest systematic review and meta-analysis by Smith et al (1) confirms the high incidence and prevalence rates of Patellofemoral Pain (PFP) of up to 14.9% and 28.9% respectively across a number of populations including military recruits, amateur runners and adolescent amateur athletes. However, despite this high prevalence currently there is no consensus of the best management for PFP, and a wide range of treatments have been suggested including foot orthoses, patellar taping, knee supports and physiotherapy (2,3). Little data exists which allows a clear distinction in the biomechanical presentation between individuals with and without PFP. ...
Objective: To date no study exists to determine whether knee kinematics in the coronal and transverse planes during step descent are different between healthy subjects and patients with patellofemoral pain (PFP) despite patients often reporting pain and instability during this task. This study investigated the differences in knee kinematics between healthy subjects and patients with PFP during a step descent task.
Methods: Thirty healthy subjects and 29 patients diagnosed with PFP performed a slow step descent from a 20cm step. Kinematic data were collected using a ten camera infra-red motion analysis system. Reflective markers were placed on the foot, shank and thigh using the Calibrated Anatomical Systems Technique (CAST).
Results: The coronal plane knee range of motion was 2.7 degrees, 41% greater, in the PFP patients compared to healthy subjects (p=0.006), with 4 degrees greater internal rotation although this was not significant (p=0.087). A trend towards significance was also seen between males and females (p=0.059), with females having a greater range of motion in the transverse plane than both the healthy subjects and male patients, with females with PFP showing the greatest range of motion.
Conclusions: This study further reinforces the view that coronal plane mechanics should not be overlooked when studying PFP. Future research should focus on developing more clinically viable techniques that can provide clinicians with reasonable estimates of coronal plane knee kinematics during various functional tasks, this may help identify important clinical subgroups and responders and non-responders to different interventions.
... 5 Patient education and gait retraining have been recently promoted as well but with little research support. 5 6 While there are several systematic reviews that focus on different treatments for PFP, [7][8][9][10][11][12] the comparative effectiveness of all available treatments has never been examined. This is challenging for clinicians and patients who are faced with uncertainty when presented with so many potentially beneficial treatment options. ...
Introduction Patellofemoral pain (PFP) affects 1 in every 14 adults. Many treatments for PFP have been evaluated, but the comparative effectiveness of all available treatments has never been examined. Network meta-analysis is the only design to study the comparative effectiveness of all available treatments in one synthesis. This protocol describes the methods for a systematic review including network meta-analysis to assess which treatment is most likely to be effective for patients with PFP.
Methods and analysis The primary outcome measures of this network meta-analysis are the global rating of change scale at 6–12 weeks, 13–52 weeks and >52 weeks. The secondary outcome measures are patient-rated pain scales at 6–12 weeks, 13–52 weeks and >52 weeks. Completed published and unpublished randomised controlled trials with full-text reports are eligible for inclusion. We will search Embase, PubMed (including MEDLINE), CENTRAL, Scopus, Web of Science, and CINAHL, SPORTDiscus, OpenGrey, WorldCat, conference Proceedings and multiple trial registers for relevant reports. Two researchers will appraise the study eligibility and perform data extraction. Risk of bias will be assessed with the Cochrane Risk of Bias Tool V.2.0.
Bayesian network meta-analyses will be constructed for global rating of change scale and patient-rated pain. Consistency between direct and indirect comparisons will be assessed. Between study variability will be explored, and a threshold analysis for the credibility of the network meta-analyses’ conclusions will be performed.
Ethics and dissemination Ethical approval is not required, as this study will be based on published data. The study commenced at 1 February 2018, and its expected completion date is 15 January 2019. Full publication of the work will be sought in an international peer-reviewed journal, as well as translational articles to disseminate the work to clinical practitioners.
PROSPERO registration number CRD42018079502.
... Foot Orthoses. Results from systematic reviews 45,136,137 agreed that the addition of orthoses had no greater benefit than multimodal physical therapy in improving VAS and AKPS scores at the 6-, 12-, and 52-week follow-up periods. However, orthoses should be considered an adjunctive strategy for patients who demonstrate excessive foot pronation during gait. ...
Objective: :
To present recommendations for athletic trainers and other health care providers regarding the identification of risk factors for and management of individuals with patellofemoral pain (PFP).
Background: :
Patellofemoral pain is one of the most common knee diagnoses; however, this condition continues to be one of the most challenging to manage. Recent evidence has suggested that certain risk factors may contribute to the development of PFP. Early identification of risk factors may allow clinicians to develop and implement programs aimed at reducing the incidence of this condition. To date, clinicians have used various treatment strategies that have not necessarily benefitted all patients. Suboptimal outcomes may reflect the need to integrate clinical practice with scientific evidence to facilitate clinical decision making.
Recommendations: :
The recommendations are based on the best available evidence. They are intended to give athletic trainers and other health care professionals a framework for identifying risk factors for and managing patients with PFP.
... More recently Selfe et al. [4] identified 3 distinct patellofemoral pain subgroups, one of which was 'weak and pronated' defined by strength measurement of the quadriceps and hip abductors and a foot posture index (FPI) score over 6. Currently there is no consensus about what is the best management for PFP, and a wide range of treatments have been suggested including foot orthoses, patellar taping, knee supports and physiotherapy [5]. Pitman and Jack [6] suggested that foot orthoses could be used as a first line treatment in PFP patients. ...
Background:
An increased load of the patellofemoral joint is often attributed to foot function in patients with patellofemoral pain. Foot orthoses are commonly prescribed for this condition; however the mechanisms by which they work are poorly understood. The aim of this study was to investigate the kinematics and kinetics of the knee between patellofemoral pain patients and a group of healthy subjects when using a standardised foot orthosis prescription during walking and step descent.
Method:
Fifteen healthy subjects and fifteen patients diagnosed with PFP with a foot posture index greater than 6, had foot orthoses moulded to their feet. They were asked to walk at a self-selected pace and complete a 20 cm step descent using customised orthoses with ¾ and full length wedges. Kinematic and Kinetic data were collected and modelled using Calibrated Anatomical System Technique.
Results:
Significant differences were seen in both the kinematics and kinetics between the healthy group and the PFP patients at the knee. A significant reduction in the knee coronal plane moment was found during the forward continuum phase of step descent when wearing the foot orthoses; this was attributed to a change in the ground reaction force as there were no changes reported in the kinematics of the knee with the orthoses.
Conclusions:
This study identified potentially clinically important differences in the knee mechanics between the PFP patients and the healthy group during walking and step descent. The foot orthoses reduced the coronal plane knee moment in the PFP patients to a value similar to that of the healthy subjects with no intervention.
... At present, research tends to focus on inexpensive prefabricated 563 foot orthoses, often modified to optimise patient comfort (Collins, et al., 2008;Mills, 564 Blanch, & Vicenzino, 2012). Based on current evidence, this prescription approach is 565 effective at reducing pain and improving outcomes in the short term (6 weeks) when 566 compared to a wait and see or sham device (Barton, Munteanu, Menz, & Crossley, 567 2010;Collins, et al., 2008;Hossain, Alexander, Burls, & Jobanputra, 2011;Mills, 568 M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT Blanch, Dev, Martin, & Vicenzino, 2012). Importantly, the number needed to treat 569 ranges between two and four (Collins, et al., 2008;Mills, Blanch, Dev, et al., 2012). ...
