1230
ORIGINAL ARTICLE
Training Program and Additional Electric Muscle Stimulation
for Patellofemoral Pain Syndrome: A Pilot Study
Walter Bily, MD, Lukas Trimmel, MD, Michaela Mödlin, MD, Alexandra Kaider, MSc, Helmut Kern, MD
ABSTRACT. Bily W, Trimmel L, Mödlin M, Kaider A,
Kern H. Training program and additional electric muscle stim-
ulation for patellofemoral pain syndrome: a pilot study. Arch
Phys Med Rehabil 2008;89:1230-6.
Objectives: To evaluate the beneficial effect of training in
patients with patellofemoral pain syndrome (PFPS) and influ-
ence of additional electric muscle stimulation (EMS) of the
knee extensor muscles.
Design: A randomized clinical trial.
Setting: Supervised physiotherapy (PT) training and home-
based EMS.
Participants: Patients (N⫽38; 14 men, 24 women) with
bilateral PFPS.
Interventions: One group (PT) received supervised PT
training for 12 weeks. The other received PT and EMS. The
stimulation protocol was applied to the knee extensors for 20
minutes, 2 times daily, 5 times a week for 12 weeks at 40Hz,
with a pulse duration of .26ms, at 5 seconds on and 10 seconds
off. Maximal tolerable stimulation intensity was up to 80mA.
Main Outcome Measures: Patellofemoral pain assessment
with visual analog scale during activities of daily life, Kujala
patellofemoral score, and isometric strength measurement be-
fore and after 12 weeks treatment as well as after 1 year.
Results: Thirty-six patients completed the 12-week follow-
up. There was a statistically significant reduction of pain in
both groups (PT group, P⫽.003; PT and EMS group, P⬍.001)
and significant improvement of the Kujala score in both groups
(PT group, P⬍.001; PT and EMS group, P⬍.001) after 12
weeks of treatment with improvement of function and reduc-
tion of pain at the 1-year follow-up. The difference between the
2 treatment groups was statistically not significant. We could
not measure any significant change in isometric knee extensor
strength in either group.
Conclusions: A supervised PT program can reduce pain and
improve function in patients with PFPS. We did not detect a
significant additional effect of EMS with the protocol described
previously.
Key Words: Electric stimulation; Knee; Rehabilitation.
© 2008 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Department of Physical Medicine and Rehabilitation, Wilhelminenspital
Vienna, Austria (Bily, Trimmel, Mödlin, Kern); and Core Unit for Medical Statistics
and Informatics, Section of Clinical Biometrics, Medical University of Vienna,
Austria (Kaider).
Supported by Hochschuljubiläumsstiftung der Stadt Wien (grant no. 30/2000).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Walter Bily, MD, Dept of Physical Medicine, Wilhelminenspi-
tal, Montleartstr 37, A-1160 Vienna, Austria, e-mail: walter.bily@wienkav.at.
0003-9993/08/8907-00774$34.00/0
doi:10.1016/j.apmr.2007.10.048
Arch Phys Med Rehabil Vol 89, July 2008
ATELLOFEMORAL PAIN syndrome is a common pain
P problem in adolescents and young adults. It is frequently
1
seen in sports medicine clinics, up to 10% of all visits, and in
2-4
armed forces recruits, up to 15%. Only a few studies have
been performed to evaluate the natural course of PFPS in
adolescents. The study of Nimon et al5 looked at the long-term
outcome of female adolescents suffering from PFPS. They
found that, after a mean follow-up of 16 years, only 22% were
free of pain and about 25% continued to have significant
symptoms, although 90% were able to participate regularly in
sports.5 Although the long-term outcome of nonoperative-
treated PFPS is good in 75% to 85%, 15% to 25% still have
symptoms or objective signs of patellofemoral abnormality.6,7
There are several theories about mechanisms for acquiring
PFPS. Overloading of the patellofemoral joint or malalignment
are suspected to be possible reasons.8 Dysfunction of the extensor
mechanism and related maltracking of the patella within the fem-
oral trochlea are commonly accepted as a possible cause.8-10
Decreased knee extensor strength may be another cause or a
consequence of pain perception.8 Because of the various possible
origins, the cause of pain is not the same for all patients.10
Although there are no valid clinical tests to diagnose PFPS,
it is generally accepted that a specific combination of symp-
toms and signs is sufficient for diagnosis. Usually patients
complain about anterior knee pain associated with prolonged
sitting, kneeling, squatting, stair climbing, or running.11 To
confirm the diagnosis, it is necessary to rule out intra-articular
pathology, peripatellar tendinitis, and bursitis.12
Different conservative treatment approaches have been re-
ported; however, exercise therapy is widely accepted and rou-
tinely applied as the main treatment method.8,13-17 There are
different hypotheses of the biomechanic and neurophysiologic
contributing mechanisms of the beneficial effect of exercise
therapy.8,11,14,15,18-20 Good clinical results have been shown
with quadriceps strengthening, with both open and closed ki-
netic chain exercises.14,17,20,21 A more specific physiotherapeu-
tic approach was introduced by McConnell.22,23 With respect
to simultaneous timing of contraction of the VMO relative to
the vastus lateralis, this rehabilitation program incorporates
quadriceps strengthening, patellar taping, and weight-bearing
exercises to influence the timing of contraction and strength of
hip and thigh musculature.15-17,19,20,22,23 Recently, good results
of a 6-week training program have been shown in the short-
term management of patellofemoral pain.16 Studies on the
long-term effect of training intervention are sparse.
