Clinical Journal of Sport Medicine, 11:103–110 © 2001 Lippincott Williams & Wilkins, Inc.

, Philadelphia

Critical Review

A Systematic Review of Physical Interventions for Patellofemoral Pain Syndrome
*§Kay Crossley, BAppSc(Physio), Grad Dip Physio(Research), *Kim Bennell, BAppSc(Physio), PhD, †Sally Green, BAppSc(Physio), PhD, Grad Dip(Manip Ther), and ‡Jenny McConnell, BAppSc(Physio), Grad Dip(Manip Ther), MBiomedEng
*Centre for Sports Medicine Research and Education; School of Physiotherapy, University of Melbourne, Melbourne; †Institute of Public Health, Monash University, Melbourne; ‡McConnell and Clements Physiotherapy, Sydney, New South Wales; and §Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia

Objective: 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. Data Sources: 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. Study Selection: 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. Results: 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. Conclusions: 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. Key Words: Patellofemoral joint—Anterior knee pain— Physiotherapy—Physical therapy—Orthoses—Vastus medialis obliquus—Quadriceps—Treatment—Outcome measures— Brace—Patellar tape. Clin J Sport Med 2001;11:103–110.

INTRODUCTION Patellofemoral pain syndrome (PFPS) remains one of the most common and challenging musculoskeletal entities encountered by physiotherapists and sports medicine practitioners.1–3 While the pain associated with PFPS is characteristic, the cause of the pain remains unknown. Traditional beliefs related to articular cartilage damage are countered by the knowledge that articular cartilage is
Address correspondence and reprints to Ms. Kay Crossley, School of Physiotherapy, The University of Melbourne, Melbourne, Victoria, 3010, Australia. E-mail: k.crossley@pgrad.unimelb.edu.au

aneural.4 This has led to theories of pain arising from other structures including subchondral bone,5,6 synovium,7,8 lateral and medial retinaculum,9–11 and the infrapatellar fat pad.12 Since a variety of pathologies may present with similar signs and symptoms, PFPS is an umbrella term used to encompass all anterior or retropatellar pain in the absence of other specific pathology. Other pathologies that may manifest as anterior or retropatellar pain include patellar or quadriceps tendonopathy, bursitis around the patella (including prepatella), meniscal lesions, osteoarthritis, plica syndrome, traction apophysitis around the patellofemoral complex, and hipor spinal-referred pain. 103

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K. CROSSLEY ET AL. RESULTS From the retrieved literature, 16 controlled clinical trials evaluated the effectiveness of a physical intervention for PFPS and were included in the review.16–31 The selection criteria used to define PFPS in the reviewed clinical trials are summarized in Table 2. In general, PFPS was defined as the presence of pain around the patella, which was associated with activities that load the patellofemoral joint (i.e., squatting, stair ascending and descending). While there was some consensus in the literature, no standard definitions were used. Among the small number of clinical trials reviewed, a large number of outcome measurements were used to assess the effects of treatment (Table 3). This probably reflects the absence of a “gold standard” assessment tool for PFPS. Pain was a primary outcome measure in all trials,16,17,19–24,27–30 with most authors opting to use a 10 cm visual analogue scale (VAS). The VAS is reliable and valid in PFPS.29,32–35 A range of functional scales were also included, some of which have been previously tested for reliability and validity in this patient population.32–37 Some trials used scales that were not designed for PFPS, but were intended to measure change in subjects with ligamentous instability38,39,50 or osteoarthritis.40 Global assessments of change, physical activity levels, or functional, clinical, and radiological evaluations were rarely used. The main methodology criteria of the 16 trials are summarized in Table 4. Of these trials, none adhered to all of the recommended requirements for a randomized, controlled trial (randomization, adequate allocation concealment, blinding, and follow-up). No trial described measurements of compliance or cointerventions, and one trial had a high number of participants lost to follow-up. Two studies23,29 only included women and most other studies included more women than men in their sample, which reflects the incidence of PFPS in the general popu-