Patellofemoral pain (PFP) is one of the most prevalent conditions within sports medicine, orthopaedic and general practice settings. Long-term treatment outcomes are poor, with estimates that more than 50% of people with the condition will report symptoms beyond 5 years following diagnosis. Additionally, emerging evidence indicates that PFP may be on a continuum with patellofemoral osteoarthritis. Consensus of world leading clinicians and academics highlights the potential benefit of delivering tailored interventions, specific to an individual's needs, to improve patient outcome. This clinical masterclass aims to develop the reader's understanding of PFP aetiology, inform clinical assessment and increase knowledge regarding individually tailored treatment approaches. It offers practical application guidance, and additional resources, that can positively impact clinical practice.
... The objective of this systematic review, as a sub group analysis of the overall work, was to identify and review the evidence from randomised controlled trials (RCTs) to assess effectiveness and cost-effectiveness of prosthetic and orthotic interventions. While an extensive number of systematic reviews have examined the specific prosthetic [9][10][11][12][13][14][15] and orthotic [16][17][18][19][20] interventions in the treatment of specific medical conditions and/or injuries, as such no one has completed an overall examination of orthotic and prosthetic interventions across healthcare. This review also provides an opportunity to provide an update to previous systematic reviews in the area, as more recent research is now available for many of the previously published systematic reviews. ...
Background
Assistive products are items which allow older people and people with disabilities to be able to live a healthy, productive and dignified life. It has been estimated that approximately 1.5% of the world’s population need a prosthesis or orthosis.
Objective
The objective of this study was to systematically identify and review the evidence from randomized controlled trials assessing effectiveness and cost-effectiveness of prosthetic and orthotic interventions.
Methods
Literature searches, completed in September 2015, were carried out in fourteen databases between years 1995 and 2015. The search results were independently screened by two reviewers. For the purpose of this manuscript, only randomized controlled trials which examined interventions using orthotic or prosthetic devices were selected for data extraction and synthesis.
Results
A total of 342 randomised controlled trials were identified (319 English language and 23 non-English language). Only 4 of these randomised controlled trials examined prosthetic interventions and the rest examined orthotic interventions. These orthotic interventions were categorised based on the medical conditions/injuries of the participants. From these studies, this review focused on the medical condition/injuries with the highest number of randomised controlled trials (osteoarthritis, fracture, stroke, carpal tunnel syndrome, plantar fasciitis, anterior cruciate ligament, diabetic foot, rheumatoid and juvenile idiopathic arthritis, ankle sprain, cerebral palsy, lateral epicondylitis and low back pain). The included articles were assessed for risk of bias using the Cochrane Risk of Bias tool. Details of the clinical population examined, the type of orthotic/prosthetic intervention, the comparator/s and the outcome measures were extracted. Effect sizes and odds ratios were calculated for all outcome measures, where possible.
Conclusions
At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness.
... A Cochrane review found that foot orthoses may provide pain relief in the short term for this population. 29 Additional systematic reviews have found that when combined with other interventions, patellar taping and various therapeutic modalities may be beneficial in reducing pain. 30,31 In our systematic review, joint mobilization when combined with co-interventions was frequently associated with short-term pain relief and functional improvement in the experimental group. ...
Objective:
To investigate and synthesize the effects of joint mobilization on individuals with patellofemoral pain syndrome.
Data sources:
Five electronic databases (CINAHL, the Cochrane Central Register of Controlled Trials, PubMed, Scopus, and SPORTDiscus) were used.
Review methods:
Each database was searched from inception to 1 November 2017. Randomized controlled trials investigating a manual therapy intervention, with or without co-interventions, for persons with patellofemoral pain were included. Two reviewers independently screened the retrieved literature and appraised the quality of the selected studies using the PEDro rating scale. A third reviewer was used in cases of discrepancy to create a consensus.
Results:
A total of 361 articles were identified in the search. Twelve randomized trials with a total of 499 participants were selected for full review. Within-group improvements in pain and function were noted for the manual therapy groups. Between-group improvements for short-term outcomes (three months or less) were greatest when joint mobilization was directed to the knee complex and used as part of a comprehensive approach.
Conclusion:
In the articles reviewed, joint mobilization appears to be most effective in improving pain and function when coupled with other interventions, although its discrete effect is unclear due to the reviewed studies’ design and reporting.
Keywords: knee, manipulation, manual therapy, pain, patellofemoral
... The comparator Usual physiotherapy typically involves strengthening exercises [55][56][57], taping [17,58], stretches [59] and foot orthoses [60], and these are often aimed at restoring the assumed patella malalignment [16,17]. The comparator will be usual physiotherapy as directed by the normal assessment and clinical decisionmaking by the treating physiotherapist. ...
Background
Patellofemoral pain (PFP) is one of the most common forms of knee pain in adults under the age of 40, with a prevalence of 23% in the general population. The long-term prognosis is poor, with only one third of people pain-free 1 year after diagnosis.
The biomedical model of pain in relation to persistent PFP has recently been called into question. It has been suggested that interventions for chronic musculoskeletal conditions should consider alternative mechanisms of action, beyond muscles and joints. Modern treatment therapies should consider desensitising strategies, with exercises that target movements and activities patients find fearful and painful.
High-quality research on exercise prescription in relation to pain mechanisms, not directed at specific tissue pathology, and dose response clearly warrants further investigation.
Our primary aim is to establish the feasibility and acceptability of conducting a definitive RCT which will evaluate the clinical and cost-effectiveness of a loaded self-managed exercise programme for people with patellofemoral pain.
Method
This is a single-centred, multiphase, sequential, mixed-methods trial that will evaluate the feasibility of running a definitive large-scale randomised controlled trial of a loaded self-managed exercise programme versus usual physiotherapy. Initially, 8–10 participants with a minimum 3-month history of PFP will be recruited from an NHS physiotherapy waiting list and interviewed. Participants will be invited to discuss perceived barriers and facilitators to exercise engagement, and the meaning and impact of PFP. Then, 60 participants will be recruited in the same manner for the main phase of the feasibility trial. A web-based service will randomise patients to a loaded self-managed exercise programme or usual physiotherapy. The loaded self-managed exercise programme is aimed at addressing lower limb knee and hip weakness and is positioned within a framework of reducing fear/avoidance with an emphasis on self-management. Baseline assessment will include demographic data, average pain within the last week (VAS), fear avoidance behaviours, catastrophising, self-efficacy, sport and leisure activity participation, and general quality of life. Follow-up will be 3 and 6 months. The analysis will focus on descriptive statistics and confidence intervals. The qualitative components will follow a thematic analysis approach.
Discussion
This study will evaluate the feasibility of running a definitive large-scale trial on patients with patellofemoral pain, within the NHS in the UK. We will identify strengths and weaknesses of the proposed protocol and the utility and characteristics of the outcome measures. The results from this study will inform the design of a multicentre trial.
Trial registration
ISRCTN35272486.
... Magnitude of effects: Either as stand-alone treatment or mostly in combination with other treatments, aids and devices for musculoskeletal pain have generally shown small effects (see supplementary S5 Table) on pain, function or work outcomes [16, 20, 38, 58, 66, 77, [131][132][133]. Routine use of collars has not been found to confer any clinically significant benefits for neck pain [38,58,66,133]. ...
Background & aims
Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.
Methods
A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.
Results
Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.
Conclusion
This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
... 95 However, other studies have not found any effects of foot orthoses on clinical outcome in patients with PFP. 96 This heterogeneity in study results demonstrates that there may be substantial variations in individual responses to this treatment and that foot orthoses may not be beneficial for all patients with PFP. 2 Patients with foot abnormalities, such as those with increased rearfoot eversion or pes pronatus, may benefit the most from foot orthotics. Therefore, foot orthoses might be a treatment option for patients with the combination of disorders of foot posture and PFPS. ...
