See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/371702798

Association of patellofemoral pain syndrome (PFPS) with quadratus

lumborum and lower limb muscle tightness a cross-sectional study

Article in Journal of Orthopaedics · June 2023

DOI: 10.1016/j.jor.2023.06.007

CITATION READS

1 35

3 authors, including:

Sannasi Rajasekar Akshitha Rajashekar

Srinivas Group of Colleges Srinivas Group of Colleges
22 PUBLICATIONS 147 CITATIONS 7 PUBLICATIONS 1 CITATION

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Akshitha Rajashekar on 22 January 2024.

The user has requested enhancement of the downloaded file.

 Journal of Orthopaedics xxx (xxxx) 1–5

Contents lists available at ScienceDirect

Journal of Orthopaedics
journal homepage: www.elsevier.com/locate/jor

F
Association of patellofemoral pain syndrome (PFPS) with quadratus
lumborum and lower limb muscle tightness a cross-sectional study

OO
Rajasekar Sannasi a, Akshitha Rajashekar a, *, Nirath S. Hegde b
a Srinivas University, Institute of Physiotherapy, India
b Srinivas Institute of Medical Sciences, India

PR
ARTICLE INFO ABSTRACT

Keywords: Background: Patellofemoral pain syndrome (PFPS) is characterized by peripatellar or retro patellar pain, as a re-
Anterior knee pain sult of changes in the physical and biochemical components of the patellofemoral joint. The main contributory
Muscle tightness factor is being the excessive load on the patellofemoral joint. The change in the flexibility of lower limb muscles
Patellofemoral pain syndrome
is one of the factors for developing PFPS.
Hamstring
Objective: To find the association of quadratus lumborum (QL) and lower limb muscles tightness in patients with
Rectus femoris
Illiotibial band unilateral PFPS.
D
Gastrocnemius Materials and methods: 50 PFPS participants (21 male and 29 female) were included and assessed for muscle
Quadratus lumborum tightness on both affected and unaffected side. The QL, rectus femoris, hamstring, iliotibial band (ITB) and gas-
trocnemius tightness were measured using inch tape and mobile inclinometer. A Chi Square test and phi cram-
mer's v criteria were used to check the association and the strength of it.
TE

Results: A significant association was found between tightness of rectus femoris (PFPS-right Chi 19.99
p < 0.001; Phi-0.632, PFPS-left Chi-5.52 p = 0.019 and Phi- 0.332), gastrocnemius (PFPS-right Chi 8.78
p = 0.003; Phi-0.419, PFPS-left Chi- 11.41 p = 0.001; Phi- 0.478), iliotibial band (PFPS-right Chi 7.83
p = 0.005; Phi-0.396, PFPS left Chi-3.68 p = 0.055; Phi- 0.27). There was no significant association of ham-
string tightness (PFPS-right Chi – 3.68 p = 0.055; Phi-0.055, PFPS left Chi-1.11 p = 0.291; Phi- 0.019) and QL
(PFPS right Chi – 1.10 p = 0.293; Phi-0.293, PFPS left Chi-0.79 p = 0.372; Phi- 0.372).
Conclusion: PFPS was associated with tightness of rectus femoris, gastrocnemius, ITB and no association found
EC

between hamstring and QL muscle tightness and PFPS.

1. Introduction of the foot, and proximal instability of lumbopelvic-hip musculature.

External factors such as the type of sport, how the sport is practised,
Patellofemoral pain syndrome (PFPS) is the most recurrently identi- sate of the environment, the equipment used during activities may also
RR

fied knee complaint by a general practitioner and orthopaedic special-
ist.1 It is more common in females than males with the ratio of 2:1. Ath-
letes irrespective of age have a likelihood of developing the condition.2
One in four of the total population is likely to come across one event/
episode of PFPS in their lifetime.3 (see Figs. 1 and 2).
PFPS is also termed as anterior knee pain and is characterized by
CO
have an impact on the development of PFPS.5,6
Assessment of PFPS involves the examination of foot posture, align-
ment of the patella, tenderness, muscle strength and flexibility.7 Con-
servative treatment includes rest, application of ice, combined exercise
program of strengthening and stretching therapies, using modalities
like taping, orthotics for foot, biofeedback training, and pharmacologi-