The lack of understanding of the etiology and pathology associated with patellofemoral pain and dysfunction is reflected in the vast number of treatment options for PFPS. Nonoperative treatments are usually used (especially in the first instance), and physiotherapy is a commonly used conservative physical intervention. Physiotherapy treatments often include vastus medialis obliquus (VMO) strengthening to promote active medial stabilization of the patella within the femoral trochlea13 and/or patellar realignment procedures (taping, bracing, stretching).14,15 While these treatments appear to be based on sound theoretical rationale, the evidence for the efficacy of these interventions is not well established. The purpose of this critical review is to examine the efficacy of nonpharmacological, nonsurgical physical interventions for PFPS. METHODS Computerized bibliographic databases (MEDLINE, Current Contents, CINAHL) were searched without language restrictions from the earliest date to October 2000 using a search strategy detailed in Table 1. In addition, one author (K.C.) hand-searched the reference lists of appropriate conference proceedings, textbooks, and the reference lists of all retrieved articles. The Physiotherapy Evidence Database (PedRO) was searched to confirm that all relevant systematic reviews and clinical trials were included in this review. Of the 89 potentially relevant titles identified by the computerized search, only 16 articles fulfilled the eligibility criteria. The critical eligibility criteria were that the PFPS intervention was neither surgical nor pharmacological, and that the study be a controlled trial with adequately described outcome assessment. One author (K.C.) reviewed the selection criteria, outcome measures, and eligibility criteria.

TABLE 1. Yield from computerized search strategies for MEDLINE, CINAHL, and Current Contents, using a combination of key words and MEDLINE subject headings (MeSH)
Key words 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Patellofemoral Patella Anterior knee pain 1 + 2 or 3 Treatment Extensor mechanism Therapy Electrotherapy Exercise Tape Taping Rehabilitation Physiotherapy 5 + 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 15 4 + 14 16 15 and limits clinical trial MEDLINE 1966–Oct 2000 1,046 5,688 233 6,103 1,097,573 305 455,793 461 78,217 4,961 291 39,936 3,525 1,471,318 1,476 64 CINAHL 1982–Aug 2000 216 231 47 394 31,602 131,523 19,985 176 9,044 861 134 12,406 1,557 64,865 197 5 Current Contents 1990–Oct 2000 662 1,603 184 1,933 292,824 282 159,438 112 37,710 8,377 507 17,726 3,000 357,494 1,370 25

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SYSTEMATIC REVIEW OF TREATMENT FOR PFPS
TABLE 2. Selection criteria used to define patellofemoral pain syndrome in clinical trials
Selection criteria INCLUSION CRITERIA History Peripatellar or retropatellar pain Female only Examination Pain/crepitus on grinding or apprehension test Pain on palpation of the patellar facets Pain on aggravating activities (e.g., stairs, squats) Retropatellar pain on resisted knee extension Calcaneal valgus or forefoot varus >6° Arthroscopic evidence of chondromalacia EXCLUSION CRITERIA History General illness Pregnancy Current medication Previous corticosteroid Previous surgery Previous physiotherapy or orthotic treatment Previous acupuncture treatment History of patellar subluxation or dislocation History of knee joint swelling Known articular cartilage damage Examination Clinical findings of other knee pathology Joint effusion Pain referred from hip or lumbar spine Known disorder that could affect gait Leg length discrepancy >1 cm Q° > 15° (males) or 20° (females) Abnormal radiographs patellar tilt, bipartite, or degeneration Studies Pain scales General (not stated) On activity At worst, least and usual during that day McGill Pain Questionnaire47 Pain intensity perception: NRS-101 Questionnaire48 On squatting, going up/down stairs, walking, running/sitting for 1 hour Questionnaire49 Series of Visual Analog Scale36 Disability scales KPS37 Functional Index Questionnaire32 Patellofemoral Function Scale33 Subjective functional questionnaire Overall knee function Cincinnati Knee Rating Scale38 Patient-specific functional knee scale50 WOMAC40 Disability score: effect of pain on mood, gait, sleep work, sport (not referenced) Physical activity level Participation in sport (and frequency of activity) Activity rating system39 Global improvement score (patient) 3-point scale Patient satisfaction Satisfied discharged; not satisfied continue or refer to consultant Anxiety and depression scales Hospital Anxiety and Depression Scale Functional evaluation Time until pain onset or change during stepping down Maximum number of steps Stair hopping test Pain on walking up 90 steps, walking down 90 steps, isometric knee extension, concentric/eccentric knee extension, vertical-jump test Single-leg squat test, step-up test, and triple-jump test Clinical evaluation Pain on palpation Pain on pressing the patella against the femur General clinical knee examination Radiological patellar position PFCA Muscle function Isokinetic knee extensor function Isometric knee extensor function and muscle inhibition Electromyelogram activity of quads, various activities Thigh circumference Manual muscle test (quadriceps, hamstring, gastrocnemius, tibialis anterior)

