The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning

Are adjunct treatments effective in improving pain and function when added to exercise therapy in people with patellofemoral pain? A systematic review with meta-analysis and appraisal of the quality of interventions

OBJECTIVE

To compare the effectiveness of adjunct treatments combined with exercise to exercise alone in people with patellofemoral pain (PFP) and explore the quality of intervention descriptions in randomised controlled trials (RCTs).

DESIGN

Systematic review.

DATA SOURCES

Seven databases were searched in November 2023.

ELIGIBILITY

RCTs that evaluated the effectiveness of any adjunct treatment combined with exercise to exercise alone on self-reported pain and function in people with PFP.

RESULTS

We included 45 RCTs (2023 participants), with 25 RCTs (1050 participants) contributing to meta-analyses. Pooled analysis indicated very low-certainty evidence that neuromuscular electrical stimulation or monopolar dielectric diathermy combined with exercise leads to small and large improvements in self-reported pain when compared with exercise alone (standardised mean difference (95% CI)=-0.27 (-0.53 to -0.02) and -2.58 (-4.59 to -0.57), respectively) in the short-term. For self-reported pain and function, very low-certainty evidence indicates that knee taping, whole-body vibration, electromyographic biofeedback and knee brace combined with exercise do not differ from exercise alone. Interventions are poorly described in most RCTs, adjunct treatments scored on average 14/24 and exercise therapy 12/24 in the Template for Intervention Description and Replication checklist.

CONCLUSION

Neuromuscular electrical stimulation and monopolar dielectric diathermy combined with exercise seem to improve self-reported pain in people with PFP compared with exercise alone. Knee taping, whole-body vibration, electromyographic biofeedback and knee brace do not offer additional benefits to exercise alone. Most interventions are poorly described, which is detrimental to translating research knowledge into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42020197081.

Effects of high frequency strengthening on pain sensitivity and function in female runners with chronic patellofemoral pain

OBJECTIVE

To investigate the effects of a high frequency strengthening program on function, pain, and pain sensitization in female runners with chronic patellofemoral pain (PFP).

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Thirty female runners (mean age 32 ± 8.1 years) with chronic PFP completed an 8-week home strengthening program.

MAIN OUTCOME MEASURES

Variables assessed at baseline, 8-weeks, and 12 weeks included single leg step down test (SLSD), pain, Anterior Knee Pain Scale (AKPS), University of Wisconsin Running Injury and Recovery Index (UWRI), and quantitative sensory testing.

RESULTS

There was large and statistically significant improvement at 8 and 12 weeks for average knee pain (ηp2 = 0.334, p < 0.001), worst knee pain (ηp2 = 0.351, p < 0.001), SLSD (ηp2 = 0.161, p = 0.001), AKPS (ηp2 = 0.463, p < 0.001), and UWRI (ηp2 = 0.366, p < 0.001). A medium to large effect and statistically significant improvement in pressure pain threshold testing was found for all local and remote structures (ηp2 range, 0.110 to 0.293, range p < 0.001 to p = 0.009) at 8 and 12 weeks.

CONCLUSIONS

There was a significant decrease in local and remote hyperalgesia via mechanical and thermal pain sensitivity testing in female runners with chronic PFP. There was a large effect and significant improvement in self-reported pain and function.

The Immediate Biomechanical Effects of a Flat, Flexible School Shoe in Adolescents with Patellofemoral Pain

INTRODUCTION

Treatment options for adolescent patellofemoral pain (PFP) are limited. School footwear might be a suitable intervention to modulate patellofemoral joint (PFJ) loads in adolescents with PFP. This study examined the immediate effects of a flat, flexible school shoe compared with a traditional school shoe on knee joint kinematics and kinetics, and PFJ reaction force during walking and running in adolescents with PFP.

METHODS

A total of 28 adolescents (12 female, 16 male; mean ± SD age, 14.3 ± 1.7 yr) with PFP walked and ran on an instrumented treadmill in two randomly ordered conditions: (i) flat, flexible school shoe and (ii) traditional school shoe. Three-dimensional marker trajectory and ground reaction force data were sampled at 250 and 1000 Hz, respectively. Continuous ankle and knee joint angles and moments, PFJ reaction force, and ankle power were compared between conditions using one-dimensional statistical parametric mapping paired t -tests ( α < 0.05).

RESULTS

Walking in the flat, flexible school shoe resulted in a significant reduction in knee flexion (15%-35% of gait cycle, P < 0.001), knee extension moment (15%-40% of gait cycle, P < 0.001), and PFJ reaction force (15%-40% of gait cycle, P < 0.001) compared with the traditional school shoe. During running, knee flexion (10%-33% of gait cycle, P < 0.001), knee extension moment (15%-25% of gait cycle, P < 0.001), and PFJ reaction force (15%-25% of gait cycle, P < 0.001) were lower when wearing the flat, flexible school shoe compared with the traditional school shoe.

CONCLUSIONS

PFJ reaction force is reduced when adolescents walk and run in a flat, flexible school shoe compared with a traditional school shoe. Flat, flexible school shoes may be an effective intervention to modulate biomechanical factors related to PFP.

Effect of adding short foot exercise to hip and knee focused exercises in treatment of patients with patellofemoral pain syndrome: a randomized controlled trial

BACKGROUND

Patellofemoral pain syndrome is considered a common cause of anterior knee pain that could disturb function and limit daily activities. The purpose of the study was to investigate the effect of adding short foot exercise on pain, function, balance, and hip abductors, and quadriceps muscles strength in the treatment of patients with patellofemoral pain syndrome.

METHODS

Twenty-eight male and female patients with patellofemoral pain syndrome with age ranged from 18 to 35 years old participated in this study. They were equally and randomly assigned into two groups; the study group which received short foot exercise in addition to hip and knee exercises (n = 14) and thecontrol group which received hip and knee exercises only (n = 14). Participants received their interventions during 6 consecutive weeks (12 sessions). Pain intensity, function, abductors quadriceps muscle strength, and balance were assessed using the Visual Analog Scale, anterior knee pain scale (AKPS), hand-held dynamometer, and the Biodex Balance System respectively. All measurements were taken before and after 6 weeks of intervention in both groups. Multivariate analysis of variance was performed to compare the within and between groups effects for measured variables.

RESULTS

The within-group comparison showed significant improvement in pain severity, function, balance, and hip abductors, and quadriceps muscles strength in both groups post-treatment compared with pre-treatment. Between groups analysis, however, showed no significant statistical difference between both groups in all variables, except in pain, function, and mediolateral stability which showed better improvement compared to the control group.

CONCLUSIONS

Adding short foot exercise to hip and knee exercises improved pain, function, and mediolateral stability in patients with patellofemoral pain syndrome.

TRIAL REGISTRATION

clinicaltrials.gov. NO: NCT05383781. Date 19/ 5/2022.

Global research trends and hotspots in patellofemoral pain syndrome from 2000 to 2023: a bibliometric and visualization study

Background

Patellofemoral pain syndrome (PFPS) is a prevalent condition in sports medicine, and as sports competitions become more popular, the incidence of sports injuries is on the rise. Despite the increasing research on PFPS, there remains a lack of bibliometric analyses on this topic. The aim of this study was to identify the research hotspots and trends in the field of PFPS by reviewing 23 years of literature in this field.

Methods

By analyzing the literature on PFPS research from 2000 to 2023 in the core dataset of the Web of Science database and utilizing bibliometric tools like CiteSpace 6.1, VOSviewer 1.6.18, R-bibliometrix 4.6.1, Pajek 5.16, and Scimago Graphica 1.0.26, our aim was to gain insights into the current status and key areas of PFPS research. The study examined various aspects including the number of publications, countries, institutions, journals, authors, collaborative networks, keywords, and more. Through the visualization of relevant data, we also attempted to forecast future trends in the field.

Results

There were 2,444 publications were included in this visualization study, published in 322 journals by 1,247 authors from 818 institutions in 67 countries. The Journal of Orthopaedic and Sports Physical Therapy had the highest number of publications, with the USA leading in article count. La Trobe University contributed the most articles, while Rathleff MS and Barton CJ emerged as the most prolific authors. Hip and knee strength and core strength, lower extremity kinematics and biomechanics, females (runners), muscle activation, risk factors, gait retraining, clinical practice guidelines, and rehabilitation were research hotspot keywords.