peripatellar or retro patellar pain as a result of changes in the physical
and biochemical components of the patellofemoral joint due to in-
creased load during activities such as running, squatting, going up and
down stairs, cycling and jumping.4 It may result from various factors
which include altered patellar alignment which may be due to muscle
or soft tissue impairment, increased joint stress, dynamic valgus caused
by a reduced strength of the hip musculature, or excessive protonation
cal treatment.1,8
Muscle tightness is the inability of a muscle or group of muscles to
move across the full range of motion in a particular joint.9 Decreased
hamstring length would require increased force generation in the
quadriceps to overcome the resistance in the knee.10 Despite the short-
ening of quadriceps leading to increased patellofemoral compression,
no studies have attempted to find the association between quadriceps

* Corresponding author. Srinivas University Institute of physiotherapy, Mangalore, Karnataka, 575001, India.
E-mail address: vnodakr19@gmail.com (A. Rajashekar).

https://doi.org/10.1016/j.jor.2023.06.007
Received 18 February 2023; Received in revised form 9 June 2023; Accepted 17 June 2023
0972-978/© 20XX

Note: Low-resolution images were used to create this PDF. The original images will be used in the final composition.
R. Sannasi et al.
Graph 1. Shows right side PFPS and the number of presence and absence of muscle tightness on right and left sides (RF-R = rectus femoris right, RF-L = rectus
femoris left, H–R = hamstring right, H-L = hamstring left, ITB-R = iliotibial band right, ITB-L = iliotibial band left, G-R = gastrocnemius).
PR
D
Graph 2. Shows left side PFPS and the number of presence and absence of muscle tightness on right and left sides (RF-R = rectus femoris right, RF-L = rectus
femoris left, H–R = hamstring right, H-L = hamstring left, ITB-R = iliotibial band right, ITB-L = iliotibial band left, G-R = gastrocnemius right, G-L = gas-
trocnemius left, QL-R = quadratus lumborum right, QL-L = quadratus lumborum left).
TE
tightness and PFPS so far.10–12 Distally the iliotibial band (ITB) splits
into two functional elements i.e. the Iliopatellar band and the Iliotibial
tract. The presence of lateral structure tightness may increase transla-
tory force and cause abnormal lateral tracking of the patella and in-
creases patellofemoral joint compression.6,13 Reduced length in the gas-
EC
trocnemius also limit the knee extension and is one of the risk factors
for developing PFPS.14 The hip abductor weakness due to trunk insta-
bility is correlated with PFPS as per some studies.15 However the exis-
tence of differences in the length of hamstring, quadriceps, gastrocne-
mius, and ITB between PFPS and control group was found in previous
studies, but the correlation is yet to be ascertained.7,10 Roach et al.8
RR
found the presence of myofascial trigger points on QL, hence it may af-
fect the length of the muscle. Citaker et al. found a significant difference
between the affected and unaffected side of the PFPS patient in terms of
static balance, but no studies have compared the symptomatic and
asymptomatic side in terms of flexibility of muscles of the lower limb.16
Experimental studies have found that stretching exercises in a patient
CO
with PFPS are effective.17
As there is no objective data available to quantify the muscle tight-
ness and PFPS, this study aims to find the association between tightness
of hamstring, quadriceps, ITB, gastrocnemius, and QL muscles and uni-
lateral PFPS patients on affected and unaffected sides.
1.1. Materials and methods
1.1.1. Study design
A cross-sectional study design was employed on 50 participants (21
male and 29 female) with PFPS. A purposive sampling approach was
used to choose the participants for the study, which happened between
September 2021 and august 2022. The sample size was calculated using
formula N = [(Zα+Zβ)/C]2 + 3 = 50 based on the previous study.10
Physical examination and subjective screening were performed to rule
2
Journal of Orthopaedics xxx (xxxx) 1–5
F
OO
out other conditions or other criteria to exclude the participants from
the study.
1.1.2. Participants
Inclusion criteria of the study were participants aged between 18
and 40 with anterior, retro, or peripatellar pain of non-traumatic origin
with minimum severity of 3/10 on the numerical pain rating score for
at least 6 weeks and aggravated during squatting, prolonged sitting,
stair climbing, or descending stairs and running were considered. Pa-
tient s with a history of any surgery in the lumbar, hip, knee, and ankle
region past year, systemic arthritis, bursitis, ligamentous knee injury,
plica syndrome, recurrent patellofemoral dislocation or subluxation,