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TABLE 3. Outcome measures used in clinical trials for patellofemoral pain syndrome
Outcome measure Study n 12 28,30a 16,17,20,22,24b 21,23b 19 19 29b 23 27 n 10 16,22 21 21 26 23 20,31 19 17 30 n 23 23 n 21 n 17 n 17 n 21 26 20 23b 1

16–20, 22–29,31 23,29 16,21,29,31 16,21,28,29,31 19 16,21 29 30 21,25 22 29 21 16,19,21–26 17,29 20 17,19,22–24 23 23 16,17,19–21,23–28, 30,31 21,22 21 29 29 24 24

1 1 1 5

lation. The average age of participants in the trials varied from adolescents to those in their early 30s.21–23,26,27,31 Most trials used a treatment duration of 4–8 weeks. Table 4 includes a summary of the physiotherapy intervention used in the clinical trials and the results of each trial. DISCUSSION/INTERPRETATION Are Physical Interventions Effective in the Management of PFPS? This review identified and appraised the existing evidence for physical interventions for PFPS. The poor study quality and lack of standardization with respect to interventions and outcome measures prevented metaanalysis, and the inclusion of multiple interventions made it difficult to ascertain treatment effectiveness. Physiotherapy Physiotherapy interventions for PFPS are varied, but mostly focus on VMO retraining. Some trials use standard (open kinetic chain)23,31 or isokinetic quadriceps strengthening.26,31 Other trials17,21,25 use a McConnell-

16 n 4 23,b19c a 23, 25 24 n 2 22,24 n 9 16,23,26,27 18 18,23,27 20,24 17,31

a 4-point scale: 1, discomfort; 2, moderate pain; 3, significant pain; 4, severe pain. b 10 cm visual analogue scale: pressure-pain threshold and pressurepain tolerance. c Pressure-pain threshold and pressure-pain tolerance. NRS, Numerical Rating Scale; KPS, Knee Pain Scale; WOMAC, Western and Ontario and McMaster Universities index; PFCA, Patellofemoral Congruence Angle.

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TABLE 4. Summary of clinical trials for patellofemoral pain syndrome
Sample Total: 60 Drop-outs: 0 Total: 81 Drop-outs: 10 at 3 mos; 32 at 1 yr Total: 113 (45 m, 68 f) Drop-outs: 20 initially; 54 at 1 yr Duration: 4 wk Follow-up: 1 yr Duration: 3 mos. Follow-up: 1 yr Duration: 5 wk Follow-up: 3 mos. Group A: eccentric quadriceps Group B: standard quadriceps Participantsa *(SD) Intervention Effect size for Painb,c *(95% CI) NA Mixed results

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Study (ref no)

Method

Physiotherapy Witvroux16

R, UBA, UBP

Clark17

R, BA, NBP

Harrison21

R, BA, UBP

Age: 20.3 Sym dur: 15.1 Baseline pain: 5.8d Baseline comparability: yes Age: 28d Sym dur: most >12 Baseline pain: 3.9d Baseline comparability: yes Age: 21.8 (7.9) m, 22.9 (8.6) f Sym dur: NA Baseline pain: 4.4A, 4.7B, 4.6C Baseline comparability: yes Duration: 12 wk Follow-up: 1 yr Duration: 8 wk Follow-up: 1 yr Duration: 12 wk or painfree Follow-up: no Duration: 4 wk Follow-up: no Duration: 4 wk Follow-up: no