List of Abbreviations
EMS electric muscle stimulation
ICC intraclass correlation coefficient
KPS Kujala patellofemoral score
PFPS patellofemoral pain syndrome
PT physiotherapy
VAS visual analog scale
VMO vastus medialis oblique
 TRAINING AND ELECTRIC MUSCLE STIMULATION IN PFPS, Bily
To overcome the dysfunction of the extensor mechanism,
especially in the case of reduced voluntary activation of the
VMO, it has been shown that EMS is a promising therapeutic
procedure. EMS has been successfully used in quadriceps
rehabilitation after knee injuries and surgical intervention.24-26
It has been shown that EMS (alone or in combination with
exercise therapy) is able to increase the neural activation and
functional properties of the knee extensor and plantarflexor
muscles in sports people and patients with osteoarthritis of the
knee.27,28 Frequent obstacles for muscle exercise can be pain
and resulting reflex inhibition in the exercised muscles.29 This
problem can be overcome by reinforcement of the volitional
muscle contraction through electrically induced muscle activa-
tion.30,31 Beneficial results of EMS have been reported in
patients with PFPS concerning the improvement of quadriceps
strength and fatigue resistance, clinical outcome measures, and
pain reduction.32,33 Different stimulation protocols with a min-
imum duration of 40 minutes a day have been shown to be
successful in improving subjective and objective parameters of
patients with PFPS.32,33
Drawing on our extensive clinical observations and based on
previous reports, we hypothesized that EMS of the quadriceps
muscle in patients with PFPS could be an additional helpful
tool to overcome pain and reflex inhibition during volitional
muscle activation. The improvement of knee extensor activa-
tion should have an additional pain-reducing effect in addition
to an exercise therapy program alone.
The purpose of this pilot study was to evaluate whether a
clinically applicable exercise therapy program could be bene-
ficial and whether the therapeutic effect of exercise therapy
could be improved by adding EMS. We assessed the long-term
effect of therapy after 1 year, sex-specific aspects, and whether a
longer duration of symptoms before participating in the therapy
program had a negative effect on outcome measurements.
METHODS
Participants
Between June 2003 and August 2005, 64 participants were
referred by outside orthopedic surgeons, and 40 fulfilled the
eligibility criteria. Inclusion criteria were bilateral anterior
knee pain for 6 to 120 months and at least 3 of the 4 following
clinical criteria: pain associated with prolonged sitting with
bended knees, descending stairs, kneeling and squatting, or
sports activities.
Exclusion criteria were clinical evidence of patellar dislo-
cation or subluxation, periarticular bursitis or tendonitis, liga-
mentous instability, or intra-articular pathology. Before begin-
ning therapy, all patients were thoroughly clinically examined.
Those who did not reveal any obvious reason for a systemic
disorder like patellar or lower-extremity alignment problems or
benign joint hypermobility syndrome were not excluded. To
Table 1: Demographic Data of Patients
Group
Demographics PT PT and EMS
Age (y) 23.7⫾5.5 27.0⫾7.7
Height (cm) 168.7⫾4.9 174.5⫾9.3
Weight (kg) 59.4⫾5.7 68.8⫾13.7
Sex (men/women) 5/14 9/10
Duration of pain complaints (mo)* 16 (6–24) 12 (6–24)
NOTE: Values are mean ⫾ SD.
*Values are median (quartiles).