Osgood Schlatter's decease, Siding lanssen-Johansson syndrome, Hof-
fa's syndrome, ligament laxity, presence of spinal deformity, positive
patellar apprehension test, pregnancy and individuals who have under-
gone physiotherapy for the same were excluded from the study.18–21
1.1.3. Procedure
The principal examiner is a qualified physiotherapist and was purs-
ing master of physiotherapy. Mobile inclinometer was used to measure
the joint range when assessing rectus femoris, hamstring, gastrocne-
mius, ITB muscle length. Inch tape was used to assess the length of the
OL muscle (from inferior angle of the scapula to the couch). Adjustable
table was used to stabilize as well to keep the leg in 90° of knee flexion
and 90° of hip flexion to assess hamstring length. Mobilization belt was
used to stabilize the pelvis while assessing the rectus femoris length.
The muscle length was measured for three times and the average mean
value was considered and it was recorded as tight or normal against
normal bench mark value.
Readers can find the details of the muscle length test procedure else-
where.22–24,26
R. Sannasi et al.
2. Data analysis
Kolmogorov-Smirnov test was used to assess the normality of the
data. As the data did not follow a normal distribution, they were ex-
pressed in median and interquartile ranges. The Chi-square test was
used to find the association between PFPS and muscle tightness. The
strength of association was reported based on Phi Cramer's v criteria
(0.0–0.1 – Negligible association; 0.1 to 0.2 – weak association; 0.2 to
0.4 – moderate association; 0.4 to 0.6 – relatively strong; 0.6 to 0.8 –
strong association; 0.8 to 1.0 – very strong association). The probability
level for all the tests was set at p < 0.05. data were analyzed using sta-
tistical software, statistical package for the social sciences (SPSS) ver-
sion 20.0 (Armonk, NY: IBM Crop.) for Windows 10.
3. Results
There were fifty patients (21 male and 29 female) with a range be-
tween 18 and 39 years of age. 29 and 21 patients were affected right
and left sides respectively The subject's demographic data such as age,
gender, height, weight, VAS and duration of the pain are presented in
PR
Table 1 The number of PFPS patients in right and left as well as the
presence and absence of muscle tightness in right and left sides is shown
in graph 1 and graph 2.
There was a statistically significant association between PFPS and
RF tightness (right chi-square value = 19.997, P < 0.001 and left chi-
square value = 5.520, P = 0.019) with relatively strong and moderate
strength of association respectively. The association between PFPS and
hamstring musculature tightness is not statistically significant and have
D
a weak strength of association. A statistically significant association ex-
ists between PFPS-R and ITB-R with moderate strength of association.
The association between PFPS –L and ITB-L is not statistically signifi-
cant. And the association between PFPS-R and ITB-L as well as PFPS- R
TE
have negative strength of association. A statistically significant associa-
tion found between gastrocnemius and PFPS with relatively strong
strength of the association seen on both sides. The association between
QL muscle tightness and PFPS is not statistically significant, the
strength of the association is weak (Table 2).
EC
4. Discussion
This is the first study to check the association between PFPS and
hamstring, rectus femoris, ITB, gastrocnemius, and QL muscle tightness
on the involved and uninvolved side of the same subject. PFPS patients
tend to have a reduced step length with a limited range of lower ex-
RR
tremity movement to compensate for joint stress. Similarly, in the
course of bilateral tasks, the alteration of the articular kinematics of one
limb may affect the other limb.27
Previous authors reported a reduction in the length of the rectus
femoris in PFPS patients relative to the control group.10–12 The same
trend was observed in our study, along with a statistically significant as-
CO
sociation between PFPS and the rectus femoris muscle tightness. It may
be due to the presence of the altered activation of the quadriceps and its
maximal strength28 and it is the main muscle to attenuate increased
load on the patellofemoral joint, consequently, there may be reduced
flexibility of the lower limb29–31 Also, there may be an increased pull of
the patella causing compression on the knee joint, or excessive activa-
Table 1
Demographic dimensions Median (IQR) Range
Age (Years) 24 (22, 28.3) 18 to 39
Height (cm) 169 (163.5, 183) 155 to 195
Weight (kg) 61 (52, 76.3) 45 to 96
BMI (kg/m2) 20.5 (19.4, 22.1) 16.9 to 32.5
VAS (NPRS) 5 3 to 8
Duration of pain (weeks) 8 6–12