Wolf Petersen,1 Ingo Rembitzki,2 Christian Liebau3 1Department of Orthopaedic and Trauma Surgery, Martin Luther Hospital, Grunewald, Berlin; 2German Sport University Cologne, 3Asklepios Clinic, Bad Harzburg, Germany Abstract: Patellofemoral pain (PFP) is a frequent cause of anterior knee pain in athletes, which affects patients with and without structural patellofemoral joint (PFJ) damage. Most younger patients do not have any structural changes to the PFJ, such as an increased Q angle and a cartilage damage. This clinical entity is known as patellofemoral pain syndrome (PFPS). Older patients usually present with signs of patellofemoral osteoarthritis (PFOA). A key factor in PFPS development is dynamic valgus of the lower extremity, which leads to lateral patellar maltracking. Causes of dynamic valgus include weak hip muscles and rearfoot eversion with pes pronatus valgus. These factors can also be observed in patients with PFOA. The available evidence suggests that patients with PFP are best managed with a tailored, multimodal, nonoperative treatment program that includes short-term pain relief with nonsteroidal anti-inflammatory drugs (NSAIDs), passive correction of patellar maltracking with medially directed tape or braces, correction of the dynamic valgus with exercise programs that target the muscles of the lower extremity, hip, and trunk, and the use of foot orthoses in patients with additional foot abnormalities. Keywords: anterior knee pain, dynamic valgus, hip strength, rearfoot eversion, single leg squat, hip strength
... Detection of the mechanical consequences of the AN may have implications for the prevention and/or treatment of patellofemoral complaints. For example, the use of soft foot orthotics is an effective mean of treatment for the patient with patellofemoral pain syndrome and can correct foot pronation (Hossain et al., 2011;Pinto et al., 2012). ...
Quadriceps angle (Q angle) provides useful information about the alignment of the patellofemoral
joint. The aim of the present study was to assess a possible link between malalignment
of the patellofemoral joint and symptomatic accessory navicular (AN) bone as an underlying
cause in early adolescence using Q angle measurements.
This study was performed on patients presenting to the Foot and Ankle Clinic at the Jordanian
Royal Medical Services because of pain on the medial side of the foot that worsened
with activities or shoe wearing, with no history of knee pain, between September 2013 and
April 2015. The Q angle was measured using a goniometer in 27 early adolescents aged 10-18
years diagnosed clinically and radiologically with symptomatic AN bone, only seven patients
had associated pes planus deformity; the data were compared with age appropriate normal
arched feet without AN. Navicular drop test (NDT) was used to assess the amount of foot
pronation.
The mean Q angle value among male and female patients with symptomatic AN with/without
pes planus was significantly higher than in controls with normal arched feet without AN
(p<0.05). Symptomatic AN feet were also associated with higher NDT values (p<0.001).
The present findings suggest an early change in patellofemoral joint alignment in patients with
symptomatic AN bone with/without arch collapse. Therefore, it is recommended that Q angle
assessment should be an essential component of the examination in patients with symptomatic
AN bone.
... 8 PFPS often becomes a chronic condition that may fail to respond to conservative measures 9 and is more common in the female population. 9,10 Therapeutic exercise, [11][12][13][14][15][16] bracing, 17,18 taping, 19,20 and orthotics 21,22 have all shown some level of benefit in the treatment of PFPS; however, there is paucity in the literature regarding the effects of joint mobilization in the treatment of chronic PFPS. As a result, joint mobilization may be less considered in routine physical therapy care in those with chronic PFPS as there is little evidence to support its effectiveness in managing pain and function in this population. ...
Background and purpose:
Patellofemoral pain syndrome (PFPS) is a common source of anterior knee pain. Controversy exists over the exact clinical findings which define PFPS, thus, diagnosis and management can be challenging for clinicians. There is paucity in the literature concerning joint mobilization as treatment for PFPS, particularly at the tibiofemoral joint, as standard management is currently focused on therapeutic exercise, orthotics, bracing and taping. Therefore, the purpose of this case report is to describe the effects of tibiofemoral joint mobilization in the successful treatment of an individual with chronic PFPS as it relates to pain, function and central processing of pain.
Study design:
Case Report.
Case description:
The subject was a 28-year-old female with a two year history of left anterior, inferior patellar knee pain consistent with chronic PFPS. She demonstrated diminished pressure pain threshold (PPT) and allodynia at the anterior knee, suggesting a component of central sensitization to her pain. She met several common diagnostic criteria for PFPS, however, only tibiofemoral anterior-posterior joint mobilization increased her pain. Subsequent treatment sessions (Visits 1-6) consisted of solely joint mobilization supplemented by instruction in a home exercise program (therapeutic exercise and balance training). As outcomes improved, treatment sessions (Visits 7-8) consisted of solely therapeutic exercise and balance training with focus on return to independent pain free functional activity.
Outcomes:
Improvements consistent with the minimally clinically important difference were noted on the Kujala Anterior Knee Pain Scale, Numeric Pain Rating Scale, Global Rating of Change (GROC). Scores on the Fear Avoidance-Belief Questionnaire (6/24 to 2/24 PA, 31/42 to 5/42 W), PPT (119 to 386 kPa) and Step Down Test (11 to 40 steps) also demonstrated improvement. At a two month follow up, the subject reported continued improvement in functional activity, 0/10 pain and GROC = +5.
Discussion:
This case describes the successful use of tibiofemoral joint mobilization in a subject with chronic PFPS and supports the use of joint mobilization as management in PFPS, particularly in cases where a centrally mediated component of pain may be present.
Level of evidence:
Therapy, Level 5.
... The mean number of NHS physiotherapy treatment sessions for patients referred with PFP is reported as eight with the maximum number of sessions reported as 17 [12]. The Cochrane Library lists 4 current reviews [13,14,15,16]; 2 withdrawn reviews [17,18] . This group has also highlighted the need for future studies to adopt a sub-grouping targeted approach in order to improve our understanding of the mechanisms underlying musculoskeletal problems to optimise patient management. ...
... 127,128 A recent Cochrane Review concluded that "while foot orthoses may help relieve knee pain over the short term, the benefit may be marginal." 129 Several issues may explain the discrepancies and minimal effects of foot orthoses reported in the literature, including underpowered sample sizes 130 and a failure to screen for lower-extremity mechanics that may influence response to an orthosis. Predictors for response to foot orthoses include lower baseline pain levels, increased midfoot mobility (change in midfoot width between non-weight-bearing and weightbearing), reduced ankle dorsiflexion, and use of less supportive shoes. ...
Patellofemoral pain is characterized by insidious onset anterior knee pain that is exaggerated under conditions of increased patellofemoral joint stress. A variety of risk factors may contribute to the development of patellofemoral pain. It is critical that the history and physical examination elucidate those risk factors specific to an individual in order to prescribe an appropriate and customized treatment plan. This article aims to review the epidemiology, risk factors, diagnosis, and management of patellofemoral pain.
... There is minimal evidence for any benefit of custom orthoses over generic shoe inserts or physiotherapy treatment (22) . In fact patients treated with orthoses are more likely to suffer mild adverse effects (23) . ...
... Reviews of taping and foot orthoses conclude that there is limited evidence for their long term effectiveness in pain when combined with exercises, compared to exercise alone (Hossain et al., 2011;Callaghan and Selfe, 2012;Barton et al., 2014). Taping has shown some benefit in terms of short term pain reduction, and it is it thought current best practice to tailor the application to control specific patella movement, i.e. lateral tilt, glide and spin (Barton et al., 2015). ...
Background:
Insoles are commonly prescribed to treat pathologies in a variety of patient groups; however, there is limited evidence to guide clinical decision-making. A well-validated sham insole is critical to conducting a double-blind placebo-controlled trial.