1231
rule out osteoarthritic changes or hypoplastic femoral trochlea,
radiographs were performed.
Additional exclusion criteria were: pregnancy, a history of
knee surgery, or oral or intra-articular administration of drugs
within the last 3 months. Two of the recruited participants
withdrew for personal reasons. Thirty-eight subjects (14 men,
24 women) diagnosed with bilateral PFPS by 2 independent
physiatrists were randomly assigned to group PT training or
group PT training and EMS (table 1). Random allocation of the
patients to the 2 treatment groups was performed by using
shuffled sealed envelopes.
The study was approved by the local ethics committee. All
subjects provided written informed consent.
Outcome Measures
The assessments were performed before treatment with fol-
low-ups after 3 months of therapy and after 1 year.
Assessment of pain. Patellofemoral pain was assessed with
a VAS comprising a 10-cm line, with 0 representing no pain
and 10 representing worst pain. The reliability of VAS scoring
in patients with PFPS is established through a number of
studies, showing ICCs of .60 to .79 for usual pain and .88 for
worst pain.34-36 A weaker ICC of .66 was reported for activity-
dependent VAS.36 In this study, we used VAS scores for 2
different conditions: VAS 1, average pain with activities of
daily living (descending stairs, prolonged sitting, kneeling, or
squatting), and VAS 2, pain during sports activities (walking,
jogging, jumping). The VAS scores were performed 1 week
before treatment, after 12 weeks of treatment, and as a fol-
low-up after 1 year.
Assessment of function. The KPS, which is a valid and
reliable tool in scoring patellofemoral disorders,37 was used to
assess knee pain and function. This KPS scoring system is
valid in the evaluation of patients with PFPS, with an intraclass
reliability correlation coefficient range of .90 to .98.35,36
Assessment of isometric strength. Strength measurements
were performed in a sitting position by using a specifically
designed chair. Strain gauges, connected in a full bridge circuit
configuration, were placed on a lever near the center of rotation
and the output fed to a measurement amplifier.38 Subjects were
fixed with shoulder and hip straps and performed 3 maximal
isometric contractions of the knee extensors of 10 seconds in
30° and 60° knee flexion with a 2-minute rest between the
contractions. The peak extension torque was recorded, and the
best result of the 3 attempts was used for calculation.
Training Protocol
Training was instructed and performed as described by
Thomeé.11 The 12-week training program consisted of isomet-
ric, concentric, and excentric leg raises and pulls as well as
stepping and squatting exercises. Balance exercises started
from week 4 onward and consisted of standing on 1 leg for 2
minutes each. To increase the exercise demand, patients were
instructed to draw circles in the air with the free contralat-
eral leg from week 6 onward. From week 8 onward, patients
had to do the 1-legged balance exercises in a toe-raised
position with drawing circles with the contralateral leg in
weeks 11 and 12.
Static stretching exercises of the calf and thigh muscles
consisted of 3 sets of 10-second passive sustained stretching
for each muscle group that were performed by the patients
themselves at the end of each training session from weeks 4
to 12.
Appendix 1 provides a detailed description of the training
program. Patients were instructed for daily training during the
Arch Phys Med Rehabil Vol 89, July 2008
1232 TRAINING AND ELECTRIC MUSCLE STIMULATION IN PFPS, Bily
Table 2: Maximum Values of VAS 1 and VAS 2 in Both Groups
Maximum VAS PT PT and EMS
Before treatment 5.3 (2.9–7.6) 5.6 (3.5–8.3)
After 3mo of treatment 1.3 (0.4–3.3) 1.5 (0.3–2.8)
One-year follow-up 0.4 (0.2–3.4) 1.8 (0.1–3.6)
NOTE. Values are median (quartiles).
first 2 weeks and had a group session once a week under the
supervision of the same physical therapist. From the third week
on, they were instructed to train with higher loads 3 times a
week for a total of 12 weeks. All subjects received an exercise
instruction booklet with detailed instructions for every training
session (type of exercise, number of repetitions and sets) and
were instructed to report about their pain during every training
session. Training protocols were controlled once a week for
compliance. The information was used for further progression
of exercises. A pain level of up to 2 on the VAS during the
exercises was accepted for further increasing the loads. In case
of reported pain levels of 3 or 4, the loads were kept constant;
in case of a reported pain level above 5, during the exercise the
loads were reduced accordingly.