3
Journal of Orthopaedics xxx (xxxx) 1–5
tion of the hip flexors while walking can also result from rectus femoris
muscle tightness.10 A negative association was found on the unaffected
side of the rectus femoris muscle. This finding helps us to place empha-
sis on the evaluation and treatment of PFPS on the implicated side.
A significant association has been found between gastrocnemius and
PFPS, we noticed more reduction in gastrocnemius length in a limb
with PFPS when compared to the normal side. This could be explained
by the observations made by Ota et al. and Chisolm et al. that the range
of ankle dorsiflexion has an inverse impact on the range of knee exten-
sion and extensor torque. Also, a systematic review by Mason-Mackay
F
et al. concluded that the altered landing mechanics is due to a reduced
range of dorsiflexion.10,32
Previous studies were also attempted to find the correlation be-
OO
tween the flexibility of gastrocnemius muscle and PFPS subjects. How-
ever, they used non-weight-bearing positions to measure the ankle dor-
siflexion range of motion,10 and adolescent age group patients,33
whereas we included patients from 18 to 40 years of age as this age
group is commonly affected by PFPS.
The results from this revealed a moderate strength of association be-
tween PFPS and ITB muscle tightness on the affected side. This supports
the hypothesis that PFPS has an association with ITB muscle tightness.
The dynamic and static balance between the lateral and medial stabiliz-
ers is necessary to move the patellofemoral joint painlessly.34–36 Re-
duced length of lateral retinaculum and ITB may increase the joint load
on the patellofemoral joint by pulling the patella laterally.38,39 Michael
et al. reported a decreased tightness of ITB in 17 patients with PFPS
aged between 13 and 17years and ITB length was assessed by Ober's
test. Two studies showed no difference in ITB length when compared to
the PFPS and comparison groups.10,11 Piva et al. used a modified Ober
test on a relatively smaller sample size.30 Smith et al.11 carried out a
study on elite athletes with a mean age of 15.9 years so it cannot be
compared with the results of our study. In our study a negative strength
of association was found between the PFPS and the unaffected side sug-
gesting a strong association between the PFPS and the affected side of
the muscle length.
We failed to prove the hypothesis that there is an association be-
tween hamstring muscle tightness and PFPS, this is in agreement with
Witvrouw et al.12 who stated that hamstring length is not a significant
factor in developing PFPS. But, it is contradicting Piva et al.10 and as
they reported a significant difference in length of hamstring occurs be-
tween PFPS patients and control group. However, they have used pas-
sive straight leg raise test to measure hamstring length which applies
more tension to the sciatic nerve than hamstring muscle as pelvis is not
stabilized during SLR. Hence, passive SLR is a key neurodynamic test to
check the tension in lumbosacral nerve roots37 Whereas, active knee ex-
tension test could be the better option to check the hamstring length as
the pelvis is stabilized proximally.
Our result suggests that QL tightness is not associated with PFPS. As
far as we know this is the first study to draw the QL tightness concept in
PFPS patients. Samani et al. conducted a prevalence study on 30 pa-
tients with PFPS and reported that there is a high prevalence of devel-
oping trigger points in the lumbopelvic muscle.38 The sample size of
this study was very small. However, a difference was noted between the
affected and unaffected sides in terms of length while measuring QL
muscle. It may be due to the trunk leaning ipsilaterally to compensate
for the impairment in the hip musculature.
This study has few limitations. The reliability of the QL length test
we used in our study has not been established so further research is
needed to understand the relationship between PFPS and QL tight-
ness.15 As it is a cross sectional study, It does not explain the cause-and-
effect relationship between the tightness and PFPS. In Addition, the
length of the adductors and proximal hamstring muscle should have
been considered. As the hip flexes during increased loading activities
such as landing from a jump or running, the hip collapse into internal
 R. Sannasi et al.
Table 2
Association of PFPS with rectus femories, gastrocnemius, ITB, hamstring and quadratus lumborum (R–R = right side PFPS vs right side muscle, R-L = right side PFPS vs left side muscle, L-R = Left side PFPS
vs right side muscle, L-L = Left side PFPS vs Left side muscle).
TEST PFPS VS Rectus femoris (R-L) PFPS vs Gastrocnemius (R-L) PFPS vs ITB (R-L)