Conclusion

Current research suggests that there is still significant potential for the development of PFPS research. Key areas of focus include the clinical effectiveness of combined hip and knee strengthening to address PFPS, characterization of lower limb kinematics and biomechanics, gait retraining, risk factors, and clinical practice guidelines. Future research could explore the effectiveness of innovative exercise therapies such as blood flow restricting training, gait retraining, and neuromuscular control training for PFPS improvement. Further investigation into gait retraining for runners, particularly females, and clinical efficacy study of a novel PRP formulation for the treatment of PFPS.

The relationship of behavioral and psychological traits with pain sensitivity in females with patellofemoral pain: A cross-sectional study

OBJECTIVE

The purpose of this study was to describe the relationship between behavioral and psychological traits with indicators of central sensitization in female runners with patellofemoral pain (PFP), and to determine if behavioral and psychological traits improve with strength training.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Twenty-eight active females (mean age 32 ± 8.1 years) with PFP completed testing at baseline, 8 weeks (post intervention), and 12 weeks.

MAIN OUTCOME MEASURES

Behavioral and psychological questionnaires included the General Anxiety Disorder-7, Patient Health Questionairre-9, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia-11, and Central Sensitization Inventory. Quantitative sensory testing (QST) measures were also collected. After baseline testing, subjects were instructed in a hip and knee strengthening intervention to be completed twice daily over 8 weeks.

RESULTS

A statistically significant improvement was found at 12 weeks for anxiety (p = .015; ηp (Boling et al., 2010) = 0.099) and kinesiophobia (p = .041; ηp (Boling et al., 2010) = 0.076). There was no significant improvement for depression, catastrophizing, or subjective central sensitization. No significant correlations were found between any of the behavioral and psychological questionnaires with baseline QST variables.

CONCLUSIONS

No relationship was found for behavioral and psychological characteristics with QST measures in female runners with persistent PFP.

Gait biomechanics do not differ between adolescents with and without patellofemoral pain

OBJECTIVES

To determine if adolescents with patellofemoral pain exhibit different biomechanical characteristics to asymptomatic adolescents during walking and running.

METHODS

Twenty-eight adolescents with patellofemoral pain (16 male, 12 female, mean [SD] age: 14.3 [1.7] years) and 24 asymptomatic adolescents (13 male, 11 female, mean [SD] age: 14.1 [1.6] years) participated. Participants walked and ran on an instrumented treadmill in a standardized athletic shoe. Continuous hip, knee, and ankle joint angles and moments, and frontal plane pelvic motion were compared between groups using one-dimensional statistical parametric mapping independent t-tests (alpha <0.05). Cadence and stride length were compared between groups using independent t-tests.

RESULTS

During walking, adolescents with patellofemoral pain had a higher hip extension moment at 7%-8% of the gait cycle (p = 0.04) and walked with a shorter stride length (mean difference [95% confidence interval] = -0.07 [-0.1, -0.01] m). There were no other differences between groups during walking. During running, adolescents with patellofemoral pain had greater knee flexion than asymptomatic adolescents at 35%-40% of the gait cycle (p = 0.04) and ran with a higher cadence (mean difference [95% confidence interval] = 5.8 [2.0, 9.5] steps/min). There were no other statistically significant differences between groups during running.

CONCLUSIONS

Adolescents with patellofemoral pain demonstrate few biomechanical differences to asymptomatic adolescents during walking and running. The identified differences are likely of limited clinical importance. Biomechanical alterations which have been previously associated with patellofemoral pain in adults, may not need to be the target of management of adolescent patellofemoral pain.

Quadriceps or hip exercises for patellofemoral pain? A randomised controlled equivalence trial

OBJECTIVE

To assess effectiveness equivalence between two commonly prescribed 12-week exercise programmes targeting either the quadriceps or the hip muscles in patients with patellofemoral pain (PFP).

METHODS

This randomised controlled equivalence trial included patients with a clinical diagnosis of PFP. Participants were randomly assigned to either a 12-week quadriceps-focused exercise (QE) or a hip-focused exercise (HE) programme. The primary outcome was the change in Anterior Knee Pain Scale (AKPS) (0-100) from baseline to 12-week follow-up. Prespecified equivalence margins of ±8 points on the AKPS were chosen to demonstrate comparable effectiveness. Key secondary outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire pain, physical function and knee-related quality of life subscales.

RESULTS

200 participants underwent randomisation; 100 assigned to QE and 100 to HE (mean age 27.2 years (SD 6.4); 69% women). The least squares mean changes in AKPS (primary outcome) were 7.6 for QE and 7.0 for HE (difference 0.6 points, 95% CI -2.0 to 3.2; test for equivalence p<0.0001), although neither programme surpassed the minimal clinically important change threshold. None of the group differences in key secondary outcomes exceeded predefined equivalence margins.

CONCLUSION

The 12-week QE and HE protocols provided equivalent improvements in symptoms and function for patients with PFP.

TRIAL REGISTRATION NUMBER

NCT03069547.

Cumulative patellofemoral force and stress are lower during faster running compared to slower running in recreational runners

Management strategies for patellofemoral pain often involve modifying running distance or speed. However, the optimal modification strategy to manage patellofemoral joint (PFJ) force and stress accumulated during running warrants further investigation. This study investigated the effect of running speed on peak and cumulative PFJ force and stress in recreational runners. Twenty recreational runners ran on an instrumented treadmill at four speeds (2.5-4.2 m/s). A musculoskeletal model derived peak and cumulative (per 1 km of continuous running) PFJ force and stress for each speed. Cumulative PFJ force and stress decreased with faster speeds (9.3-33.6% reduction for 3.1-4.2 m/s vs. 2.5 m/s). Peak PFJ force and stress significantly increased with faster speeds (9.3-35.6% increase for 3.1-4.2 m/s vs. 2.5 m/s). The largest cumulative PFJ kinetics reductions occurred when speeds increased from 2.5 to 3.1 m/s (13.7-14.2%). Running at faster speeds increases the magnitude of peak PFJ kinetics but conversely results in less accumulated force over a set distance. Selecting moderate running speeds (~3.1 m/s) with reduced training duration or an interval-based approach may be more effective for managing cumulative PFJ kinetics compared to running at slow speeds.

The effects of a two-week neuromuscular intervention on biopsychosocial variables in people with patellofemoral pain: an observational study

Introduction

Patellofemoral pain (PFP) is common and predominately affects active populations. Altered biomechanics and psychosocial variables have been reported in people with PFP, but the effects of neuromuscular exercise on these variables is unknown. We aimed to investigate changes in biopsychosocial measures following a two-week neuromuscular intervention in people with PFP.

Materials and Methods

We measured pain (visual analogue scale), function (Kujala), activity level (Tegner), psychological well-being (Orebro), lower-limb isometric strength (handheld dynamometry), three-dimensional (3D) lower limb kinematics, and surface electromyography (sEMG), in people with PFP. 3D lower-limb kinematics and sEMG were synchronously sampled during step-up, step-down, and overground running. All measures were repeated after participants had completed a two-week neuromuscular intervention consisting of three exercises completed once per day, five days per week.

Results

18 participants completed pre/post testing (60% females, mean age 30.6 years ±7.0, height 173.4cm ±10.4, mass 70.2kg ±12.4, symptom duration 39.0 months ±58.8), with three of 21 participants lost to follow-up. Across all clinical measures (muscle onsets, muscle activation and kinematics), the 95% bootstrapped confidence intervals (CI) of the mean difference contained the null hypothesis following the two-week neuromuscular intervention, indicating no significant differences.

Conclusion

A two-week neuromuscular intervention did not change biomechanical or psychosocial measures in people with PFP. Interventions with a longer duration or greater load magnitude are required to fully evaluate the biopsychosocial mechanisms of effect for exercise in people with PFP.

Patellofemoral Syndrome: a Review of Diagnosis and Treatment

Purpose of Review

Patellofemoral syndrome (PFS) is a common condition seen in people with anterior knee pain. This review explores patient presentations and exam maneuvers used for diagnosis, as well as established/up-and-coming treatment interventions.

Recent Findings

Pain reduction and prevention are the main goals for PFS as they negatively affect quality of life. Combination hip and knee exercises have been found to be most beneficial during therapy due to the multifactorial etiology of PFS. Combining exercise therapy with patellar taping has also shown a reduction in acute pain. Ultrasound may be used to evaluate for associated findings. Blood flow restriction and trigger point injections are options that may be helpful for pain reduction but further research is required.

Summary

PFS is a common clinical diagnosis requiring a robust patient history, supported by various physical exam maneuvers. Treatment involves a patient tailored approach, often with combinations of conservative management and interventional procedures.