Objectives:
The aims were to establish: (1) How are sham insoles constructed? (2) What measures are undertaken to ensure adequate blinding? (3) What methods are used to validate the biomechanical effects?
Study design:
A systematic search of the methodology of level I-II therapeutic evidence.
Methods:
Searches were conducted in MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials. Inclusion criteria were placebo-controlled clinical trials, sham insoles used, treatment insoles alter biomechanics, treatment insoles meet the ISO definition of foot orthotics, sham and treatment insoles tested in normal walking, and article available in English.
Results:
The search generated 270 results. Twenty-four trials were included. 19% of sham insoles were described sufficiently to be replicated. The most common sham construction characteristics were full length, ethylene-vinyl acetate material, and flat insoles. 58% of studies were double-blinded; however, many did not describe any blinding methods. There is evidence that blinding the intervention details and a similar insole appearance is effective to blind participants. 13% of studies included a shoe-only condition to allow assessment of the biomechanical effects of sham insoles.
Conclusions:
There is inconsistent construction, blinding, and biomechanical validation of sham insoles. This casts a substantial doubt on the quality and reliability of the evidence base to support the prescription of insoles.
Anterior knee pain is common in track and field athletes mostly due to overuse. Risk factors play a relevant role, and a correct diagnosis is fundamental. Athlete’s symptoms and physical examination findings are important. Imaging modalities may give additional information. Conservative therapy aimed to the correction of the causative factors is effective in the majority of cases. When conservative measures fail, focused surgical procedures may be effective.
Introduction / Background: In the period of evidence-based medicine orthopedic insoles and orthoses require evidence of efficacy as every other form of medical therapy. Providing such evidence is in the best interest of patients as well as funders in the health care systems. This review of literature has the objective to present the current state of evidence for a prescription of insoles and foot orthoses for different indications, to identify therapies which have not been proved effective yet with scientifically qualitative and quantitative evidence and to identify promising and relevant concepts of orthoses and insoles for further clinical trials. Material and Methods: A structured research of literature was conducted in two medical databases (PubMed and Cochrane); after screening all results and applying exclusion criteria it revealed 277 clinical trials, reviews and meta-analyses as well as further scientific studies covering more than 20 different areas of indication. Before completion of this review an update was conducted. Results: In general, the number and quality of the available articles concerning orthopedic in-soles and foot orthoses presents as low and poor, especially when considering their widespread use. Ailments like diabetic foot syndrome or rheumatoid arthritis can be treated with insoles and orthoses, at least as an adjuvant therapy. For the frequently discussed unicompartimental osteoarthritis of the knee there are certain hints of efficacy for a concept of elevating the insoles’ rims, however the data situation is insufficient. Beyond that there are single trials for many indications which claim to prove efficacy, yet the number of trials and quality of designs often prevents generating scientific evidence. Superiority of customized insults over off-the-shelf insoles has not been proved yet either. Discussion / Conclusion: At large, there is a current lack of high-quality clinical trials with sufficient follow-up intervals and population sizes which are necessary to conduct for creating a base of evidence for the future.
Context:
Plantar fasciitis (PF) is a common condition in active individuals. The lack of agreement on PF etiology makes treatment challenging and highlights the importance of understanding risk factors for preventive efforts.
Objective:
The purpose of this systematic review and meta-analysis was to determine what factors may put physically active individuals at risk of developing PF.
Data sources:
CENTRAL, CINAHL, EMBASE, Gray Lit, LILACS, MEDLINE (PubMed), ProQuest, Scopus, SPORTDiscus, and Web of Science were searched through April 2018 and updated in April 2020.
Study selection:
Studies were included if they were original research investigating PF risk factors, compared physically active individuals with and without PF, were written in English, and were accessible as full-length, peer-reviewed articles.
Study design:
Systematic review and meta-analysis.
Level of evidence:
Level 3, because of inconsistent definitions and blinding used in the included observational studies.
Data extraction:
Data on sample characteristics, study design and duration, groups, PF diagnosis, and risk factors were extracted. The methodological quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology statement. When means and standard deviations of a particular risk factor were presented 2 or more times, that risk factor was included in the meta-analysis.
Results:
Sixteen studies were included in the systematic review and 11 risk factors in the meta-analysis. Increased plantarflexion range of motion (weighted mean difference [MD] = 7.04°; 95% CI, 5.88-8.19; P < 0.001), body mass index (MD = 2.13 kg/m2; 95% CI, 1.40-2.86; P < 0.001; I2 = 0.00%), and body mass (MD = 4.52 kg; 95% CI, 0.55-8.49; P = 0.026) were risk factors for PF.
Conclusion:
Interventions focused on addressing a greater degree of plantarflexion range of motion, body mass index, and body mass and their load on the force-absorbing plantar surface structures may be a good starting point in the prevention and treatment of active individuals with PF.
Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.
Background:
Various factors predispose athletes to anterior knee pain (AKP), making a holistic assessment with rehabilitation inevitable. Due to minimal rehabilitation services in under-resourced communities, runners are less likely to report this injury to medical professionals compared to runners in better resourced communities.
Objective:
The purpose of this study was to report on the prevalence of AKP among runners in under-resourced communities and to determine the extrinsic risk factors for this injury.
Methods:
This was a cross-sectional study of 347 runners in total. Convenience sampling was used to recruit 183 participants aged between 13 and 55 years with no previous history of knee surgeries, traumatic or degenerative knee conditions. Questionnaires were used to collect data on the prevalence of AKP and extrinsic risk factors. The SPSS (version 25) was used to analyse the data. Data were presented as frequencies and percentages and the results from chi-square and logistic regression tests were provided.
Results:
Forty percent (40%) of participants presented with AKP, particularly males (n=106, 58%), young runners (n=94, 51%) and those with 3-5 years of running experience (n=57, 31%). Anterior knee pain was associated with age (X2=6.484, p=0.039) and running experience (X2=8.39, p=0.04). The following extrinsic risk factors contributed to AKP significantly: training load (p=0.04, odds ratio [OR]=1.23), warm-up (p=0.04, OR=1.57)' running shoe condition (p=0.04, OR=0.14) and running surface (p=0.05, OR=1.2).
Conclusion:
A substantial presence of AKP and its extrinsic risk factors were found among all participants. These outcomes suggest that extrinsic risk factors should also be considered when managing AKP among runners.
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.
Zusammenfassung
Der vordere Knieschmerz ist häufig. Strukturelle als auch funktionelle Ursachen sind frühzeitig zu erheben um eine kausale Therapie zu planen und durchzuführen.
Der vordere Knieschmerz tritt häufig chronisch rezidivierend auf und führt zu langen Sportpausen oder gar zur Beendigung der sportlichen Karriere.
Beim vorderen Knieschmerz ist in der Mehrzahl der Fälle von einem multifaktoriellen Geschehen auszugehen.
Trotz der Häufigkeit des vorderen Knieschmerzes existiert kein allgemein akzeptierter diagnostischer und therapeutischer Algorithmus.
Im Beitrag wird eine differenzierte Anamnese- und Befunderhebung als Grundlage einer individualisierten Behandlung vorgestellt, die sich bei vorderem Knieschmerz als konservativer Therapieansatz bewährt hat.
Anterior knee pain (AKP) is a prevalent musculoskeletal condition characterised by a mechanical pain perceived in the anterior region of the knee exacerbated by activity and relieved by rest. AKP often has a poor prognosis and can significantly impact daily activities as well as participation in physical activity.
The incidence of “anterior knee pain” is high and the aetiopathogenesis is multifactorial, and a lot of intrinsic and extrinsic factors can be involved.
The patient history and the clinical examination associated and an accurate imaging are necessary to do a diagnosis that in this pathology is of exclusion.