Ex/no-ex: 0.18 (–1.17, 0.82)e Tape/no-tape: 0.10 (–0.91, 1.11)e A–B: –0.74 (–1.20, 0.27) A–C, –0.45 (–1.20, 0.27) NA NS Group A: eccentric quadriceps Group B: isokinetic quadriceps Group A: eccentric quadriceps, patellar tape Group B: standard quadriceps Group A: standard quadriceps, patellar tape Group B: standard quadriceps Group A: isokinetic quadriceps Group B: standard quadriceps Group C: no treatment NA Mixed significance NA p < 0.05 NA NS NA A and B > no treatment (0.027)

K. CROSSLEY ET AL.

Thomee23 Total: 40 f Drop-outs: 0 Total: 33 (9 m, 14 f) Drop-outs: 10 Total: 75 Drop-outs: 22 Total: 25 (8 m, 17 f) Drop-outs: 0 Total: 29 (16 m, 13 f) Drop-outs: 0

NR, UBA, UBP

Group A: eccentric quadriceps, patellar tape Group B: eccentric quadriceps, no tape Group C: patellar tape Group D: education only Group A: eccentric quadriceps biofeedback, patellar tape/ mobilization Group B: standard quadriceps , mobilize patella Group C: home program-standard quadriceps Group A: eccentric quadriceps Group B: standard quadriceps Both groups: stationary bike and balance

Stiene26

NR, UBA, UBP

Eburne25

NR, BA, NBP

Kowall27

R, UBA, NBP

McMullen31

NR, UBA, NBP

Age 20.2 (3.2) Sym dur: 43 (31.2) Baseline pain: NA Baseline comparability: NA Age: 18.3 (4.0) A; 19.6 (7.5) B Sym dur: 13.1 (12) A; 31.9 (32) B Baseline pain: NA Baseline comparability: no Age: NA Sym dur: NA Baseline pain: NA Baseline comparability: no Age: 29, range 14–40 Sym dur: 30 mos.; range 1–180 mos. Baseline pain: NA Baseline comparability: NA Age: 26.8 (10.3) m, 31.7 (8.4) f Sym dur: 4.3 (2.4) m; 3.8 (2.7) f Baseline pain: NA Baseline comparability: NA Age: NA Sym dur: NA Baseline painf: 2.6A, 2.6B, 2.2C Baseline comparability: no

Patellofemoral orthoses Finestone28 Total: 59 m Drop-outs: 0

R, UBA, NBP

Duration: 14 wk Follow-up: 2 mos.

Group A: elastic knee sleeve with silicone plastic ring Group B: elastic knee sleeve Group C: no treatment

NA NS

Miller24 Total: 59 Drop-outs: 8 Age: NA Sym dur: 3 weeks Baseline pain: NA Baseline comparability: NA Duration: 5 wk Follow-up: 8–12 wk Duration: same day Follow-up: no Duration: 4 wk Follow-up: no Duration: 4 wk Follow-up: 1 yr Duration: 3 wk Follow-up: no Group A: Patellar realignment brace Group B: Infrapatellar knee strap Group C: no brace

R, NBA, NBP

0.09 (–0.64, 0.82)e

Other interventions Rogvi-Hansen30 Total: 40 Drop-outs: 4 Total: 28 Drop-outs: 0 Total: 30 Drop-outs: NA Total: 75 Drop-outs: 5

R, BA, BP

–0.44 (–1.18, 0.30)**

Suter18

R, BA, BP

NA ***p < 0.05 –0.79 (–0.75, 0.83)

Rowlands19

R, NBA, BP

Group A: pulsed GaAs laser (17 mW , 904 nm, f, 1,000 Hz) Group B: sham laser Group A: sacroiliac joint manipulation Group B: sacroiliac joint assessment Group A: chiropractic patellar mobilization Group B: detuned ultrasound Group A: acupuncture treatment Group B: no treatment NA NS