Overweight and obesity in young adults with patellofemoral pain: Impact on functional capacity and strength

PURPOSE

This study aimed to (a) investigate the proportion of overweight/obesity in a cohort of young adults with patellofemoral pain (PFP) and (b) explore the association of body mass index (BMI), body fat, and lean mass with functional capacity and hip and knee strength in people with PFP.

METHODS

We included a mixed-sex sample of young adults (18-35 years old) with PFP (n = 100). Measurements for BMI, percentage of body fat, and lean mass (assessed by bioelectrical impedance) were obtained. Functional capacity was assessed by the Anterior Knee Pain Scale, plank test, and single-leg hop test. Strength of the knee extensors, knee flexors, and hip abductors was evaluated isometrically using an isokinetic dynamometer. The proportion of overweight/obesity was calculated based on BMI. The association between BMI, body fat, and lean mass and functional capacity and strength was investigated using partial correlations, followed by hierarchical regression analysis, adjusted for covariates (sex, bilateral pain, and current pain level).

RESULTS

A total of 38% of our cohort had their BMI categorized as overweight/obese. Higher BMI was associated with poor functional capacity (ΔR² = 0.06-0.12, p ≤ 0.001) and with knee flexion strength only (ΔR² = 0.04, p = 0.030). Higher body fat was associated with poor functional capacity (ΔR² = 0.05-0.15, p ≤ 0.015) and reduced strength (ΔR² = 0.15-0.23, p < 0.001). Lower lean mass was associated with poor functional capacity (ΔR² = 0.04-0.13, p ≤ 0.032) and reduced strength (ΔR² = 0.29- 0.31, p < 0.001).

CONCLUSION

BMI, body fat, and lean mass should be considered in the assessment and management of young people with PFP because it may be detrimental to function and strength.

Development of Provisional Acupuncture Guidelines for Pelvic Pain in Endometriosis Using an e-Delphi Consensus Process

Introduction: Growing evidence suggests that acupuncture can improve pelvic pain in women with endometriosis. The treatments used in research vary considerably. It remains unclear which treatment could be recommended for clinical practice. This research project aimed at clarifying how acupuncture could be used when treating this condition. Methods: This research comprised two phases: a systematized literature review to extract acupuncture treatment details from published research, and an e-Delphi study to gain knowledge about details as used by expert acupuncturists. Review: Four databases were searched using predefined eligibility criteria. Data were extracted based on the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. e-Delphi: Purposeful sampling from colleagues and international experts. An open first round gathered qualitative data, analyzed with the Framework method. In rounds 2 and 3, experts rated statements to build group consensus, defined as a rating of ≥5 on a 7-point Likert scale by ≥70% of the experts. The strength of agreement was graded using the median score and interquartile range. Results from the literature review and the e-Delphi were compared using the STRICTA items. Results: The literature review (n = 29 unique studies) found a wide range of treatment details with little agreement. The e-Delphi of international experts (n = 20) resulted in agreement on 94 statements (such as key factors for effectiveness); disagreement on a further 29 (such as acupressure); and absence of consensus on 55 statements (such as the number of needle insertions). A comparison of the review and e-Delphi results found little agreement. Conclusions: Details of acupuncture treatment for endometriosis-related pelvic pain were presented. In the absence of acupuncture guidelines for this condition, the researchers of this e-Delphi recommend using the treatment details on which experts agreed as guidance for good practice. The effectiveness of these guidelines should be evaluated in future research. Study registration: Deutsches Register Klinischer Studien, DRKS00022215, June 30, 2020, retrospectively registered.

Electromyographic analysis of the three subdivisions of gluteus medius during two different exercises: Wall press exercise and figure-of-four position

BACKGROUND

Gluteus medius (GM) is a segmented muscle involving three muscular subdivisions. Rehabilitation exercises has been suggested to strengthen specific subdivisions.

OBJECTIVE

This study aimed to evaluate muscular activation of the anterior, middle, and posterior subdivisions of the GM during two different exercises.

METHODS

A total of 28 healthy active subjects participated in this study. Muscle activity using surface electromyography was recorded for the three GM subdivisions during figure-of-four position (FFP) and wall press (WP). Non-parametric Kruskal-Wallis test was used to detect differences between GM subdivisions on each exercise and the Mann-Whitney U test was used to compare muscular activation across exercises.

RESULTS

There were statistically significant differences (P< 0.001) in all GM subdivision during FFP and WP exercises. Both exercises showed greater activation of the posterior subdivision than the middle and anterior subdivisions, with the WP causing highest activation of the posterior subdivision.

CONCLUSION

In line with the WP exercise, the FFP produces sufficient activity to provide potential strength gains on the posterior subdivision and could be a viable option to include in the early stages of the rehabilitation process. Clinicians may use this information to make more informed decisions about exercise selection for strengthening specific GM subdivision.

Morphometric Parameters and MRI Morphological Changes of the Knee and Patella in Physically Active Adolescents

Background and Objectives: The immature skeleton in a pediatric population exposed to frequent physical activity might be extremely prone to injuries, with possible consequences later in adulthood. The main aim of this study is to present specific morphometric parameters and magnetic resonance imaging (MRI) morphological changes of the knee and patella in a physically active pediatric population. Additionally, we wanted to investigate the morphological risk factors for patellar instability. Materials and Methods: The study included the MRI findings of 193 physically active pediatric patients with knee pain. The participants underwent sports activities for 5 to 8 h per week. Two divisions were performed: by age and by patellar type. We evaluated three age groups: group 1 (age 11-14), group 2 (age 15-17), and group 3 (age 18-21 years). In addition, participants were divided by the patellar type (according to Wiberg) into three groups. The following morphometric parameters were calculated: lateral trochlear inclination (LTI), the tibial tubercle-trochlear groove distance (TT-TG), trochlear facet asymmetry (TFA), Insall-Salvati index, modified Insall-Salvati index, Caton-Deschamps index, articular overlap, morphology ratio and contact surface ratio. Results: We found a statistically significant association between patellar type groups in LTI (p < 0.001), TFA (p < 0.001), Insal-Salvati (p = 0.001) index, and Caton-Deschamps index (p = 0.018). According to age groups, we found statistical significance in the Caton-Deschamps index (p = 0.039). The most frequent knee injury parameter, according to Wiberg, in physically active pediatric patients was patella type 2 in boys and type 3 in girls. Conclusions: The MRI morphometric parameters observed in our study might be factors of prediction of knee injury in physically active children. In addition, it might be very useful in sports programs to improve the biomechanics of the knee in order to reduce the injury rate in sports-active children.

Running gait modifications can lead to immediate reductions in patellofemoral pain

Gait modifications are commonly advocated to decrease knee forces and pain in runners with patellofemoral pain (PFP). However, it remains unknown if clinicians can expect immediate effects on symptoms. Our objectives were (1) to compare the immediate effects of gait modifications on pain and kinetics of runners with PFP; (2) to compare kinetic changes in responders and non-responders; and (3) to compare the effects between rearfoot strikers (RFS) and non-RFS. Sixty-eight runners with PFP (42 women, 26 men) ran normally on a treadmill before testing six modifications: 1- increase step rate by 10%; 2- 180 steps per minute; 3- decrease step rate by 10%; 4- forefoot striking; 5- heel striking; 6- running softer. Overall, there were more responders (pain decreased ≥1/10 compared with normal gait) during forefoot striking and increasing step rate by 10% (both 35%). Responders showed greater reductions in peak patellofemoral joint force than non-responders during all conditions except heel striking. When compared with non-RFS, RFS reduced peak patellofemoral joint force in a significant manner (P < 0.001) during forefoot striking (partial η ² = 0.452) and running softer (partial η ² = 0.302). Increasing step rate by 10% reduced peak patellofemoral joint force in both RFS and non-RFS. Forty-two percent of symptomatic runners reported immediate reductions in pain during ≥1 modification, and 28% had reduced pain during ≥3 modifications. Gait modifications leading to decreased patellofemoral joint forces may be associated with immediate pain reductions in runners with PFP. Other mechanisms may be involved, given that some runners reported decreased symptoms regardless of kinetic changes.