The literature provides evidence for a multimodal and individualised nonoperative therapy concept with short-term use of NSAIDs, short-term use of a medially directed tape and complex exercise programmes with the inclusion of the lower extremity and hip and trunk muscles.
The surgical treatment is necessary only in selected cases and is important to avoid unnecessary surgery because its consequences are often the cause of pain.
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.
Patellofemoral pain syndrome (PFPS)—also known as runner’s knee—and patellar tendinopathy (PT) pose a significant challenge to orthopaedic surgeons treating recreational and professional athletes. The purpose of this chapter is to review the strategies available for treatment of PFPS and PT. A bibliographic search was conducted for papers published until 2012. The review comprised 37 articles addressing the treatment of PFPS and PT. Articles were included if they specifically addressed the treatment of PFPS and PT. Both conservative and surgical treatment options are proposed in the literature. Non-surgical treatment options include physical therapy, patellar taping and foot orthoses, extracorporeal shock wave therapy (ESWT), and different injection treatments. Physical therapy is indicated to strengthen the quadriceps muscles and should be combined with hip strengthening exercises. Open and closed kinetic chain exercises have been shown to be equally effective and patellar taping and foot orthoses may augment the benefits gained from quadriceps exercises. If carefully followed conservative non-surgical treatment is unsuccessful after 3–6 months, surgical intervention may be an option in motivated recreational and professional athletes suffering from PT. No study indicates that surgical treatment of PT is in any way superior to eccentric strength training. Open surgical techniques include longitudinal splitting of the tendon, resection of any pathological tissue encountered, and patellar drilling through Hoffa’s fat pad. Arthroscopic procedures such as shaving of the dorsal aspect of the proximal patellar tendon, removal of any hypertrophic synovitis from the inferior pole of the patella and débridement of the patellar tendon with resection of the distal patella seem to be as effective as open surgical approaches.
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]
Measurement of calcaneal inversion and eversion during walking is limited when subjects wear shoes. The authors of this study propose the use of transverse tibial rotation as a viable alternative measurement when barefoot assessment is not possible. The purpose of this study, therefore, was to: 1) determine the relationship between transverse tibial rotation and rearfoot motion during the stance phase of normal walking and 2) demonstrate the usefulness of measuring transverse tibial rotation when evaluating the effect of footwear and insole foot orthotic devices. Part 1 consisted of eight volunteers (five women, three men) whose rearfoot and transverse tibial motion was videotaped while they walked along a 12-m walkway. The results of this study showed that although absolute values were not comparable, the two motion patterns are related to each other. The correlation between the mean rearfoot and tibial motion patterns of all 16 feet was r = .953. Part 2 investigated the effect of footwear and orthotics on transverse tibial rotation using two case presentations. A video camera was positioned in front of each subject as they walked at a self-selected speed under various footwear or orthotic conditions. The results of the case studies revealed that footwear or foot orthotics decrease maximum tibial internal rotation compared with barefoot walking. In addition, internal tibial rotation velocity and acceleration were decreased by the use of shoes, an accommodative orthosis, and an inflatable medial longitudinal arch support. A rigid orthotic produced a slight increase in transverse tibial rotation and a dramatic increase in transverse tibial acceleration.(ABSTRACT TRUNCATED AT 250 WORDS)
Patellofemoral pain syndrome is a frequently reported condition in active adults. A wide variety of conservative treatment strategies have been described. As yet, no optimal strategy has been identified. Application of orthotic devices e.g. knee braces, knee straps, forms of taping of the knee, active training devices, knee sleeves and in-shoe orthotics to support the foot have been advocated to treat this condition.
To assess the effectiveness of foot and knee orthotics for treatment of patellofemoral pain syndrome.
We searched the Cochrane Musculoskeletal Injuries Group specialised register (December 2001), the Cochrane Controlled Trials register (Issue 2, 2000), MEDLINE (January 1966 to March 2000; EMBASE (January 1988 to March 2000); CINAHL (January 1982 to March 2000) and PEDro (up to March 2000). Relevant orthotic companies were contacted.
All randomised and quasi-randomised trials comparing the effectiveness of knee or foot orthotics for treatment of patellofemoral pain syndrome were selected. Trials describing the use of orthotic devices in conjunction with operative treatment were excluded.
Three reviewers independently assessed methodological quality of the identified trials by use of a modified version of the Cochrane Musculoskeletal Injuries Group assessment tool, consisting 11 items. Two reviewers extracted data without blinding. Trialists were contacted to obtain missing data.
Five trials involving 362 participants were included in this review. Five other trials await possible inclusion if further information can be obtained and one awaits further assessment. Due to clinical heterogeneity, we refrained from statistical pooling and conducted analysis by grading the strength of scientific evidence. The level of obtained research-based evidence was graded as limited as all trials were of low methodological quality. This limited research-based evidence showed the Protonics orthosis at six week follow-up was significantly more effective for decrease in pain (weighted mean difference (WMD) between groups 3.2; 95% confidence interval (CI) 2.8 to 3.6), functional improvement on the Kujala score (WMD 45.6; 95% CI 43.4 to 47.7) and change in patellofemoral congruence angle (WMD 17.2; 95% CI 14.1 to 20.3) when compared to no treatment. A comprehensive programme including tape application was significantly superior to a monitored exercise programme without tape application for decrease in worst pain (WMD 1.6; 95% CI 0.4 to 2.8) and usual pain (WMD 1.2; 95% CI 0.2 to 2.1), and clinical change and functional improvement questionnaire scores (WMD 10, 95% CI 2.07 to 17.93) at four weeks follow-up. The trials reported statistically significant differences in patient satisfaction after applied therapy (WMD 3.3; 95% CI 0.5 to 6.1) in favour of the McConnell regimen compared with the Coumans bandage at six weeks follow-up.
The evidence from randomised controlled trials is currently too limited to draw definitive conclusions about the use of knee and foot orthotics for the treatment of patellofemoral pain. Future high quality trials in this field are warranted.
Systematic review of the literature.
To develop a grading scale to judge the quality of randomized clinical trials (RCTs) and conduct a systematic review of the published RCTs that assess nonoperative treatments for patellofemoral pain syndrome (PFPS).
Systematic reviews of the quality and usefulness of clinical trials allow for efficient synthesis and dissemination of the literature, which should facilitate clinicians' efforts to incorporate principles of evidence-based practice in the clinical decision-making process.
Using a scale based on criteria in the Cochrane Collaboration Handbook, we sought to critically appraise the methodology used in RCTs related to the nonoperative management of PFPS, synthesize and interpret our results, and report our findings in a user-friendly fashion. A scale to assess the methodological quality of trials was designed and pilot tested for its content and reliability. Published RCTs identified during a literature search were then selected and rated by 6 raters. We used predefined cutoff scores to identify specific weaknesses in the clinical research process that need to be improved in future clinical trials.
The quality scale we developed was demonstrated to be sufficiently reliable to warrant interpretation of the reviewers' findings. The percentage of trials that met a minimum level of quality for each specific criterion ranged from a low of 25% for the adequacy of the description of the randomization procedure to a high of 95% for the description and standardization of the intervention.
Based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with PFPS were acupuncture, quadriceps strengthening, the use of a resistive brace, and the combination of exercises with patellar taping and biofeedback. The use of soft foot orthotics in patients with excessive foot pronation appeared useful in decreasing pain. In addition, at a short-term follow-up, patients who received exercise programs were discharged earlier from physical therapy. Unfortunately, most RCTs reviewed contained qualitative flaws that bring the validity of the results into question, thus diminishing the ability to generalize the results to clinical practice. These flaws were primarily in the areas of randomization procedures, duration of follow-up, control of cointerventions, assurance of blinding, accountability and proper analysis of dropouts, number of subjects, and the relevance of outcomes. Also, given the limited number of high-quality clinical trials, recommendations about supporting or refuting specific treatment approaches may be premature and can only be made with caution.