Jenson20

R, NBA, BP

Age: 35A, 31B Sym dur: 4 yr A, 6 yr B Baseline pain: 6.0A; 7.0B Baseline comparability: yes Age: 37(12) A; 31(14) B Sym dur: NA Baseline pain: NA Baseline comparability: NA Age: NA Sym dur: NA Baseline pain: NA Baseline comparability: NA Age: 29.0A, 33.4B Sym dur: 6.4A, 6.8B Baseline pain: 3.5A, 3.1B Baseline comparability: yes Age: 29.1 (6.4) A, 32.4 (5.9) B Sym dur: 3.1 (1.6) A, 3.2 (1.1) B Baseline pain: 6.5A; 6.5B Baseline comparability: yes Age: 14.4 (1.1) A, 15.1 (1.4) B Sym dur: >1.5 Baseline pain: NA Baseline comparability: yes Duration: 8 wk Follow-up: no Duration: 4 wk Follow-up: no Group 1: progressive resistance brace Group 2: no treatment Group 1: soft corrective foot orthoses Group 2: flat insole

Progressive resistance brace NR, UBA, UBP Timm22 Total: 100 (60 m, 40 f) Drop-outs: 0 Total: 20 f Drop-outs: 0

–3.05 (–3.29, 2.80)

Corrective foot orthoses R, UBA, UBP Eng29

NA p < 0.05

a

SYSTEMATIC REVIEW OF TREATMENT FOR PFPS

Participants: Age recorded in years; sym dur, symptom duration recorded in weeks unless stated. Effect size calculated for pain scales as: (*[final scores intervention A] − [final scores intervention B]/common standard deviation; 95% CI, 95% confidence interval, calculated where possible; where no data available to calculate effect size, then significance recorded, NS, not significant p > 0.05. c Pain recorded on a 10 cm Visual Analog Scale unless stated. d Estimated from graphical data. e Effect size calculated from change scores; **standard deviation calculated from range (SD 1/4 range); ***effect calculated on muscle inhibition. f Measured on a 4-point scale. R, randomized; NR, not randomized; BA, blinded assessor; NBA, not blinded assessor; UBA, no recording of assessor blinding; BP, blinded patient; NBP, not blinded patient; UBP, no recording of patient blinding; NA, not available from the information presented; A, intervention A; B, intervention B; C, intervention C; D, intervention D; m, male; f, female; wk, week(s); mos., month(s); yr, year(s). Standard quadriceps strengthening includes open kinetic chain exercises: isometric), terminal extension exercises, and straight leg raises. Eccentric exercise includes step-ups and step-downs, squats, and closed kinetic chain exercises. , included a step down exercise, but much less emphasis on eccentric retraining than standard quadriceps; , wavelength; f, frequency.

b

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K. CROSSLEY ET AL. patients in the intervention group who showed substantial improvement were lost to follow-up. The authors concluded that any of the treatments could provide longterm improvements in pain and function. While the evidence indicates that physiotherapy can reduce the pain associated with PFPS, there is inconclusive evidence to support the superiority of one physiotherapy intervention compared with others. In general the eccentric quadriceps strengthening program resulted in a better treatment response than other forms of strengthening, particularly for functional impairment measures. The inconsistent results may reflect disparity in the rigorous nature of the methodology. In addition, the physiotherapy interventions were standardized for all patients, and it is possible that treatments may be more effective when they are individually tailored to address specific deficits (e.g., altered motor control of the vasti or excessive tightness in soft tissues of the patellofemoral joint). This hypothesis requires investigation in a clinical trial. Patellar Taping Patellar taping was originally developed by McConnell15 as a novel component of the treatment for PFPS. The purported aim of patellar taping is to create a mechanical medial shift of the patella, thus centralizing it within the trochlea groove and improving patellar tracking.15 This patellar realignment may enhance the activation and/or timing of the VMO relative to the vastus lateralis muscle and improve the knee flexion loading response during gait. These taping effects have been recently reviewed.42 Two randomized clinical trials have failed to find any benefits of using patellar tape in addition to physiotherapy intervention. Recently, Clarke et al.17 compared patients who received patellar taping with those who did not. The authors described no benefits over a 3-month period. Kowall and colleagues27 found no differences between a physiotherapy-only group and a physiotherapy with patellar taping group after 4 weeks. The patellar tape was applied only during the exercises; this does not reflect the use of patellar tape in routine clinical practice. These trials question the usefulness of patellar taping in addition to a physiotherapy regimen. Further research is required to establish whether the short-term pain relief associated with patellar taping noted in uncontrolled trials43–45 results in additional benefits for subgroups of patients with PFPS. Patellofemoral Orthoses Two clinical trials have investigated patellofemoral orthoses designed to realign the patella in military populations.24,28 The knee brace evaluated by Finestone et al.28 was compared with an elastic knee sleeve and a no-treatment control. The patellofemoral orthosis was ineffective as fewer recruits using the orthosis had complete resolution of pain compared with recruits in the other groups. In a more recent randomized controlled trial, Miller et al.24 failed to find a difference between a realignment brace, an infrapatellar strap, and no brace. While both studies have significant limitations, there is