Six Treatments Have Positive Effects at 3 Months for People With Patellofemoral Pain: A Systematic Review With Meta-analysis

OBJECTIVE: To determine the effects of nonsurgical treatments on pain and function in people with patellofemoral pain (PFP). DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched MEDLINE, Web of Science, and Scopus databases from their inception until May 2022 for interventional randomized controlled trials (RCTs) in people with PFP. STUDY SELECTION CRITERIA: We included RCTs that were scored ≥7 on the PEDro scale. DATA SYNTHESIS: We extracted homogenous pain and function data at short- (≤3 months), medium- (>3 to ≤12 months) and long-term (>12 months) follow-up. Interventions demonstrated primary efficacy if outcomes were superior to sham, placebo, or wait-and-see control. Interventions demonstrated secondary efficacy if outcomes were superior to an intervention with primary efficacy. RESULTS: We included 65 RCTs. Four interventions demonstrated short-term primary efficacy: knee-targeted exercise therapy for pain (standardized mean difference [SMD], 1.16; 95% CI: 0.66, 1.66) and function (SMD, 1.19; 95% CI: 0.51, 1.88), combined interventions for pain (SMD, 0.79; 95% CI: 0.26, 1.29) and function (SMD, 0.98; 95% CI: 0.47, 1.49), foot orthoses for global rating of change (OR = 4.31; 95% CI: 1.48, 12.56), and lower-quadrant manual therapy for function (SMD, 2.30; 95% CI: 1.60, 3.00). Two interventions demonstrated short-term secondary efficacy compared to knee-targeted exercise therapy: hip-and-knee-targeted exercise therapy for pain (SMD, 1.02; 95% CI: 0.58, 1.46) and function (SMD, 1.03; 95% CI: 0.61, 1.45), and knee-targeted exercise therapy and perineural dextrose injection for pain (SMD, 1.34; 95% CI: 0.72, 1.95) and function (SMD, 1.21; 95% CI: 0.60, 1.82). CONCLUSIONS: Six interventions had positive effects at 3 months for people with PFP, with no intervention adequately tested beyond this time point. J Orthop Sports Phys Ther 2022;52(11):750-768. Epub: 8 September 2022. doi:10.2519/jospt.2022.11359.

Change of the cross-sectional area of vastus medialis oblique in patients with recurrent patellar dislocation treated by tibial tubercle transfer combined with medial patellofemoral ligament reconstruction on axial CT

PURPOSE

To investigate the change of the cross-sectional area (CSA) of vastus medialis oblique (VMO) in patients with recurrent patellar dislocation (RPD) treated by tibial tubercle transfer combined with medial patellofemoral ligament (MPFL) reconstruction by imaging methods, and to guide clinical treatment and rehabilitation.

METHODS

From October 2015 to March 2022, 23 patients with RPD who underwent tibial tubercle transfer combined with MPFL reconstruction were retrospectively enrolled. All patients were assessed by CT in the supine position with the knee fully extended and the quadriceps relaxed. The CSA of VMO and the ratio of CSA of VMO to body weight (CSA/BW) were measured at the upper pole of the patella, 5 mm above the upper pole of the patella and 5 mm below the upper pole of patella. The differences of measured parameters were compared before surgery and at follow-up, including CSA of VMO and CSA/BW. Test level α = 0.05.

RESULTS

The tibial tubercle-trochlear groove (TT-TG) distance was significantly reduced at follow-up compared with that before surgery (27.91 ± 1.95 mm vs 12.33 ± 1.07 mm, P < 0.001). The CSA of VMO was significantly increased at follow-up compared with that before surgery at 5 mm below the upper pole of the patella (473.06 ± 106.32 mm² vs 562.97 ± 157.90 mm², P < 0.001), at the upper pole of the patella (641.23 ± 188.45 mm² vs 700.23 ± 177.55 mm², P = 0.029), and at 5 mm above the upper pole of the patella (788.25 ± 238.62 mm² vs 849.79 ± 180.84 mm², P = 0.018). The CSA/BW was significantly increased at follow-up compared with that before surgery at 5 mm below the upper pole of the patella (7.83 ± 2.52 mm²/kg vs 9.22 ± 3.54 mm²/kg, P < 0.001), at the upper pole of the patella (10.48 ± 3.62 mm²/kg vs 11.42 ± 4.14 mm²/kg, P = 0.020), and at 5 mm above the upper pole of the patella (12.86 ± 4.65 mm²/kg vs 13.68 ± 3.86 mm²/kg, P = 0.017).

CONCLUSION

After tibial tubercle transfer combined with MPFL reconstruction, CSA of VMO increased in patients with RPD, which will help to enhance patellar stability and reduce recurrence.

Strategies to prevent and manage running-related knee injuries: a systematic review of randomised controlled trials

OBJECTIVE

To evaluate the effectiveness of interventions to prevent and manage knee injuries in runners.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Web of Science and SPORTDiscus up to May 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) with a primary aim of evaluating the effectiveness of intervention(s) to prevent or manage running-related knee injury.

RESULTS

Thirty RCTs (18 prevention, 12 management) analysed multiple interventions in novice and recreational running populations. Low-certainty evidence (one trial, 320 participants) indicated that running technique retraining (to land softer) reduced the risk of knee injury compared with control treadmill running (risk ratio (RR) 0.32, 95% CI 0.16 to 0.63). Very low-certainty to low-certainty evidence from 17 other prevention trials (participant range: 24 -3287) indicated that various footwear options, multicomponent exercise therapy, graduated running programmes and online and in person injury prevention education programmes did not influence knee injury risk (RR range: 0.55-1.06). In runners with patellofemoral pain, very low-certainty to low-certainty evidence indicated that running technique retraining strategies, medial-wedged foot orthoses, multicomponent exercise therapy and osteopathic manipulation can reduce knee pain in the short-term (standardised mean difference range: -4.96 to -0.90).

CONCLUSION

There is low-certainty evidence that running technique retraining to land softer may reduce knee injury risk by two-thirds. Very low-certainty to low-certainty evidence suggests that running-related patellofemoral pain may be effectively managed through a variety of active (eg, running technique retraining, multicomponent exercise therapy) and passive interventions (eg, foot orthoses, osteopathic manipulation).

PROSPERO REGISTRATION NUMBER

CRD42020150630.

Immediate effects of hip strap and foot orthoses on self-reported measures and lower limb kinematics during functional tasks in individuals with patellofemoral osteoarthritis: protocol for a randomised crossover clinical trial

Background

Elevated patellofemoral joint stress has been associated with patellofemoral osteoarthritis (PFOA). Changes in lower limb kinematics, such as excessive femoral adduction and internal rotation and excessive rearfoot eversion during the stance phase of functional activities, may increase patellofemoral stress. There is a lack of studies that assess the effects of interventions for controlling femur and subtalar joint movements during functional activities on self-reported measures in individuals with PFOA. Thus, the primary aim of the study is to determine the immediate effects of the hip strap and foot orthoses during level-ground walking and the single-leg squat test on self-reported outcomes. The secondary aim is to investigate whether the hip strap and foot orthoses result in the kinematic changes that these devices are purported to cause.

Methods

Twenty-nine individuals with PFOA aged 50 years or older will take part in the study. The main outcome is pain intensity. The secondary outcomes are other self-reported measures (global rating of change, acceptable state of symptoms, ease of performance, and confidence) and lower limb kinematics (peak femoral adduction and internal rotation, and peak rearfoot eversion). These outcomes will be assessed during functional tasks performed under three conditions: (i) control condition, (ii) hip strap intervention, and (iii) foot orthoses intervention. To investigate whether these interventions result in the lower limb kinematic changes that they are purported to cause, three-dimensional kinematics of the femur and rearfoot will be captured during each task. Linear mixed models with two fixed factors will be used to test associations between the interventions (control, hip strap, and foot orthoses) and conditions (level-ground walking and single-leg squat test) as well as interactions between the interventions and conditions.

Discussion

To the best of the authors’ knowledge, this is the first study to evaluate the immediate effects of the hip strap and foot orthoses on self-reported measures and lower limb kinematics during functional tasks in individuals with PFOA. The findings of this study will enable future trials to investigate the effects of these interventions in rehabilitation programmes.

Trial registration

ClinicalTrials.gov NCT04332900. Registered on 3 April 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06676-0.

Exploring patients' and physiotherapists' visions on modelling treatments and optimising self-management strategies for patellofemoral pain: A future workshop approach

OBJECTIVE

To identify challenges confronting patients and physiotherapists in managing patellofemoral pain by seeking their perspectives via generative activities involving critique, ideation and formulating shared visions for future treatments.

DESIGN

Two Future Workshops, Reflexive Thematic Analysis.

METHODS

We recruited 8 patients (median age 36 yrs, 4 women) who were experiencing patellofemoral pain and 10 physiotherapists (54 yrs, 8 women) who treated patients with the condition. Several vignette cases and design cards were constructed and included as tools for facilitating dialogue, throughout all three phases (each ∼40 min duration) of the workshops (i.e., critique, fantasy, implementation). Participants' discussions were audio recorded, transcribed and thematically analyzed independently by four investigators until no additional themes emerged.