There have been numerous reports about the use of knee braces to prevent traumatic knee injuries. Despite the frequent use of braces, very few prospective studies have been performed to study the effect of knee braces for preventing anterior knee pain syndrome (AKPS). The purpose of this study was to assess the effectiveness of a dynamic patellofemoral brace (On-Track System, dj Orthopedics) in the prevention of AKPS. 167 military recruits without history of knee pain were randomized into two groups prior to the start of their 6-week basic military training (BMT) program. The first group (brace group) consisted of 54 recruits who wore the braces for all physical activities during these 6 weeks. 113 recruits served as a control group, and followed the same 6-week strenuous training program. Chi square statistics (Fisher exact test) were used to compare the number of AKPS patients in the brace group and in the non-brace group. Our results indicated that recruits in the brace group appeared to develop significantly less anterior knee pain compared to the recruits in the control group (p=0.020). Out of the 54 recruits in the brace group, ten (18.5%) developed anterior knee pain during this study. In the control group (n=113), 42 recruits (37%) developed anterior knee pain. We conclude that the result of the present study suggests that the use of a dynamic patellofemoral brace is an effective way to prevent the development of anterior knee pain in persons undergoing a strenuous training program.
Objective:
To compare the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome with flat inserts or physiotherapy, and to investigate the effectiveness of foot orthoses plus physiotherapy.
Design:
Prospective, single blind, randomised clinical trial.
Setting:
Single centre trial within a community setting in Brisbane, Australia.
Participants:
179 participants (100 women) aged 18 to 40 years, with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks' duration, who had no previous treatment with foot orthoses or physiotherapy in the preceding 12 months.
Interventions:
Six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy.
Main outcome measures:
Global improvement, severity of usual and worst pain over the preceding week, anterior knee pain scale, and functional index questionnaire measured at 6, 12, and 52 weeks.
Results:
Foot orthoses produced improvement beyond that of flat inserts in the short term, notably at six weeks(relative risk reduction 0.66,99%confidence interval 0.05 to 1.17; NNT 4 (99% confidence interval 2 to 51). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses. All groups showed clinically meaningful improvements in primary outcomes over 52 weeks.
Conclusion:
While foot orthoses are superior to flat inserts according to participants' overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain. Given the long term improvement observed in all treatment groups, general practitioners may seek to hasten recovery by prescribing prefabricated orthoses.
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.
Foot orthoses are commonly dispensed for musculoskeletal complaints of the foot and lower limb. Few randomized clinical trials evaluate the clinical effectiveness of foot orthoses.
In this randomized clinical trial with a crossover design, 42 participants wore custom orthoses and prefabricated inserts in their regular footwear for 4 weeks each, consecutively. Twenty-seven participants received prefabricated inserts first and 13 received custom orthoses first. A numeric pain rating scale (possible score, 0-10) was used to measure participant pain.
Statistically and clinically important decreases in pain were reported after 3 weeks by participants wearing custom orthoses first (-1.39 pain units, t(12) = 2.70, P = .02). Participants who wore prefabricated inserts first reported no statistically significant change in pain. When the alternative intervention was introduced, participants now wearing prefabricated inserts had greater pain after 1 and 2 weeks (1.1 pain units, t(12) = 3.09, P = .01 and 0.9 pain units, t(12) = 2.65, P = .02, respectively). Participants now wearing custom orthoses did not demonstrate significantly lower pain at any week compared with the second baseline but did have significantly lower pain scores compared with their initial baseline scores (-0.81 pain units, t(12) = 2.31, P = .03).
Full-contact custom-made foot orthoses provide symptomatic relief after 3 weeks of use for patients with lower-extremity musculoskeletal pain if they are prescribed as the initial treatment.
To develop a clinical prediction rule to identify patients with patellofemoral pain (PFP) who are more likely to benefit from foot orthoses.
Posthoc analysis of one treatment arm of a randomised clinical trial.
Single-centre trial in a community setting in Brisbane, Australia.
42 participants (mean age 27.9 years) with a clinical diagnosis of PFP (median duration 36 months).
Foot orthoses fitted by a physiotherapist.
Five-point global improvement scale at 12-week follow-up, dichotomised with marked improvement equalling success.
Potential predictor variables identified by univariate analyses were age, height, pain severity, anterior knee pain scale score, functional index questionnaire score, foot morphometry (arch height ratio, mid-foot width difference from non-weight bearing to weight bearing) and overall orthoses comfort. Parsimonious fitting of these variables to a model that explained success with orthoses identified the following: age (>25 years), height (<165 cm), worst pain visual analogue scale (<53.25 mm) and a difference in mid-foot width from non-weight bearing to weight bearing (>10.96 mm). The pretest success rate of 40% increased to 86% if the patient exhibited three of these variables (positive likelihood ratio 8.8; 95% CI 1.2 to 66.9).
Post-hoc analysis identified age, height, pain severity and mid-foot morphometry as possible predictors of successful treatment of PFP with foot orthoses, thereby providing practitioners with information for prescribing foot orthoses in PFP and stimulating further research.
This project was supported by a grant from the Physiotherapy Foundation of Canada. The purpose of this study was to determine the reliability and validity of the following outcome measures in a group of 18 patients with patellofemoral pain syndrome: the visual analog pain scale (VAS), a functional index questionnaire (FIQ), selected temporal components of gait on level walking and ascending stairs, knee joint angle on downhill walking, and electromyographic activity of the quadriceps during stair climbing. Subjects were tested at initial assessment (time 0), after 24 hours (time 1), and after clinically significant improvement, following a course of treatment (time 2). Using the intraclass correlation coefficient (r1), the VAS (r1 = 0.603) and FIQ (r1 = 0.483) exhibited poor day-to-day reliability (time 0 versus time 1). However an ANOVA between time 0 and time 2 showed them to be valid measures for detection of clinical change (p < 0.01). No differences in the gait variables were observed from time 0 to time 1 or time 2, suggesting that gait analysis may not be sensitive enough to detect changes in pain and function in this patient population. J Orthop Sports Phys Ther 1989;10(8):302-308.
Excessive foot pronation has been speculated to be a cause of leg and foot problems among runners. Foot orthotic devices are often used to modify this condition. Examination of the records of 180 patients treated for various running injuries showed that 83 individuals (46%) were prescribed orthotic devices and that 65 of these runners (78%) were able to return to their previous running programs. In order to assess further the effects of this type of orthotic device, six runners were selected from this group and filmed using two cameras (200 frames/sec) under three conditions: (1) barefoot, (2) regular shoe, and (3) regular shoe plus orthotic device. Both the period of pronation and the amount of maximum pronation were significantly reduced by using the foot orthotic device. The data support the conclusion that foot orthotic devices can be successfully used to modify selected aspects of lower extremity mechanics during the support phase of running.
To develop and validate a knee pain scale (KPS) for use with osteoarthritis (OA) of the knee.
Patients with documented evidence of knee OA completed the KPS and a test battery including measures of physical functioning, physical performance, and depression. Analyses were conducted to confirm the 4-factor structure of the measure, determine alpha reliabilities, assess the test-retest reliability, and examine the construct validity of the KPS.
Confirmatory factor analysis revealed that the KPS has 4 subscales, including frequency and intensity of pain experienced during both ambulation/climbing and transfer activities. All reliabilities were in excess of 0.80 and the subscales of the KPS shared expected variance with both self-reported and objective indices of dysfunction.