based program,15 which includes motor retraining of the VMO in functional weight-bearing activities. This program uses patellar taping, patella mobilization, and stretching in addition to the VMO training to reduce pain and enhance VMO activation. Eight trials evaluated physiotherapy, but none compared the intervention with a placebo control. This may reflect the ethical constraints of withholding treatment or difficulties in establishing an effective placebo for physiotherapy treatment. The results of these trials suggest that physiotherapy may be effective in reducing the pain associated with PFPS. Is One Type of Physiotherapy Intervention More Effective? There is inconsistency in the types of physiotherapy interventions evaluated in these trials, making it difficult to recommend the superiority of one physiotherapy intervention relative to another. Many compared essentially eccentric exercises with alternative forms of quadriceps strengthening (standard or isokinetic strengthening). Five of the trials described an overall better response to treatment in the eccentric exercise group in all or some of the outcome measures.16,17,21,25,26 This provides some evidence to support the use of eccentric exercises over alternative forms of quadriceps strengthening, but these results require further verification before they can be accepted. Two of the most scientifically rigorous trials in this area essentially compared two physiotherapy interventions with a group receiving education and advice.17,21 Harrison et al.21 investigated two physiotherapy treatment options, one of which best reflects the protocol designed by McConnell,15,41 while Clark et al.17 compared four treatment groups: 1) eccentric quadriceps strengthening, 2) eccentric strengthening and patellar tape, 3) patellar tape and advice, and 4) advice only. Despite similar methodology, these two trials reported contrasting results. In the trial by Clark et al.,17 significantly more patients in supervised exercise groups reported greater patient satisfaction and were discharged than in the nonexercising groups. There was no significant difference between the exercise and no-exercise groups for pain (measured on a 10 cm VAS) or function (measured on the WOMAC [Western and Ontario and McMaster Universities index]). At the 12-month follow-up, the patients in the exercise group reported significantly less pain than those in the no-exercise group, and were less likely to have severe knee pain. In contrast, Harrison et al.21 found that the patients in the McConnell-based program showed significant improvements in pain and function compared with a group that had supervised standardized quadriceps exercises, but did not differ from the group given a home standardized quadriceps exercise program only. However, the sample size was only sufficient to detect a large effect between the groups. The large dropout rate (up to 48%) at 12 months may have affected the results at this timepoint, especially since a significantly greater number of
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SYSTEMATIC REVIEW OF TREATMENT FOR PFPS currently no evidence to support the use of these braces in the military setting. The role of patellofemoral orthoses in other populations requires evaluation. Other Interventions Four trials investigated different physical intervention techniques in isolation. These techniques include lowlevel laser,30 chiropractic patellar mobilization,19 acupuncture,20 and sacroiliac joint manipulation.18 Lowlevel laser resulted in no difference in outcome compared with sham laser in a triple-blind trial of patients with arthroscopically confirmed chondromalacia patella.30 Chiropractic patellar mobilization was compared with a placebo treatment in an unblinded trial that failed to show an overall statistical improvement in patient symptoms.19 A 4-week acupuncture treatment significantly improved functional knee symptoms compared with a no-treatment group at 12 months after baseline assessment.20 It is possible that acupuncture may be used as an adjunct to treatment of PFPS for potential pain relief or other physiological responses, but this intervention is associated with a significant placebo effect46 and requires appropriate control in future trials. While pain relief is an important aim of treatment for PFPS, there is insufficient evidence to suggest that the responses in this trial are attributed to the acupuncture intervention, and further research is required to support the use of this intervention. Sacroiliac joint manipulation was found to significantly decrease immediate quadriceps muscle inhibition in a recent randomized controlled trial.18 There was no effect on muscle strength or electromyelographic activation. The authors did not describe how patient blinding was maintained and did not measure pain or function as an outcome. This study provides an interesting mechanism for the use of manipulation, but further investigation is required to establish longer-term effects of this technique and correlations of this impairment measure with pain and functional measures. In summary, there is no evidence to suggest that isolated physical intervention techniques of low-level laser or chiropractic mobilization can improve pain or disability in patients with PFPS. The improvements associated with acupuncture require verification in a placebocontrolled trial, and the effects of sacroiliac joint manipulation on pain and disability are still unknown. Progressive Resistance Brace Timm22 compared a program of high volume submaximal quadriceps strengthening (using a progressive resistance brace) with no treatment and found a significant improvement in pain, radiological patellar alignment, and function. The lack of a control group, in combination with the absence of random allocation and the possibility of nonblinding of the patients and the assessor, makes it difficult to evaluate the effects of this device. Given the expense of this device, future studies are required to confirm its success before clinical recommendations can be made.