EMS Protocol
For EMS of the quadriceps, a commercially available por-
table battery-operated stimulation device (N607 E.M.S.)a was
used. The EMS device is a 2-channel stimulator, which pro-
duces asymmetric biphasic pulses for a duration of .26ms.
Maximal amplitude is 80mA, with maximal output of 50V at
500⍀. The stimulation frequency was set at 40Hz, with a duty
cycle of 5 seconds on and 10 seconds off. The patients ran-
domized to the EMS group were carefully instructed in a
home-based self-stimulation program by a physician. Four
self-adhesive electrodes were placed respectively on both ends
of the quadriceps muscles (50⫻130mm; total area, 130cm2 on
each thigh). The daily stimulation protocol consisted of two
20-minute sessions with a minimum of 60-minute rests be-
tween each session. The protocol was followed for 12 weeks.
The intensity of the stimulation was kept as high as possible;
however, pain tolerance and patient discomfort were modifying
factors. Patients were given instruction protocols of electrode
placement, and they were asked to record each stimulation
session to ensure compliance.
Statistical Analysis
Pain was described by the largest value of the 2 VAS
evaluations, VAS 1 and VAS 2. The KPS was used to assess
knee pain and function. Differences between values before
treatment and after 3 months of therapy were considered as
main outcome parameters measuring the treatment effect.
Mean values ⫾ SDs are given in case of normally distributed
variables. Median (quartile) values are mentioned, describing
variables with skewed distributions.
The Spearman correlation coefficient was used to describe
the correlation between pain, function, and strength before and
after training. The paired t test was used to test for differences
between pre- and post-treatment values. To calculate the dif-
ferent effects of the 2 therapies (with vs without EMS) and
differences between men and women, the unpaired t test was
used. To evaluate the influence of the potential prognostic
factors, the duration of pain complaints (log-transformed),
and sports activities (measured on an ordinal scale with
codes 0⫽no sports, 1⫽1h sports a week, 2⫽2–3h sports a
week, 3⫽⬎3h sports a week) on the treatment effect, uni-
Arch Phys Med Rehabil Vol 89, July 2008
variate and multiple linear regression models were esti-
mated. Two-sided P values smaller than .05 were considered
statistically significant.
RESULTS
Pain and Function
In the supervised PT group, we started with 19 patients. One
patient did not return for the 3-month control for personal
reasons. Eighteen patients were analyzed after 3 months of
training. In the PT group, 13 patients completed the 1-year
follow-up. Of the 5 patients missing, 1 was diagnosed with
rheumatoid arthritis, 1 had to undergo knee surgery because of
his PFPS, and 3 patients did not return for the 1-year follow-up
investigations.
Nineteen patients started in the PT and EMS group, receiving
PT and additional EMS. One patient withdrew. The remaining 18
patients were analyzed after 3 months of training and EMS.
Sixteen subjects of this group finished the study and participated
and completed the 1-year follow-up. One did not want to return
for the 1-year follow-up, and 1 could not be contacted (fig 1).
The duration of pain complaints before participation in the
study was comparable in the 2 treatment groups: median (quar-
tile) values (in months): 16 (6⫺24) in PT group and 12 (6⫺24)
in PT and EMS group.
There was a statistically significant reduction of pain in both
groups from pretraining values to the 3-month measurements.
The mean decrease ⫾ SD in the VAS evaluation (maximum
value of VAS 1 and VAS 2) was ⫺2.84⫾3.50 (P⫽.003) in the
PT group and ⫺3.39⫾3.43 (P⬍.001) in the PT and EMS
group. At the 1-year follow-up, the reduction of pain remained
constant. Values are given in table 2.
There was also a statistically significant improvement of the
KPS. Values improved in both therapy groups from pretraining
to the 3-month control. The improvement was 8.4⫾7.9
(P⬍.001) in the PT group and 12.1⫾11.9 (P⬍.001) in the PT
and EMS group. Improvement in KPS values persisted at the
1-year follow-up. Values are given in table 3.
There was no statistically significant difference of improve-
ment between the 2 treatment groups (VAS evaluation, P⫽.64;
KPS, P⫽.29). Moreover, we did not find a statistically signif-
icant difference between men and women with respect to the
VAS score and KPS (P⫽.32, P⫽.79, respectively). Univariate
and multiple linear models revealed no statistically significant
influence of the duration of pain complaints (both univariate
and multiple model, P⫽.16) and sports activities (P⫽.80,
P⫽.88, respectively) on the decrease in the VAS evaluation.