The KPS has good psychometric properties for assessing pain experienced in conjunction with the performance of activities of daily living. Although at present it is a research tool, with further study it should prove valuable in clinical practice as well.
Although foot orthotics are often prescribed to alter the lower-extremity mechanics during the stance period of gait, there is little documentation of the actual effect of foot orthotics on the movement of the lower-extremity joints during walking and running. This study examined the effect of foot orthotics on the range of motion of the talocrural/subtalar joint and the knee joint in three dimensions during walking and running.
Ten female adolescent subjects, aged 13 to 17 years (X = 14.4, SD = 1.1) who were diagnosed with patellofemoral pain syndrome and exhibited forefoot varus greater than 6 degrees and/or calcaneal valgus greater than 6 degrees participated in the study.
Thirty strides of walking and running on a treadmill were recorded for each of the orthotic and nonorthotic conditions for each subject using an optoelectronic recording technique. Analyses of variance for repeated measures were performed on the range of motion of the talocrural/subtalar joint and knee joint for each plane of motion (ie, six separate analyses). The main factors of each analysis were the effect of the orthotic (orthotic condition versus nonorthotic condition), mode of ambulation (walking and running), and phase of the stance period (contact, mid-stance, and propulsion).
No differences were found in sagittal-plane movements. Reductions of 1 to 3 degrees occurred with orthotic use for the talocrural/subtalar joint during walking and running in the frontal and transverse planes. The orthotics reduced knee motion in the frontal plane during the contact and mid-stance phases of walking, but increased the motion during the contact and mid-stance phases of running.
This study shows that corrections to the static position of forefoot varus and calcaneal valgus can result in changes in transverse- and frontal-plane motion of the foot and knee during walking and running.
The effectiveness of soft foot orthotics in the treatment of patients who have patellofemoral pain syndrome was investigated.
Subjects were 20 adolescent female patients, aged 13 to 17 years (mean = 14.8, SD = 1.2), who were diagnosed with patellofemoral pain syndrome and who exhibited excessive forefoot varus or calcaneal valgus.
Subjects were randomly assigned to one of two groups: a control group (n = 10), which took part in an exercise program, or a treatment group (n = 10), which used soft foot orthotics in addition to participating in the exercise program. The exercise program consisted of quadriceps femoris and hamstring muscle strengthening and stretching exercises. A visual analogue scale was used to assess the level of pain of the subjects over an 8-week period.
Both the treatment and control groups demonstrated a significant decrease in the level of pain, but the improvement of the treatment group was significantly greater than that of the control group.
The results suggest that in addition to an exercise program, the use of soft foot orthotics is an effective means of treatment for the patient with patellofemoral pain syndrome.
A new questionnaire was used to evaluate subjective symptoms and functional limitations in patellofemoral disorders. The questionnaire was completed independently by four groups of female subjects: controls (N = 17), and subjects with anterior knee pain (N = 16), patellar subluxation (N = 16), and patellar dislocation (N = 19). The questionnaire mean scores for the groups were 100, 83, 68, and 62 points, respectively (p < 0.0001). The items dealing with abnormal painful patellar movements (subluxations) (p < 0.0001), limp (p < 0.0001), pain (p < 0.0001), running (p < 0.0001), climbing stairs (p < 0.0001), and prolonged sitting with the knees flexed (p < 0.0001) differentiated the study groups most clearly. We recommend that these questions be asked when taking a standardized clinical history of an anterior knee pain patient. We also analyzed lateral patellar tilt and displacement by magnetic resonance imaging (MRI) in 28 subjects with patellar subluxation or dislocation. Low questionnaire sum score correlated best with increased lateral patellar tilt measured during quadriceps contraction in 0 degree knee flexion. It seems that a tendency to lateral patellar tilt during quadriceps contraction causes anterior knee pain and can be imaged in knee extension when the patella is not fully supported by femoral condyles.
This study was undertaken to determine if commonly used orthotics (Palumbo "Dynamic Patellar Brace" [DynOrthotics, Vienna, Virginia] and the Cho-Pat Knee Strap [Cho-Pat Inc, Hainesport, New Jersey]) are helpful in the management of anterior knee pain in an active population who are unable to significantly modify their activity due to basic training requirements. In a prospective, randomized study, 59 Air Force Academy basic cadets who presented with anterior knee pain during the initial phases of basic cadet training, were placed into one of the three treatment groups. Group A was assigned no brace, group B was issued a Palumbo "Dynamic Patellar Brace," and group C was issued a Cho-Pat Knee Strap. All patients were started on physical therapy with "closed chain" rehabilitation and given nonsteroidal anti-inflammatory medications. Patients then underwent weekly follow-up with serial examinations and completion of a visual analog pain/motivation questionnaire. At the completion of training (6 to 8 weeks after study initiation), all charts were collected and statistically analyzed with analysis of variance (ANOVA). Eight patients were removed from the study group because of insufficient follow-up or failure to complete training (correlated with low motivation scales). There was no significant difference between the groups regarding change in pain throughout the study. The only statistically significant item was the proportion of females presenting with anterior knee pain (2.7% versus 1.4% incidence). Two patients voluntarily separated (disenrolled) due to incapacitating anterior knee pain at the completion of the study. Both of these patients were assigned to the Palumbo group. Despite manufacturer claims, these two orthotics do not appear to be effective in controlling anterior knee pain in this basic trainee populations.
We describe a consecutive series of girls with idiopathic anterior knee pain in adolescence and who were treated nonoperatively. At a mean follow-up of 16 years, 22% had no pain, 71% thought that their symptoms were better than at presentation, 88% used analgesics rarely or not at all, and 90% continued to participate regularly in sports. Nevertheless, about one in four of the patients continued to have significant symptoms for < or = 20 years after presentation. No features were identified that predicted those patients in whom symptoms would persist. We conclude that surgical treatment of idiopathic anterior knee pain in adolescents is not justified until a procedure has been shown to provide a better outcome than that reported here or until a way has been found to distinguish the few patients who will not get better spontaneously from the majority who will.
Physical interventions (nonpharmacological and nonsurgical) are the mainstay of treatment for patellofemoral pain syndrome (PFPS). Physiotherapy is the most common of all physical interventions and includes specific vastus medialis obliquus or general quadriceps strengthening and/or realignment procedures (tape, brace, stretching). These treatments appear to be based on sound theoretical rationale and have attained widespread acceptance, but evidence for the efficacy of these interventions is not well established. This review will present the available evidence for physical interventions for PFPS.
Computerized bibliographic databases (MEDLINE, Current Contents, CINAHL) were searched, including the keywords "patellofemoral," "patella," and "anterior knee pain," combined with "treatment," "rehabilitation," and limited to clinical trials through October 2000.
The critical eligibility criteria used for inclusion were that the study be a controlled trial, that outcome assessments were adequately described, and that the treatment was a nonpharmacological, nonsurgical physical intervention.
Of the 89 potentially relevant titles, 16 studies were reviewed and none of these fulfilled all of the requirements for a randomized, controlled trial. Physiotherapy interventions were evaluated in eight trials, and the remaining eight trials examined different physical interventions. Significant reductions in PFPS symptoms were found with a corrective foot orthosis and a progressive resistance brace, but there is no evidence to support the use of patellofemoral orthoses, acupuncture, low-level laser, chiropractic patellar mobilization, or patellar taping. Overall the physiotherapy interventions had significant beneficial effects but these interventions were not compared with a placebo control. There is inconclusive evidence to support the superiority of one physiotherapy intervention compared with others.
The evidence to support the use of physical interventions in the management of PFPS is limited. There appears to be a consistent improvement in short-term pain and function due to physiotherapy treatment, but comparison with a placebo group is required to determine efficacy, and further trials are warranted for the other interventions.