R–R R-L L-R L-L R–R R-L L-R L-L R–R R-L L-R L-L

Chi square 19.997 9 5.52 19.997 5.52 8.782 11.416 8.782 11.416 7.83 3.67 7.83 3.687
(p < 0.001) (p = 0.019) (p < 0.001) (p = 0.019) (p = 0.003) (p = 0.001) (p = 0.003) (p = 0.001) (p = 0.005) (p = 0.055) (p = 0.005) (p = 0.055)
Phi- 0.632 −0.332 −0.632 0.332 0.49 −0.478 −0.419 0.478 0.396 −0.272 −0.396 0.272
cramer's (p < 0.001) (p = 0.019) (p < 0.001) (p = 0.019) (p = 0.003) (p = 0.001) (p = 0.003) (p = 0.001) (p = 0.005) (p = 0.019) (p = 0.005) (p = 0.019)
PFPS vs Hamstring (R-L) PFPS vs Quadratus lumborum (R-L)

R–R R-L L-R L-L R–R R-L L-R L-L

Chi square 3.687 (p = 0.055) 1.16 (p = 0.291) 3.687 (p = 0.055) 1.116 (p = 0.291) 1.104 (p = 0.293) 0.797 (p = 0.372) 1.104 (p = 0.293) 0.797 (p = 0.372)
Phi-cramer's 0.272 (p = 0.055) −0.149 (p = 0.019) −0.272 (p = 0.055) 0.149 (p = 0.019) 0.149 (p = 0.293) −0.126 (p = 0.372) −0.149 (p = 0.293) 0.126 (p = 0.372)