Evaluating the correlation between pain, function, and
strength, the only significant correlation was between pain and
the KPS (before treatment, ␳⫽⫺.54, P⬍.001; after 3mo,
␳⫽⫺.77, P⬍.001; after 12mo, ␳⫽⫺.64, P⬍.001), showing
that lower pain values correlate with a higher function score.
No correlation was detected between pain and strength or
between the KPS and strength (␳ range, ⫺0.3 to 0.3).
Table 3: KPS Values in Both Groups
KPS PT PT and EMS
Before treatment 83 (72–88) 73 (66–85)
After 3mo of treatment 90 (85–95) 89 (82–96)
One-year follow-up 95 (85–96) 94 (88–96)
NOTE. Values are median (quartiles).
 TRAINING AND ELECTRIC MUSCLE STIMULATION IN PFPS, Bily
Fig 1. Progress of patients through the study.
Isometric Muscle Strength
In the PT group, the mean isometric muscle strength in 30°
knee flexion was 94.7⫾23N before training and 89.7⫾20.8N
after the 3-month training program. With 60° knee flexion,
isometric strength was 152⫾45N before and 149⫾33N after
training.
In the PT and EMS group, isometric strength with 30° was
108.7⫾29N before and 128⫾49N after 3 months of training
and EMS. At 60° knee flexion values were 188⫾77N before
and 199⫾77N after training and EMS.
There were no significant differences of pretraining and
posttraining values of isometric strength for both tested knee
flexion angles in both groups.
DISCUSSION
The results of the study indicate that a supervised PT training
program over a period of 3 months can decrease pain and
improve function in patients with PFPS. Both groups, PT as
1233
well as PT and EMS, showed significant and clinically relevant
treatment effects.
The results are similar to those reported by Thomeé,11 Cross-
ley,16 Boling,17 and colleagues. Our training program consisted
of concentric and eccentric exercises of trunk and leg muscu-
lature and balance and stretching exercises. We used a clearly
defined protocol of repetitions and sets (see appendix 1). An
individual approach was obtained by the previously described
pain monitoring protocol during training sessions (see training
protocol). With the help of this system, we tried to prevent
overloading of the painful peripatellar tissues despite progres-
sively increasing loads.
It was not possible to have a control group with sham
treatment because of the methodologic limitation of our treat-
ment protocol to be applied as sham therapy. Furthermore, it
was also not possible to have a control group without therapy
because patients were referred from outpatient orthopedic pro-
grams for treatment; therefore, it was not acceptable to with-
Arch Phys Med Rehabil Vol 89, July 2008
1234 TRAINING AND ELECTRIC MUSCLE STIMULATION IN PFPS, Bily
hold them from therapy. To overcome these limitations, we
evaluated the effect of EMS in the PT and EMS group and
compared it with the PT group, which served as the control
group. The baseline values before treatment were used to
assess the therapy effect and the difference to the baseline
values describing intervention induced improvement.
We have shown in this pilot study a reduction of pain and
improvement of function, which could also be an effect of time or
modified physical activity. However, described results suggest
that the training program is the main reason for improvement.
Moreover, we should not forget the possible role of altered sen-
sorimotor behavior.39 Because of the chronicity of the complaints
in both groups (16mo in the PT and EMS group, 12mo in the PT
group), it is not likely that the improvement can be attributed to
time or modified physical activity. It could be argued that the
subjects could act as their own controls because for an average
period of 12 to 16 months before participating in the study, they
did not display any improvement. Thus, it seems unlikely that any
significant natural improvement of the patient’s condition could
have had an influence on the treatment effects.
The group with additional EMS (polytherapy) showed sim-
ilar results as the training-only (monotherapy) group; likewise,
no significant differences in pain relief and functional scoring
were found between the 2 groups. We could neither discover
any significant additional effect on pain reduction nor did we
find any adverse effect or worse outcome in the EMS group.
When EMS is used as monotherapy, the suppressive effect
on pain is more modest.32,33 Werner32 and Callaghan33 and
colleagues both showed that the range of possible improvement
through EMS was less than that one can achieve with training.
These findings support our results.
Study Limitations
In addition, we should be concerned about the potential ceiling
effect of one monotherapy when polytherapy is applied. This
could be the case in our study such that exercise therapy reached
a ceiling effect, and, therefore, it was not possible to document an
additional effect of EMS. Another explanation could be that the
statistical power was too low to reveal distinct differences.