RESULTS/FINDINGS

Four themes were identified; (i) challenges confronting patients, (ii) learning to manage patellofemoral pain (knowledge), (iii) stakeholder accountability and (iv) development/use of portable applications (apps). Some challenges and strategies were related to family and social networks, financial costs, and psychological factors. Knowledge related to the condition, mental and physical impact of pain, exercises and physical activity. The physiotherapist's role in moderating accurate information was raised, as was that of the GP and personal trainer. Visions of future treatments centered about the inclusion of flexible modes of communication and cultivating mutual accountability. Social determinants and the invisible work of patients in managing their condition was apparent.

CONCLUSION

Enacting patient centered care was sought/recommended - requiring consideration of social contexts and flexible delivery. The physiotherapist was seen as a source of accurate information and a point of accountability.

Protocol for a randomised, assessor-blinded, parallel group feasibility trial of flat flexible school shoes for adolescents with patellofemoral pain

Background

There are limited evidence-based treatment options for adolescents with patellofemoral pain (PFP). Flat, flexible footwear have been shown to reduce patellofemoral joint loading and pain in adults with PFP. The efficacy of this intervention in adolescents with PFP is not established. The primary aim of this study is to determine the feasibility of conducting a large-scale randomised controlled trial (RCT) of the effect of flat, flexible school footwear, when compared to traditional school footwear, in adolescents with PFP. The secondary aim is to describe changes in self-reported outcome measures for adolescents with PFP while wearing flat, flexible footwear when compared to traditional school shoes.

Methods

Twenty-four adolescents with PFP will be recruited from the community. Following baseline assessment, participants will be randomly allocated to receive either (i) flat, flexible school footwear or, (ii) traditional school footwear. Participants will wear the shoe as per school requirements throughout a 12-week intervention period. Feasibility will be assessed with (i) ≥ 75% adherence to allocated shoe wear of their total weekly school wear time, (ii) a recruitment rate of one participant per fortnight, and (iii) a dropout rate of ≤ 20%. Patient reported outcome measures will describe changes in knee pain, function, quality of life and global rating of change at 6 and 12 weeks. Descriptive statistics will be used for the primary outcomes of feasibility.

Discussion

This study will determine the feasibility of conducting a large scale RCT evaluating the effect of flat, flexible school shoes for adolescents with PFP. A full-scale study will guide evidence-based management of adolescent PFP.

Trial registration

Australian New Zealand Clinical Trials Registry reference: ACTRN12621001525875, Date registered: 9th November 2021.

Interventions used by Brazilian physiotherapists in the rehabilitation of patellofemoral pain: A web-based survey

BACKGROUND

No studies have evaluated whether interventions used by Brazilian physiotherapists for the treatment of patellofemoral pain (PFP) are in line with the best existing scientific evidence.

OBJECTIVES

Identify the interventions most commonly used by Brazilian physiotherapists for the rehabilitation of PFP and determine whether characteristics of physiotherapists and knowledge regarding evidence-based practice (EBP) influence the choice of interventions.

DESIGN

Cross-sectional web-based survey.

METHODS

Brazilian physiotherapists who treat patients with PFP participated in the study. Characteristics of the participants, information regarding EBP and interventions used in the treatment of PFP were collected through an online questionnaire. Descriptive analysis of the data was performed. Logistic regression analysis was employed to investigate associations between the interventions and both the characteristics of the physiotherapists and their knowledge regarding EBP.

RESULTS

One hundred and ninety-four physiotherapists completed the questionnaire, 97.4% of whom reported using combined hip and quadriceps strengthening exercises, whereas only 25.3% reported using foot orthoses. A significant number of physiotherapists also reported using interventions that are not recommended (such as patellar mobilization, lumbar, hip and knee mobilization/manipulation and biophysical agents). Physiotherapists with a master's or doctoral degree and those who were aware of clinical practice guidelines were respectively 2.57-fold and 3.81-fold more likely to use recommended interventions.

CONCLUSION

Most Brazilian physiotherapists choose interventions that are in line with current scientific evidence. However, a significant number also use interventions that are not recommended for the treatment of PFP.

Clinicians' experience of the diagnosis and management of patellofemoral pain: A qualitative exploration

BACKGROUND

Patellofemoral pain (PFP) is common and has a poor long-term prognosis. There is a lack of clarity about the clinical reasoning of recognised inter-disciplinary experts in the published literature.

OBJECTIVES

To help identify best practice by exploring the clinical reasoning of a range of inter-disciplinary experts that regularly diagnose and treat PFP.

DESIGN

Qualitative study with semi-structured interviews.

METHOD

Recruitment resulted in a convenience sample for semi-structured interview, which were recorded and transcribed verbatim. Data were analysed until theoretical saturation, as determined by multiple investigators.

FINDINGS

Interviews with 19 clinical experts (15 men, 4 women; mean experience 18.6 years ± 8.6) from four broad professions yielded four themes. Firstly, the assessment and diagnosis process should include a thorough history and examination to rule in PFP. Secondly, information provision should aim to increase patients' understanding, aid in controlling symptoms, and facilitate behaviour change. Thirdly, active rehabilitation, which was a salient theme and included advocacy of combined hip and knee exercise that is adapted to the individual. Finally, treatment adjuncts, which can be used selectively to modify symptoms, may include running retraining, taping, or foot orthoses.

CONCLUSIONS

PFP should be diagnosed clinically, and tailored treatment programmes should be prescribed for people with PFP. Exercise was considered the most effective treatment and underlying psychological factors should be addressed to improve prognosis.

Strength, Flexibility and Postural Control of the Trunk and Lower Body in Participants with and without Patellofemoral Pain

Patellofemoral pain (PFP) is a frequent knee condition. The aim of this study was to investigate strength, flexibility and postural control in people with and without PFP. Fifty-five participants between 14 and 54 years of age (PFP = 18, control group = 37) were included. Strength and flexibility for all trunk, hip, knee and ankle muscle groups were measured along with postural control outcomes. Analyses were conducted based on the “affected” and “non-affected” leg within-group and between-groups. Between-groups analysis demonstrated a statistically lower strength of trunk muscles (range: 35.8–29.3%, p < 0.001), knee extensors (20.8%, p = 0.005) and knee flexors (17.4%, p = 0.020) in PFP participants. Within-group analysis proved an 8.7% (p = 0.018) greater hip internal rotation strength and ankle extension flexibility (p = 0.032) of the “affected side” in PFP participants. This was, to our knowledge, the first study to investigate the strength of all trunk muscle groups. The results indicate that participants with PFP exhibit impaired strength of trunk muscle groups, along with knee muscle deficits, which may present a rehabilitation target. Clinicians should consider implementing trunk strengthening exercises into PFP programs along with knee-targeting exercise programs.

Patient experience of the diagnosis and management of patellofemoral pain: A qualitative exploration

BACKGROUND

Patellofemoral pain (PFP) is common and long-term treatment outcomes are unsatisfactory. Qualitative exploration of diagnosis and management from the perspective of people with PFP is lacking.

OBJECTIVES

To inform care and improve intervention delivery by exploring the experience of people with PFP regarding diagnosis and management.

DESIGN

Qualitative study with semi-structured interviews.

METHOD

Online recruiting yielded a convenience sample of participants with PFP for semi-structured interview. Interviews were recorded, transcribed verbatim, and analysed using thematic analysis until theoretical saturation by multiple investigators to determine themes and sub-themes.

RESULTS

12 participants were interviewed, with three themes identified; the value of diagnosis, the need for tailored (individualised) care, and the role of education. Participants viewed receiving a diagnosis as essential to guide management, yet one was rarely provided, causing uncertainty about pain mechanisms; "it's nice to be told what it is that's wrong". Interventions needed to be tailored to the individual as not all participants responded in the same way to treatment(s) or had the same needs; "everyone copes and reacts differently". Finally, participants viewed education as essential to empower them to understand and manage the condition; "if I'd have been given more information, I think I'd know how to deal with it more".

CONCLUSIONS

The overarching narrative from three themes was a desire for clearly communicated personalised care that meets individual needs. People with PFP desire a diagnosis to explain their pain, tailored interventions, and appropriate education to optimise their experience and outcomes.

Confidence and Knowledge of Athletic Trainers in Managing Patellofemoral Pain

CONTEXT

Patellofemoral pain (PFP) is prevalent and challenging to manage. Most patients with PFP are unsatisfied with their knee function at 6 months after treatment and report ongoing pain up to 16 years after diagnosis. The confidence and knowledge of athletic trainers (ATs) in providing evidence-based care to people with PFP is unknown.