Journal of Orthopaedics xxx (xxxx) 1–5

O O
P R
D
R. Sannasi et al.
rotation and adduction. Control of femoral rotation is important to re-
establish normal function in the patellofemoral joint.39
5. Conclusion
We found strong association between the rectus femoris, gastrocne-
mius muscle tightness and PFPS. A moderate association has been es-
tablished between ITB tightness and PFPS. Whereas, no relationship
was observed between hamstring, QL muscles tightness and PFPS. This
demonstrated that reduced length of rectus femoris, gastrocnemius and
ITB is associated with PFPS and those muscles have to be considered for
length assessment and treatment in patients with PFPS.
Informed consent
All the participants were thoroughly informed about the procedure
and agreed to participate in the study by signing the informed consent
form.
Institutional ethical committee approval
PR
Ethical approval was obtained from the Institutional Review Board
of the university (in accordance with declaration Helsinki).
Uncited References
25.
D
References
1. Rixe J.A., Glick J.E., Brady J., Olympia R.P. A review of the management of
patellofemoral pain syndrome. Physiother Sport. 2013;41(3):19–28. https://doi.org/
TE
10.3810/psm.2013.09.2023.
2. Barton C.J., Levinger P., Menz H.B., Webster K.E. Kinematic gait characteristics
associated with patellofemoral pain syndrome: a systematic review. Gait Posture.
2009;30(4):405–416. https://doi.org/10.1016/j.gaitpost.2009.07.109.
3. Harvie D., O’Leary T., Kumar S. A systematic review of randomized controlled
trials on exercise parameters in the treatment of patellofemoral pain: what works? J
Multidiscip Healthc. 2011;4:383–392. https://doi.org/10.2147/JMDH.S24595.
4. Jellad A., Kalai A., Guedria M., et al. Combined hip abductor and external rotator
EC
strengthening and hip internal rotator stretching improves pain and function in
patients with patellofemoral pain syndrome: a randomized controlled trial with
crossover design. Orthop J Sports Med. 2021;9(4):2325967121989729. Published
2021 Apr 14. https://doi.org/10.1177/2325967121989729.
5. Petersen W., Ellermann A., Gösele-Koppenburg A., et al. Patellofemoral pain
syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264–2274. https://
doi.org/10.1007/s00167-013-2759-6.
6. Puniello M.S. Iliotibial band tightness and medial patellar glide in patients with
RR
patellofemoral dysfunction. J Orthop Sports Phys Ther. 1993;17(3):144–148. https://
doi.org/10.2519/jospt.1993.17.3.144.
7. White L.C., Dolphin P., Dixon J. Hamstring length in patellofemoral pain
syndrome. Physiotherapy. 2009;95(1):24–28. https://doi.org/10.1016/
j.physio.2008.05.009.
8. Roach S., Sorenson E., Headley B., San Juan J.G. Prevalence of myofascial
trigger points in the hip in patellofemoral pain. Arch Phys Med Rehabil. 2013;94(3):
522–526. https://doi.org/10.1016/j.apmr.2012.10.022.
9. Bhimani R., Gaugler J.E., Felts J. Consensus definition of muscle tightness from
CO
multidisciplinary perspectives. Nurs Res. 2020;69(2):109–115. https://doi.org/
10.1097/NNR.0000000000000404.
10. Piva S.R., Goodnite E.A., Childs J.D. Strength around the hip and flexibility of
soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop
Sports Phys Ther. 2005;35(12):793–801. https://doi.org/10.2519/
jospt.2005.35.12.793.
11. Smith A.D., Stroud L., McQueen C. Flexibility and anterior knee pain in
adolescent elite figure skaters. J Pediatr Orthop. 1991;11(1):77–82. https://doi.org/
10.1097/01241398-199101000-00015.
12. Witvrouw 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(4):480–489. https://doi.org/
10.1177/03635465000280040701.
13. Hudson Z., Darthuy E. Iliotibial band tightness and patellofemoral pain
syndrome: a case-control study. Man Ther. 2009;14(2):147–151. https://doi.org/
10.1016/j.math.2007.12.009.
14. Waryasz G.R., McDermott A.Y. Patellofemoral pain syndrome (PFPS): a
systematic review of anatomy and potential risk factors. Dyn Med. 2008;7(9).
View publication stats
Journal of Orthopaedics xxx (xxxx) 1–5
Published 2008 Jun 26. https://doi.org/10.1186/1476-5918-7-9.
15. Nakagawa T.H., Moriya E.T., Maciel C.D., Serrão F.V. Trunk, pelvis, hip, and
knee kinematics, hip strength, and gluteal muscle activation during a single-leg
squat in males and females with and without patellofemoral pain syndrome. J Orthop
Sports Phys Ther. 2012;42(6):491–501. https://doi.org/10.2519/jospt.2012.3987.
16. Erdoganoglu Y., Pepe M., Kaya D., Tagrikulu B., Aksahin E., Aktekin C.N.
Lower extremity alignment due to patellofemoral syndrome and dynamic postural
balance. J Orthop Surg. 2020;28(1):2309499019900819. https://doi.org/10.1177/
2309499019900819.
17. Peng H.T., Song C.Y. Predictors of treatment response to strengthening and
stretching exercises for patellofemoral pain: an examination of patellar alignment.