Patellofemoral pain syndrome (PFPS) is common among adolescents and young adults. The most common symptom is pain surrounding the knee cap when sitting with bent knees (movie sign) or when performing exercises like climbing stairs or squatting. Different treatments can be tried to reduce the pain and difficulties experienced during daily activities, including drugs and massage. Exercise regimens to strengthen the muscles surrounding and supporting the knee are another option. The review of exercise therapy found some evidence that exercise therapy might help to reduce the pain of PFPS. Whether exercise reduces knee problems during daily activities is unclear however, and more trials are needed.
To examine the test-retest reliability, validity, and responsiveness of several outcome measures in the treatment of patellofemoral pain.
Evaluation of the clinimetric properties of individual outcome measures for patellofemoral pain treatment, using data collected from a previously published randomized controlled trial (RCT).
General community and private practice.
The data from 71 persons enrolled in an RCT of a conservative intervention for patellofemoral pain were used to evaluate the measures' validity and responsiveness. A subset of this cohort (n=20) was used to assess reliability.
Not applicable.
Three 10-cm visual analog scales (VASs) for usual pain (VAS-U), worst pain (VAS-W), and pain on 6 aggravating activities (walking, running, squatting, sitting, ascending and descending stairs) (VAS-activity); the Functional Index Questionnaire (FIQ); the Anterior Knee Pain Scale (AKPS); and the global rating of change.
The test-retest reliability ranged from poor (intraclass correlation coefficient [ICC]=.49) to good (ICC=.83), and the measures correlated moderately with each other (r range,.56-.72). Median change scores differed significantly between improved and unimproved persons for all measures. The effect sizes for VAS-U (.79), VAS-W (.88), and the AKPS (.98) were large, indicating greater responsiveness than the FIQ (.37) and VAS-activity (.66). Similarly, the AKPS and VAS-W were the most efficient measures for detecting a treatment effect when compared with a reference measure (VAS-U, which was assigned a value of 1). The minimal difference that patients or clinicians consider clinically important for the AKPS is 10 (out of 100) points and for the VAS it is 2cm (out of 10cm).
The AKPS and VAS for usual or worst pain are reliable, valid, and responsive and are therefore recommended for future clinical trials or clinical practice in assessing treatment outcome in persons with patellofemoral pain.
Patellofemoral pain syndrome (PFPS) is common among adolescents and young adults. It is characterised by pain behind or around the patella and crepitations, provoked by ascending or descending stairs, squatting, prolonged sitting with flexed knees, running and cycling. The symptoms impede function in daily activities or sports. Pharmacological treatments focus on reducing pain symptoms (non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids), or restoring the assumed underlying pathology (compounds containing glucosamine to stimulate cartilage metabolism, anabolic steroids to increase bone density of the patella and build up supporting muscles). In studies, drugs are usually applied in addition to exercises aimed at building up supporting musculature.
This review aims to summarise the evidence of effectiveness of pharmacotherapy in reducing anterior knee pain and improving knee function in people with PFPS.
We searched the Cochrane Musculoskeletal Injuries Group and Cochrane Rehabilitation and Related Therapies Field trials registers, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), PEDro (up to January 2004), MEDLINE (1966 to January 2004), EMBASE (1988 to January 2004), and CINAHL (1982 to January 2004).
Controlled trials (randomised or not) comparing pharmacotherapy with placebo, different types of pharmacotherapy, or pharmacotherapy to other therapies for people with PFPS.
The literature search yielded 780 publications. Eight trials were included, of which three were of high quality. Data were analysed qualitatively using best evidence synthesis, because meta-analysis was impeded by differences in route of administration of drugs, care programs and outcome measures.
Four trials (163 participants) studied the effect of NSAIDs. Aspirin compared to placebo in a high quality trial produced no significant differences in clinical symptoms and signs. Naproxen produced significant short term pain reduction when compared to placebo, but not when compared to diflunisal. Laser therapy to stimulate blood flow in tender areas led to more satisfied participants than tenoxicam, though not significantly. Two high quality RCTs (84 participants) studied the effect of glycosaminoglycan polysulphate (GAGPS). Twelve intramuscular injections in six weeks led to significantly more participants with a good overall therapeutic effect after one year, and to significantly better pain reduction during one of two activities. Five weekly intra-articular injections of GAGPS and lidocaine were compared with intra-articular injections of saline and lidocaine or no injections, all with concurrent quadriceps training. Injected participants showed better function after six weeks, though only the difference between GAGPS injected participants and non-injected participants was significant. The differences had disappeared after one year. One trial (43 participants) found that intramuscular injections of the anabolic steroid nandrolone phenylpropionate significantly improved both pain and function compared to placebo injections.
There is only limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS. The evidence for the effect of glycosaminoglycan polysulphate is conflicting and merits further investigation. The anabolic steroid nandrolone may be effective, but is too controversial for treatment of PFPS.
Repeated-measures analysis of intervention.
To determine the effects of foot orthoses on quality of life for individuals with patellofemoral pain who demonstrate excessive foot pronation.
Foot orthoses are a common intervention for patients with patellofemoral pain. Limited information is available, however, regarding the effects of foot orthoses on quality of life for these patients.
Sixteen subjects with patellofemoral pain who also exhibited signs of excessive foot pronation were studied. Subjects underwent a 2-week period of baseline study followed by custom foot orthotic intervention. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was administered to subjects at the time of screening, just prior to foot orthotic intervention, and at 2 weeks and 3 months following foot orthotic intervention.
Wilcoxon matched-pairs signed-rank test results indicated statistically significant improvements in the pain and stiffness subscales 2 weeks following the start of foot orthotic intervention. All WOMAC subscale scores were significantly improved at 3 months compared with preintervention measurements.
Custom-fitted foot orthoses may improve patellofemoral pain symptoms for patients who demonstrate excessive foot pronation.
Patellofemoral joint function involves a complex orchestration of a number of dynamic, static, and neuromuscular factors. I will discuss the components of patellofemoral anatomy and whether the presence of certain anatomic variables may increase the risk of patellofemoral arthrosis. The patellofemoral surgeon is faced with several clinical challenges: the semantics of the language used to discuss these problems, the correlation of clinical symptoms and radiographic imaging to help diagnose a problem, and surgical challenges in optimizing extensor mechanism function.
Background:
There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice.
Objectives:
To determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.
Search strategy:
We searched the following databases: The Cochrane Back Group Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL) to March 2005, and MEDLINE, EMBASE, and CINAHL to February 2007; reviewed reference lists in review articles, guidelines and in the included trials; conducted citation tracking; contacted individuals with expertise in this domain.
Selection criteria:
We included randomized controlled trials that examined the use of customized or non-customized insoles, for the prevention or treatment of back pain, compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: self-reported incidence or physician diagnosis of back pain; pain intensity; duration of back pain; absenteeism; functional status. Studies of insoles designed to treat limb length inequality were excluded.
Data collection and analysis:
One review author conducted the searches and blinded the retrieved references for authors, institution and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using a standardized form.
Main results:
Six randomized controlled trials met inclusion criteria: Three examined prevention of back pain (2061 participants) and three examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.
Limitations:
This review largely reflects limitations of the literature, including low quality studies with heterogeneous interventions and outcome measures, poor blinding and poor reporting.
Authors' conclusions:
There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.High quality trials are required for stronger conclusions.
A randomised trial of exercise therapy and foot orthoses as treatment for knee pain in primary care
- Wiener-Ogilvie
Therapeutic ultrasound for treating patellofemoral pain syndrome
- Brosseau