Power analysis revealed that the power of the study was only
24% and thus too small to detect a difference of 1.5cm in the
VAS improvement (ie, the difference in the VAS evaluation
between values before and after therapy), considering the sam-
ple size of 18 patients in each group and the observed SD of
3.5.
It is widely considered that pain relief through EMS in patients
with PFPS is caused by an increase of extensor strength and
compensation of imbalances of the vasti muscles. Morrissey24
argued that pain inhibition occurred through a better muscular
balance, whereas Melzack and Wall40 considered that it was
caused by modification of pain-related input by posterior spinal
cord column according to their gate control theory.
APPENDIX 1: PFPS TRAINING PROTOCOL
1 2 3 4
Daily Daily 3x/wk
Exercise Weight NW 1kg 2kg
Leg raises (repetitions) 30 45 45
Supine position
Prone position 30 45 45
Lateral position lifting upper leg 30 45 45
Lateral position lifting lower leg 30 45 45
Arch Phys Med Rehabil Vol 89, July 2008
Irrespective of the good effects on pain relief and improve-
ment of function, we did not find any changes of isometric
strength values of the knee extensor muscles in our study. The
improvement of quadriceps strength is believed to be a reason
for pain relief in PFPS patients, but our patients showed a clear
reduction of pain without changes in strength parameters. It is
postulated that the reason for this could be that the improve-
ment in the clinical condition refers more to neurophysiologic
changes than to strength gains. In contrast, Werner et al32 found
small (⬍6.2% from baseline values) but significant increases in
concentric peak torques of the quadriceps muscle measured on
an isokinetic dynamometer after a 10-week EMS procedure.
One reason for this could be that they chose a study population
with a hypotrophic VMO. The lower the baseline value, the
greater the potential improvement. Callaghan and Oldham33
showed converse effects on isometric strength and isokinetic
strength in their EMS groups. These conflicting results have
been explained by their testing and stimulation protocol, but
the results also show that an improvement of function and a
decrease of pain can be achieved without relevant changes of
strength parameters.
In this study, we did not investigate neurophysiologic mech-
anisms of pain. Therefore, we cannot rule out altered sensori-
motor behavior neuromuscular activity because we did not
investigate the time relation between activity onset of vasti
muscles, as it has been mentioned by Cowan et al.39 Delayed
onset of surface electromyographic activity of VMO compared
with vastus lateralis during stair stepping was detected in
patients with PFPS, and disturbed timing of onset of vasti
muscles was suspected to be an assignable cause for dysfunc-
tion of knee extensors.39 Thus, it is not possible to rule out an
additional effect of EMS and training on the timing and acti-
vation pattern of the knee extensor muscles.
The results measured after 3 months in both groups remained
constant at the 1-year follow-up. There was no difference in the
treatment effects with respect to sex, duration of pain com-
plaints, or sports activities.
CONCLUSIONS
The results of our investigation contribute to the evidence
that a supervised physiotherapeutic training program alone can
reduce pain and improve function in patients with PFPS. The
training program was successful despite a relatively long du-
ration of complaints, irrespective of sex differences and indi-
vidual sports activities before the start of the treatment pro-
gram. The effects were observed without concomitant
improvement in isometric strength values and appeared to last
for at least 1 year after the treatment ceased. We did not detect
a significant additive effect of EMS with the protocol described
previously. Further investigations should focus on different
aspects of training exercises including measurements to un-
cover potential neurophysiologic effects of exercise and EMS.
Week
5 6, 7 8 9, 10 11, 12
3x/wk 3x/wk 3x/wk 3x/wk 3x/wk 3x/wk
3kg 3kg 4kg 4kg 5kg 6kg
30 45 45 60 60 60
30 45 45 60 60 60
30 45 45 60 60 60
30 45 45 60 60 60
 TRAINING AND ELECTRIC MUSCLE STIMULATION IN PFPS, Bily 1235

APPENDIX 1: PFPS TRAINING PROTOCOL (Cont’d)

Week

1 2 3 4 5 6, 7 8 9, 10 11, 12
Daily Daily 3x/wk 3x/wk 3x/wk 3x/wk 3x/wk 3x/wk 3x/wk
Exercise Weight NW 1kg 2kg 3kg 3kg 4kg 4kg 5kg 6kg

Toe raises (repetitions) 30 45 45 90 105 30–45 60 75–90 90

BL BL BL BL BL EL EL EL EL
Stretching (sets/s) 3/10 3/10 3/10 3/10 3/10 3/10
Plantarflexors
Knee extensors 3/10 3/10 3/10 3/10 3/10 3/10
Knee flexors 3/10 3/10 3/10 3/10 3/10 3/10
Exercises in standing position
with a rubber tube
(repetitions)
Hip flexion 15 25 35 50 50 50
Hip extension 15 25 35 50 50 50
Hip adduction 15 25 35 50 50 50
Hip abduction 15 25 35 50 50 50
Balance exercise (min) 2 EL 2 EL 2 EL 2 EL 2 EL 2 EL
Bicycling (min) 10 10 15 20 20 25

Abbreviations: BL, on both legs; EL, each leg; NW, no weight.