Knee. 2015;22(6):494–498. https://doi.org/10.1016/j.knee.2014.10.012.
18. Olivencia O., Godinez G.M., Dages J., et al. The reliability and minimal
F
detectable change of the ely and active knee extension tests. Int J Sports Phys Ther.
2020;15(5):776–782. https://doi.org/10.26603/ijspt20200776.
19. Rathleff M.S., Rathleff C.R., Holden S., Thorborg K., Olesen J.L. Exercise
therapy, patient education, and patellar taping in the treatment of adolescents with
OO
patellofemoral pain: a prospective pilot study with 6 months follow-up. Pilot
Feasibility Stud. 2018;4:73. Published 2018 Apr 13. https://doi.org/10.1186/
s40814-017-02277.
20. Peeler J., Anderson J.E. Effectiveness of static quadriceps stretching in
individuals with patellofemoral joint pain. Clin J Sport Med. 2007;17(4):234–241.
https://doi.org/10.1097/JSM.0b013e3180f60afc.
21. D’Ambrosi R., Migliorini F., Cerciello S., et al. Management of the first episode of
traumatic patellar dislocation: an international survey. Knee Surg Sports Traumatol
Arthrosc. 2023;31(6):2257–2265. https://doi.org/10.1007/s00167-022-07273-z.
22. Reese N.B., Bandy W.D. Use of an inclinometer to measure flexibility of the
iliotibial band using the Ober test and the modified Ober test: differences in
magnitude and reliability of measurements. J Orthop Sports Phys Ther. 2003;33(6):
326–330. https://doi.org/10.2519/jospt.2003.33.6.326.
23. Ferber R., Kendall K.D., McElroy L. Normative and critical criteria for iliotibial
band and iliopsoas muscle flexibility. J Athl Train. 2010;45(4):344–348. https://
doi.org/10.4085/1062-6050-45.4.344.
24. Page P., Frank C.C., Lardner R. Assessment and Treatment of Muscle Imbalance: The
Janda Approach. Human Kinetics; 2014.
25. Muscle length testing. Assessment and Treatment of Muscle Imbalance. 2010;57–58.
Published online. https://doi.org/10.5040/9781718211445.part-002.
26. Chan O., Malhotra K., Buraimoh O., et al. Gastrocnemius tightness: a population
based observational study. Foot Ankle Surg. 2019;25(4):517–522. https://doi.org/
10.1016/j.fas.2018.04.002.
27. Willson J.D., Sharpee R., Meardon S.A., Kernozek T.W. Effects of step length on
patellofemoral joint stress in female runners with and without patellofemoral pain.
Clin Biomech. 2014;29(3):243–247. https://doi.org/10.1016/
j.clinbiomech.2013.12.016.
28. D’Ambrosi R., Meena A., Raj A., Ursino N., Hewett T.E. Anterior knee pain: state
of the art. Sports Med Open. 2022;8(1):98. Published 2022 Jul 30. https://doi.org/
10.1186/s40798-022-00488.
29. Drover J.M., Forand D.R., Herzog W. Influence of active release technique on
quadriceps inhibition and strength: a pilot study. J Manip Physiol Ther. 2004;27(6):
408–413. https://doi.org/10.1016/j.jmpt.2004.05.006.
30. Heino Brechter J., Powers C.M. Patellofemoral stress during walking in persons
with and without patellofemoral pain. Med Sci Sports Exerc. 2002;34(10):
1582–1593. https://doi.org/10.1097/00005768-200210000-00009.
31. Kim S., Park J. Patients with chronic unilateral anterior knee pain experience
bilateral deficits in quadriceps function and lower quarter flexibility: a cross-
sectional study. Physiother Theory Pract. 2022;38(13):2531–2543. https://doi.org/
10.1080/09593985.2021.1946871.
32. Stergiou N., Bates B.T., James S.L. Asynchrony between subtalar and knee joint
function during running. Med Sci Sports Exerc. 1999;31(11):1645–1655. https://
doi.org/10.1097/00005768-199911000-00023.
33. Roush J.R., Curtis Bay R. Prevalence of anterior knee pain in 18-35 year-old
females. Int J Sports Phys Ther. 2012;7(4):396–401.
34. Bourne M.H., Hazel Jr W.A., Scott S.G., Sim F.H. Anterior knee pain. Mayo Clin
Proc. 1988;63(5):482–491. https://doi.org/10.1016/s0025-6196(12)65646-8.
35. Paulos L., Rusche K., Johnson C., Noyes F.R. Patellar malalignment: a treatment
rationale. Phys Ther. 1980;60(12):1624–1632. https://doi.org/10.1093/ptj/
60.12.1624.
36. Brody L.T., Thein J.M. Nonoperative treatment for patellofemoral pain. J Orthop
Sports Phys Ther. 1998;28(5):336–344. https://doi.org/10.2519/
jospt.1998.28.5.336.
37. Majlesi J., Togay H., Unalan H., Toprak S. The sensitivity and specificity of the
Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. J
Clin Rheumatol. 2008;14(2):87–91. https://doi.org/10.1097/
RHU.0b013e31816b2f99.
38. Samani M., Ghaffarinejad F., Abolahrari-Shirazi S., Khodadadi T., Roshan F.
Prevalence and sensitivity of trigger points in lumbo-pelvic-hip muscles in patients
with patellofemoral pain syndrome. J Bodyw Mov Ther. 2020;24(1):126–130.
https://doi.org/10.1016/j.jbmt.2019.10.012.
39. Powers C.M. The influence of abnormal hip mechanics on knee injury: a
biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42–51. https://
doi.org/10.2519/jospt.2010.3337.