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Corrective Foot Orthoses One clinical trial examined the additional benefits of issuing corrective foot orthoses in a group of female PFPS patients with documented rearfoot varus receiving physiotherapy.29 Patients issued with the corrective foot orthoses had significantly less knee pain during aggravating activities after 8 weeks compared with patients issued with a placebo (flat) insole. Although this trial was limited by a short follow-up and potential nonblinding of patients and assessors, it provided some evidence to support the use of corrective foot orthoses as an adjunct to physiotherapy interventions in patients with documented rearfoot varus. Further studies are required to evaluate the appropriate use of corrective foot orthoses in this common knee condition. Until such time, orthoses may provide a useful adjunct to treatment, especially for patients who participate in weight-bearing activities. CONCLUSION The strength of evidence to support the use of physical interventions in the management of PFPS is limited. Interestingly, no intervention was reportedly associated with worsening of symptoms. The randomized, controlled trials are scant and heterogeneous with respect to intervention and outcome assessments. It is clear that placebo-controlled trials are required to confirm or refute the efficacy of physiotherapy interventions. The evidence does not support the use of patellofemoral orthoses, patellar taping, or isolated techniques such as lowlevel laser, chiropractic mobilization, and acupuncture. The evidence suggests that physiotherapy can reduce pain associated with PFPS in the short term. However it is not clear whether this pain reduction is greater than that obtained from a home exercise program. Once efficacy has been established, the next challenge is to confirm the various factors that contribute to the development of PFPS. It is only when these factors can be accurately identified that appropriate treatments can be prescribed for patients within the different subgroups under the “umbrella” of PFPS. Future studies should focus on defining specific interventions and measuring outcomes in a standard, reliable, and valid manner. More scientifically rigorous trials are required to evaluate the relative effectiveness of different interventions. Based on the available evidence, clinicians would be advised to institute a program of education, stretching, and quadriceps strengthening (including eccentric exercises) and possibly the use of soft corrective foot orthoses in the conservative management of PFPS. At this stage there is insufficient evidence to promote or refute the addition of patellar taping, patellofemoral orthoses, or isolated techniques such as low-level laser, chiropractic mobilization, and acupuncture. REFERENCES
1. Baquie P, Brukner P. Injuries presenting to an Australian sports medicine centre: a 12 month study. Clin J Sports Med 1997;7: 28–31.

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Clin J Sport Med, Vol. 11, No. 2, 2001

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