OBJECTIVE

To investigate the confidence and knowledge of ATs in the diagnosis, risk factors, prognosis, and treatment with current evidence for PFP.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENT OR OTHER PARTICIPANTS

A random sample of 3000 ATs were invited to participate; 261 completed the survey (10% participation rate, 88% completion rate).

MAIN OUTCOME MEASURES(S)

We surveyed AT demographics, confidence in PFP management, and knowledge related to diagnosis, risk factors, prognosis, and treatment. The confidence and knowledge of ATs in managing PFP was assessed. Their beliefs about evidence were compared with the available evidence (ie, consensus statements, position statements, systematic reviews).

RESULTS

Of the ATs surveyed, 91% were confident that their management of PFP aligned with the current evidence, but only 59% were confident in identifying risk factors for PFP development. In addition, 91% to 92% of ATs agreed that quadriceps and hip muscle weakness were risk factors for PFP, which aligns with the current evidence for the former but not the latter. Moreover, 93% to 97% of ATs' responses related to therapeutic exercise aligned with current evidence. However, 35% to 48% supported the use of passive treatments, such as electrophysical agents and ultrasound, which did not align with the current evidence.

CONCLUSIONS

Most ATs were aware of supporting evidence for therapeutic exercise in PFP management and were confident providing it, creating a strong foundation for evidence-based care. However, varying levels of awareness of the evidence related to risk factors and passive treatments for PFP highlight the need for professional development initiatives to better align ATs' knowledge with the current evidence.

Optimizing Rehabilitation and Return to Sport in Athletes With Anterior Knee Pain Using a Biomechanical Perspective

Anterior knee pain represents one of the most common athletic knee conditions and arguably also one of the most complex. The patellofemoral joint is at the center of several forces, and alterations in any of these force vectors due to muscular imbalance, soft-tissue tightness or laxity, and altered functional movement patterns can all combine to create a painful anterior knee. While typically anterior knee pain is not a surgical entity, the orthopaedic surgeon with an understanding of these biomechanical intricacies is best positioned to provide comprehensive evidence-based care for the patient with anterior knee pain.

Level of Evidence

V, expert opinion.

Assessing biomechanics and associated factors in individuals with patellofemoral pain in a clinical setting: A qualitative study based on interviews with expert clinicians

OBJECTIVES

To explore the perspectives of ten clinicians from different medical disciplines with experience in managing PFP on how to conduct biomechanical assessments in individuals with PFP in a clinical setting.

METHODS

An explorative qualitative design was used to explore the perspectives of ten clinicians with at least five years of experience managing patients with patellofemoral pain. A series of semi-structured interviews were done over Zoom video chat. The participants were from six different medical disciplines (physiotherapy, biokinetics, podiatry, sport science, sports medicine, orthopaedic surgery). Data was analysed thematically.

RESULTS

Four main themes emerged from the data. These were: 1) biomechanical contributing factors that clinicians routinely screen for in patients with PFP; 2) relevant functional activities for biomechanical screening in patients with PFP; 3) conducting gait analysis assessments in a clinical setting; and 4) challenges of biomechanical assessment in patients with PFP. The clinicians expressed conflicting opinions on the usefulness of clinical gait analysis. The clinicians questioned the clinical applicability of some of the biomechanical factors identified as important in the evidence.

CONCLUSIONS

It is important for clinicians to include the biomechanical assessment of functional activities linked to pain when managing patients with PFP. However, some of the biomechanical factors identified in the evidence are too difficult to observe without 3D movement analysis equipment and should not be considered clinically relevant. Expert clinical opinion is important to provide contextual information when addressing biomechanics in individuals with PFP.

How Do Hip Exercises Improve Pain in Individuals With Patellofemoral Pain? Secondary Mediation Analysis of Strength and Psychological Factors as Mechanisms

OBJECTIVE

To determine whether the effect of hip exercise on patellofemoral pain is mediated through changes in hip muscle strength or psychological factors.

DESIGN

Secondary mediation analysis of a randomized clinical trial, in which 218 participants with patellofemoral pain were randomly assigned to receive foot orthoses or hip exercises.

METHODS

Pain (Knee injury and Osteoarthritis Outcome Score pain subscale) and number of pain-free squats at 12 weeks were the outcomes for this mediation analysis, as they are pathognomonic of patellofemoral pain. Hip strength dynamometry (abduction, adduction, and external rotation) and psychological characteristics (pain catastrophizing, kinesiophobia, and anxiety) measured at 6 weeks were considered as potential mediators. We used mediation analysis to decompose the total effect of treatment on the outcome into (1) the "indirect effect" (ie, the portion acting through the mediator) and (2) the "direct effect."

RESULTS

The effect of hip exercise on pain and squats was not mediated by any of the strength or psychological mediators analyzed. All indirect effects were small and showed wide 95% confidence intervals (CIs) that contained zero (eg, for pain-free squats: abduction strength, -0.13; 95% CI: -0.49, 0.23; Tampa Scale of Kinesiophobia, -0.17; 95% CI: -0.64, 0.30).

CONCLUSION

Hip strength improved after hip exercise, yet strength did not mediate improvements in pain and pain-free squats, and alternative psychological mediators were not implicated. J Orthop Sports Phys Ther 2021;51(12):602-610. doi:10.2519/jospt.2021.10674.

Short foot exercises have additional effects on knee pain, foot biomechanics, and lower extremity muscle strength in patients with patellofemoral pain

BACKGROUND

Patellofemoral pain (PFP) is a common knee problem. The foot posture in a relaxed stance is reported as a distal factor of PFP. However, the effects of short foot exercise (SFE) on the knee and functional factors have not yet been investigated in patients with PFP.

OBJECTIVE

This study aimed to investigate the additional effects of SFE on knee pain, foot biomechanics, and lower extremity muscle strength in patients with PFP following a standard exercise program.

METHODS

Thirty patients with a 'weak and pronated' foot subgroup of PFP were randomized into a control group (ConG, n= 15) and a short foot exercise group (SFEG, n= 15) with concealed allocation and blinded to the group assignment. The program of ConG consisted of hip and knee strengthening and stretching exercises. SFEG program consisted of additional SFE. Both groups performed the supervised training protocol two times per week for 6 weeks. Assessment measures were pain visual analog scale (pVAS), Kujala Patellofemoral Score (KPS), navicular drop test (NDT), rearfoot angle (RA), foot posture index (FPI), and strength tests of the lower extremity muscles.

RESULTS

Both groups displayed decreases in pVAS scores, but it was only significant in favor of SFEG. NDT, RA, and FPI scores decreased in SFEG whereas they increased in ConG. There was a significant group-by-time interaction effect in hip extensor strength and between-group difference was found to be significantly in favor of SFEG.

CONCLUSIONS

An intervention program consisting of additional SFE had positive effects on knee pain, navicular position, and rearfoot posture. An increase in the strength of the hip extensors may also be associated with improved stabilization by SFE.

Knee and Hip Isometric Force Steadiness Are Impaired in Women With Patellofemoral Pain

ABSTRACT

Ferreira, AS, de Oliveira Silva, D, Ferrari, D, Magalhães, FH, Pappas, E, Briani, RV, Pazzinatto, MF, and de Azevedo, FM. Knee and hip isometric force steadiness are impaired in women with patellofemoral pain. J Strength Cond Res 35(10): 2878-2885, 2021-The purposes were as follows: to compare knee extension and hip abduction force steadiness and maximal strength between women with patellofemoral pain (PFP) and pain-free women; and to investigate whether maximal strength, self-reported pain during force-matching tasks, self-reported knee function, symptoms duration, and physical activity level are associated with knee extension and hip abduction force steadiness. Thirty women with PFP and 30 pain-free women were recruited. Knee extension and hip abduction maximal voluntary isometric contractions and submaximal isometric force-matching tasks were evaluated using an isokinetic dynamometer. Subjects were asked to match a target force corresponding to 10% of their maximal isometric voluntary contraction while force steadiness was computed as the coefficient of variation (CV) of the exerted force. Women with PFP had significant 36% lower knee extension and 33% lower hip abduction peak strength. They also had significant 70% lower knee extension force steadiness and 60% lower hip abduction force steadiness (i.e., higher CV) than pain-free women. Self-reported pain and self-reported knee function were significantly associated (r = 0.61, p < 0.001; r = -0.35, p = 0.05) and able to predict 41% of the variance of knee extensor force steadiness. Hip abductor maximum strength was significantly associated (r = -0.57; p = 0.001) and able to predict 32% of the variance of hip abductor force steadiness. These findings indicate that muscle impairments in PFP go beyond only low knee and hip muscle strength because women with PFP also present deficits in knee extension and hip abduction force steadiness. Evidence-based treatments aiming at improving force steadiness may be a promising addition to PFP rehabilitation programs.