References
1. Kannus P, Aho H, Järvinen M, Niittymäki S. Computerized re-
cording of visits to an outpatient sports clinic. Am J Sports Med
1987;15:79-85.
2. Milgrom C, Finestone A, Shlamkovitch N, Giladi M, Radin E.
Anterior knee pain caused by overactivity: a long term prospective
follow-up. Clin Orthop Relat Res 1996;Oct(331):256-60.
3. Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemio-
logical patterns of musculoskeletal injuries and physical training.
Med Sci Sports Exerc 1999;31:1176-82.
4. Witvrouv E, Lysens R, Bellemans J, Cambier D, Vanderstraeten
G. Intrinsic risk factors for the development of anterior knee pain
in an athletic population. A two year prospective study. Am J
Sports Med 2000;28:480-9.
5. Nimon G, Murray D, Sandow M, Goodfellow J. Natural history of
anterior knee pain: a 14- to 20-year follow up of nonoperative
management. J Pediatr Orthop 1998;18:118-22.
6. Karlsson J, Thomeé R, Swärd L. Eleven year follow-up of patel-
lofemoral pain syndrome. Clin J Sports Med 1996;6:22-6.
7. Kannus P, Natri A, Paakkala T, Järvinen M. An outcome study of
chronic patellofemoral pain syndrome. Seven-year follow-up of
patients in a randomized, controlled trial. J Bone Joint Surg Am
1999;81:355-63.
8. Thomeé R, Augustsson J, Karlsson J. Patellofemoral pain syn-
drome: a review of current issues. Sports Med 1999;28:245-62.
9. Fulkerson J. Diagnosis and treatment of patients with patellofemo-
ral pain. Am J Sports Med 2002;30:447-56.
10. Crossley K, Bennell K, Green S, McConnell J. A systematic
review of physical interventions for patellofemoral pain syn-
drome. Clin J Sports Med 2001;11:103-10.
11. Thomeé R. A comprehensive treatment approach for patel-
lofemoral pain syndrome in young women. Phys Ther 1997;
77:1690-703.
12. Reid DC. The myth, mystique and frustration of anterior knee
pain. Clin J Sports Med 1993;3:139-43.
13. Aroll B, Ellis-Pegler E, Edwards A, Sutcliffe G. Patellofemoral
pain syndrome. A critical review of the clinical trials on nonop-
erative therapy. Am J Sports Med 1997;25:207-12.
14. Callaghan MJ, Oldham JA. The role of quadriceps exercise in the
treatment of patellofemoral pain syndrome. Sports Med 1996;21:
384-91.
15. Clark DI, Downing N, Mitchell J, Coulson L, Syzpryt EP, Doherty
M. Physiotherapy for anterior knee pain: a randomised controlled
trial. Ann Rheum Dis 2000;59:700-4.
16. Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical
therapy for patellofemoral pain. A randomized, double blinded,
placebo-controlled trial. Am J Sports Med 2002;30:857-65.
17. Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG.
Outcomes of a weight-bearing program for patients diagnosed
with patellofemoral pain syndrome. Arch Phys Med Rehabil 2006;
87:1428-35.
18. Kannus P, Natri A, Nittymaki S, Jarvinen M. Effect of intraartic-
ular glycosaminoglycan polysulfate treatment on patellofemoral
pain syndrome. Arthritis Rheum 1992;35:1052-61.
19. Cowan SM, Bennell KL, Hodges PW, Crossley KM, McConnell
J. Delayed onset of electromyographic activity of vastus medialis
obliquus relative to vastus lateralis in subjects with patellofemoral
pain syndrome. Arch Phys Med Rehabil 2001;82:183-9.
20. Powers CM. Rehabilitation of patellofemoral joint disorders: a
critical review. J Orthop Sports Phys Ther 1998;28:345-54.
21. Vengust R, Strojnik V, Pavlovcic V, Antolic V, Zupanc O. The
effect of electrostimulation and high load exercises in patients
with patellofemoral joint dysfunction. A preliminary report.
Pflugers Arch 2001;442(Suppl 1):R153-4.
22. McConnell J. Management of chondromalacia patellae: a long
term solution. Aust J Physiother 1986;32:215-23.
23. McConnell J. The management of patellofemoral problems. Man
Ther 1996;1:60-6.
24. Morrissey MC. Electromyostimulation from a clinical perspective.
A review. Sports Med 1988;6:29-41.
25. Wigerstad-Lossing I, Grimby G, Jonsson T, Morelli B, Peterson
L, Renstrom P. Effects of electrical muscle stimulation combined
with voluntary contractions after knee ligament surgery. Med Sci
Sports Exerc 1988;20:93-8.
26. Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL. Use of
electrical stimulation to enhance recovery of quadriceps femoris
muscle force production in patients following anterior cruciate
ligament reconstruction. Phys Ther 1994;74:901-7.
27. Maffiuletti NA, Dugnani S, Folz M, Di Pierni E, Mauro F. Effect
of combined electrostimulation and plyometric training on vertical
jump height. Med Sci Sports Exerc 2002;34:1638-44.
28. Rosemffet MG, Schneeberger EE, Citera G, et al. Effects of
functional electrostimulation on pain, muscular strength, and func-

Arch Phys Med Rehabil Vol 89, July 2008

1236 TRAINING AND ELECTRIC MUSCLE STIMULATION IN PFPS, Bily
tional capacity in patients with osteoarthritis of the knee. J Clin
Rheumatol 2004;10:246-9.
29. Graven-Nielsen T, Lund H, Arendt-Nielsen L, Danneskiold-
Samsøe B, Bliddal H. Inhibition of maximal voluntary contraction
force by experimental muscle pain: a centrally mediated mecha-
nism. Muscle Nerve 2002;26:708-12.
30. Arvidsson I, Arvidsson H, Eriksson E, Jansson E. Prevention of
quadriceps wasting after immobilisation—an evaluation of the
effect of electrical stimulation. Orthopedics 1986;9:1519-28.
31. Palmieri RM, Ingersoll CD, Edwards JE, et al. Arthrogenic muscle
inhibition is not present in the limb contralateral to a simulated
knee joint effusion. Am J Phys Med Rehabil 2003;82:910-6.
32. Werner S, Arvidsson H, Arvidsson I, Eriksson E. Electrical stim-
ulation of vastus medialis and stretching of lateral thigh muscles
in patients with patellofemoral symptoms. Knee Surg Sports Trau-
matol Arthrosc 1993;1:85-92.
33. Callaghan MJ, Oldham JA. Electric muscle stimulation of the
quadriceps in the treatment of patellofemoral pain. Arch Phys
Med Rehabil 2004;85:956-62.
34. Chesworth BM, Culham EG, Tata GE, Peat M. Validation of
outcome measures in patients with patellofemoral syndrome. J Or-
thop Sports Phys Ther 1989;10:302-8.
Arch Phys Med Rehabil Vol 89, July 2008
35. Bennell K, Bartram S, Crossley K, Green S. Outcome measures in
patellofemoral pain syndrome: test-retest reliability and inter-
relationships. Phys Ther Sport 2000;1:32-41.
36. Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of
outcome measures for persons with patellofemoral pain: which
are reliable and valid? Arch Phys Med Rehabil 2004;85:
815-22.
37. Kujala UM, Jaakola LH, Koskinen SK, Taimela S, Hurme M,
Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy
1993;9:159-63.
38. Kern H, Hofer C, Mödlin M, Forstner C, Mayr W, Richter W.
Functional electrical stimulation (FES) of long-term denervated
muscles in humans: clinical observations and laboratory findings.
Basic Appl Myol 2002;12:291-9.
39. Cowan S, Bennell K, Crossley K, Hodges PW, McConnell J.
Physical therapy alters recruitment of the vasti in patellofemoral
pain syndrome. Med Sci Sports Exerc 2002;34:1879-85.
40. Melzack R, Wall PD. Pain mechanisms: a new theory. Science
1965;19:971-9.
Supplier
a. Everyway Medical Instruments Co, 3 Fl, No 5, Lane 155, Sec 3,
Peishen Rd, Shenkeng Hsiang, Taipei Hsien, Taiwan 222.