Impaired Isometric, Concentric, and Eccentric Rate of Torque Development at the Hip and Knee in Patellofemoral Pain

ABSTRACT

Ferreira, AS, de Oliveira Silva, D, Barton, CJ, Briani, RV, Taborda, B, Pazzinatto, MF, and de Azevedo, FM. Impaired isometric, concentric, and eccentric rate of torque development at the hip and knee in patellofemoral pain. J Strength Cond Res 35(9): 2492-2497, 2021-The aims of this study were to compare maximal muscle strength and rate of torque development (RTD) of knee extensor and hip abductor during isometric, concentric, and eccentric contractions between women with and without patellofemoral pain (PFP). Thirty-eight women with PFP (PFPG) and 38 pain-free women (CG) participated in this study. Isometric, concentric, and eccentric maximal torque and RTD of knee extensor and hip abductor were assessed using an isokinetic dynamometer. Rate of torque development was calculated as the change in torque over the change in time from torque onset to 30, 60, and 90% of the maximal torque (RTD30%, RTD60%, and RTD90%) during isometric, concentric, and eccentric contractions. PFPG had lower isometric, concentric, and eccentric knee extensor maximal torque (29.9, 28.3, and 26.7%) compared with the CG. For knee extensor RTD, PFPG had slower isometric RTD30% (17.8%), RTD60% (21.5%), and RTD90% (23.4%); slower concentric RTD30% (35.7%), RTD60% (29.3%), and RTD90% (28.2%); and slower eccentric RTD30% (20.5%), RTD60% (25.2%), and RTD90% (22.5%) compared with the CG. PFPG had lower isometric, concentric, and eccentric hip abductor maximal torque (28.3, 21.8, and 17%) compared with the CG. For hip abductor RTD, PFPG had slower isometric RTD30% (32.6%), RTD60% (31.1%), and RTD90% (25.4%); slower concentric RTD90% (11.5%); and slower eccentric RTD30% (19.8%), RTD60% (26.4%), and RTD90% (24%) compared with the CG. In conclusion, women with PFP presented deficits in both maximal strength and RTD of knee extensor and hip abductor during isometric, concentric, and eccentric contractions, which highlight the potential importance of addressing different aspects of muscle function through exercise therapy.

Is Isolated Hip Strengthening or Traditional Knee-Based Strengthening More Effective in Patients With Patellofemoral Pain Syndrome? A Systematic Review With Meta-analysis

Background:

Focus on the importance of hip muscle strength in patients with patellofemoral pain syndrome (PFPS) has recently increased. It is unknown whether patients with PFPS will benefit more from hip strengthening compared with traditional knee-based strengthening.

Purpose:

To compare the efficiency of isolated hip strengthening versus traditional knee-based strengthening for patients with PFPS.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

We conducted a search for studies comparing isolated hip strengthening and knee-based strengthening by using the MEDLINE, Embase, and Cochrane Library electronic databases. The methodological quality of included studies was assessed using the PEDro scale. Predetermined variables from each study were extracted and analyzed.

Results:

A total of 5 comparative studies were included in this review; all studies were of moderate to high quality and reflected good internal and external validity. Pain (visual analog scale [VAS]) and function (Anterior Knee Pain Scale) scores improved in both the hip and knee groups after strengthening intervention, although no statistically significant differences were seen between groups in the pooled analysis. In 2 studies, VAS pain scores were reduced earlier for patients in the hip group than for those in the knee group (P < .05). In 1 study, improvement in Western Ontario and McMaster Universities Osteoarthritis Index function scores in the hip group was statistically superior compared with those in the knee group after intervention and at 6-month follow-up (P < .05). In 2 studies, patients in the hip group exhibited statistically greater hip abductor and extensor strength than did those in the knee group after intervention (P < .05).

Conclusion:

The best-available evidence suggests that overall, isolated hip strengthening and knee strengthening were equivalent for treatment of PFPS.

How effective is an evidence-based exercise intervention in individuals with patellofemoral pain?

OBJECTIVES

Guidelines for a comprehensive rehabilitation programme for patellofemoral pain (PFP) have been developed by international experts. The aim of this study was to analyse the effect of such a rehabilitative exercise programme on pain, function, kinesiophobia, running biomechanics, quadriceps strength and quadriceps muscle inhibition in individuals with PFP.

DESIGN

Observational study.

SETTING

Clinical environment.

PARTICIPANTS

Twenty-seven participants with PFP.

MAIN OUTCOME MEASURES

Symptoms [numeric pain rating scale (NPRS)and the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS)], function measured by using the KUJALA scale and KOOS, kinesiophobia measured by using the Tampa scale, three-dimensional biomechanical running data, quadriceps isometric, concentric and eccentric strength and arthrogenic muscle inhibition (AMI) were acquired before and after the six-week exercise programme.

RESULTS

Although pain did not significantly improve all patients were pain-free after the six-week exercise programme (NPRS: p = 0.074). Function, kinesiophobia and quadriceps AMI improved significantly after the six-week exercise programme (KUJALA: p = 0.001, KOOS: p = 0.0001, Tampa: p = 0.017, AMI: p = 0.018). Running biomechanics during stance phase did not change after the exercise intervention. Quadriceps strength was not different after the six-week exercise programme (isometric: p = 0.992, concentric: p = 0.075, eccentric: p = 0.351).

CONCLUSION

The results of this study demonstrate that the current exercise recommendations can improve function and kinesiophobia and reduce pain and AMI in individuals with PFP. There is a need for reconsideration of the current exercise guidelines in stronger individuals with PFP.

Effects of a Targeted Exercise Program on Inter-Leg Asymmetries in Patients with Patellofemoral Pain

Patellofemoral pain (PFP) is often associated with impaired muscle strength, flexibility, and stability. It has been suggested that inter-leg asymmetries have an important role in increasing the risk of musculoskeletal injuries, including PFP. Thus, the aim of this study was to identify significant asymmetries and determine the effects of a symmetry targeted exercise program in patients with PFP. Eighteen patients aged 13 to 54 years (24.17 ± 12.52 years) with PFP participated in this study. Strength, flexibility and stability outcomes of the trunk, hip, knee and ankle muscles were assessed. A single-group pretest–posttest design was used to assess changes in inter-leg and agonist–antagonist asymmetries resulting from the 8-week period of the supervised exercise program. Results indicated a significant improvement in inter-leg symmetry regarding bilateral stance in a semi-squat position (p = 0.020, d = 0.61, df = 17) and ankle plantarflexion (p = 0.003, d = 0.32, df = 17) and ankle dorsiflexion strength (p < 0.001, d = 0.46, df = 17). In addition, the ratio of ankle dorsiflexion/plantarflexion (p = 0.036, d = 1.14, df = 17) and hip extension/flexion (p = 0.031, d = 0.94, df = 16) changed significantly during the intervention period. To our knowledge, this was the first study to evaluate inter-leg asymmetries resulting from a period of a supervised exercise program. The results indicate that an exercise program focusing on individual asymmetries may influence specific deficits and contribute to better rehabilitation outcomes.

Usual Medical Care for Patellofemoral Pain Does Not Usually Involve Much Care: 2-Year Follow-up in the Military Health System

OBJECTIVES

To identify the most common type and timing of interventions used to initially manage patellofemoral pain (PFP), and whether exercise therapy as an initial treatment was associated with a decreased likelihood of recurrence of PFP.

DESIGN

Retrospective cohort.

METHODS

Active-duty military service members (n = 74 408) aged 18 to 50 years and diagnosed with PFP between 2010 and 2011 were included. We identified the type and timing of interventions from electronic medical records and insurance payer claims, and studied the influence of early exercise therapy use on injury recurrence rates.

RESULTS

In this cohort of patients with PFP, 62.3% (n = 46 338) sought no additional care after the initial visit. The most common initial pharmacological interventions were nonsteroidal anti-inflammatory drugs (4.1%), corticosteroid injections (0.4%), and muscle relaxers (0.3%). The most common initial nonpharmacological treatments were exercise therapy (7.6%), passive modalities (eg, hot packs, electrical stimulation, ultrasound; 0.6%), and manual therapy (joint manipulation and mobilization; 0.5%). Common specialty referrals were to physical therapy (3.3%) and orthopaedic providers (0.8%). If patients received at least 6 exercise therapy visits during the initial episode of care, they were less likely to have a recurrence of knee pain (odds ratio = 0.46; 95% confidence interval: 0.42, 0.49).

CONCLUSION

Two in every 3 patients did not seek additional care after PFP diagnosis. For those who sought additional care, exercise therapy was the most common intervention, and higher doses of exercise therapy were associated with a reduced likelihood of having a recurrent episode of knee pain. J Orthop Sports Phys Ther 2021;51(6):305-313. Epub 10 May 2021. doi:10.2519/jospt.2021.10076.

Knowledge, confidence and learning needs of physiotherapists treating persistent knee pain in Australia and Canada: a mixed-methods study

Aim: To determine the knowledge and confidence of physiotherapists in managing knee osteoarthritis (OA) and patellofemoral pain (PFP); and explore their learning behaviors and preferences related to the management of these knee conditions.Methods: One hundred and sixteen Australian and Canadian Physiotherapists were recruited via social media, e-mail, and an online course. Part 1: Quantitative involved an online survey evaluating knowledge of evidence and confidence in providing treatments for knee OA and PFP. Part 2: Qualitative involved semi-structured interviews with 13 participants exploring current practice and learning needs, that were analyzed using an initial framework structured on interview questions, followed by inductive approach to identify additional themes.Results: Awareness regarding evidence supporting exercise for knee OA and PFP was good (89-96%), and qualitative themes indicated physiotherapists emphasized exercise-therapy and education. Perceived value of passive treatments and surgery varied. Preference for face-to-face workshops to address learning needs, alongside describing time and cost barriers to access them, emerged from qualitative findings. Online learning formats were viewed as convenient, but not as effective as face-to-face learning.Conclusion: Knowledge and confidence related to interventions for knee OA and PFP of Australian and Canadian physiotherapist participants broadly aligns with guidelines. Knowledge translation strategies focused on face-to-face workshops, supported by online education may help to bridge evidence-to-practice gaps.

Auxiliary Diagnostic Method for Patellofemoral Pain Syndrome Based on One-Dimensional Convolutional Neural Network

Early accurate diagnosis of patellofemoral pain syndrome (PFPS) is important to prevent the further development of the disease. However, traditional diagnostic methods for PFPS mostly rely on the subjective experience of doctors and subjective feelings of the patient, which do not have an accurate-unified standard, and the clinical accuracy is not high. With the development of artificial intelligence technology, artificial neural networks are increasingly applied in medical treatment to assist doctors in diagnosis, but selecting a suitable neural network model must be considered. In this paper, an intelligent diagnostic method for PFPS was proposed on the basis of a one-dimensional convolutional neural network (1D CNN), which used surface electromyography (sEMG) signals and lower limb joint angles as inputs, and discussed the model from three aspects, namely, accuracy, interpretability, and practicability. This article utilized the running and walking data of 41 subjects at their selected speed, including 26 PFPS patients (16 females and 10 males) and 16 painless controls (8 females and 7 males). In the proposed method, the knee flexion angle, hip flexion angle, ankle dorsiflexion angle, and sEMG signals of the seven muscles around the knee of three different data sets (walking data set, running data set, and walking and running mixed data set) were used as input of the 1D CNN. Focal loss function was introduced to the network to solve the problem of imbalance between positive and negative samples in the data set and make the network focus on learning the difficult-to-predict samples. Meanwhile, the attention mechanism was added to the network to observe the dimension feature that the network pays more attention to, thereby increasing the interpretability of the model. Finally, the depth features extracted by 1D CNN were combined with the traditional gender features to improve the accuracy of the model. After verification, the 1D CNN had the best performance on the running data set (accuracy = 92.4%, sensitivity = 97%, specificity = 84%). Compared with other methods, this method could provide new ideas for the development of models that assisted doctors in diagnosing PFPS without using complex biomechanical modeling and with high objective accuracy.

Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values

Objective

To develop a best practice guide for managing people with plantar heel pain (PHP).

Methods

Mixed-methods design including systematic review, expert interviews and patient survey.

Data sources

Medline, Embase, CINAHL, SPORTDiscus, Cochrane Central Register of Controlled Trials, trial registries, reference lists and citation tracking. Semi-structured interviews with world experts and a patient survey.

Eligibility criteria

Randomised controlled trials (RCTs) evaluating any intervention for people with PHP in any language were included subject to strict quality criteria. Trials with a sample size greater than n=38 were considered for proof of efficacy. International experts were interviewed using a semi-structured approach and people with PHP were surveyed online.

Results

Fifty-one eligible trials enrolled 4351 participants, with 9 RCTs suitable to determine proof of efficacy for 10 interventions. Forty people with PHP completed the online survey and 14 experts were interviewed resulting in 7 themes and 38 subthemes. There was good agreement between the systematic review findings and interview data about taping (SMD: 0.47, 95% CI 0.05 to 0.88) and plantar fascia stretching (SMD: 1.21, 95% CI 0.78 to 1.63) for first step pain in the short term. Clinical reasoning advocated combining these interventions with education and footwear advice as the core self-management approach. There was good expert agreement with systematic review findings recommending stepped care management with focused shockwave for first step pain in the short-term (OR: 1.89, 95% CI 1.18 to 3.04), medium-term (SMD 1.31, 95% CI 0.61 to 2.01) and long-term (SMD 1.67, 95% CI 0.88 to 2.45) and radial shockwave for first step pain in the short term (OR: 1.66, 95% CI 1.00 to 2.76) and long term (OR: 1.78, 95% CI 1.07 to 2.96). We found good agreement to ‘step care’ using custom foot orthoses for general pain in the short term (SMD: 0.41, 95% CI 0.07 to 0.74) and medium term (SMD: 0.55, 95% CI 0.09 to 1.02).

Conclusion

Best practice from a mixed-methods study synthesising systematic review with expert opinion and patient feedback suggests core treatment for people with PHP should include taping, stretching and individualised education. Patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.

A Systematic Review of Clinical Practice Guidelines for Physical Therapist Management of Patellofemoral Pain

OBJECTIVE

The purpose of this study was to conduct a systematic review to evaluate clinical practice guidelines for the physical therapist management of patellofemoral pain.

METHODS

Five electronic databases (CINAHL, Embase, Medline, Psychinfo, Cochrane Library) were searched from January 2013 to October 2019. Additional search methods included searching websites that publish clinical practice guidelines containing recommendations for physical therapist management of patellofemoral pain. Characteristics of the guidelines were extracted, including recommendations for examination, interventions, and evaluation applicable to physical therapist practice. Quality assessment was conducted using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, applicability of recommendations to physical therapist practice was examined using the AGREE Recommendation Excellence instrument, and convergence of recommendations across guidelines was assessed.

RESULTS

Four clinical practice guidelines were included. One guideline evaluated as higher quality provided the most clinically applicable set of recommendations for examination, interventions, and evaluation processes to assess the effectiveness of interventions. Guideline-recommended interventions were consistent for exercise therapy, foot orthoses, patellar taping, patient education, and combined interventions and did not recommend the use of electrotherapeutic modalities. Two guidelines evaluated as higher quality did not recommend using manual therapy (in isolation), dry needling, and patellar bracing.

CONCLUSION

Recommendations from higher-quality clinical practice guidelines may conflict with routine physical therapist management of patellofemoral pain. This review provides guidance for clinicians to deliver high-value physical therapist management of patellofemoral pain.

IMPACT

This review addresses an important gap between evidence and practice in the physical therapist management of patellofemoral pain.

LAY SUMMARY

If you have kneecap pain, this review offers guidance for your physical therapist to provide examination processes, treatments, and evaluation processes that are recommended by high-quality guidelines.

A Bayesian Network Decision Support Tool for Low Back Pain Using a RAND Appropriateness Procedure: Proposal and Internal Pilot Study

BACKGROUND

Low back pain (LBP) is an increasingly burdensome condition for patients and health professionals alike, with consistent demonstration of increasing persistent pain and disability. Previous decision support tools for LBP management have focused on a subset of factors owing to time constraints and ease of use for the clinician. With the explosion of interest in machine learning tools and the commitment from Western governments to introduce this technology, there are opportunities to develop intelligent decision support tools. We will do this for LBP using a Bayesian network, which will entail constructing a clinical reasoning model elicited from experts.

OBJECTIVE

This paper proposes a method for conducting a modified RAND appropriateness procedure to elicit the knowledge required to construct a Bayesian network from a group of domain experts in LBP, and reports the lessons learned from the internal pilot of the procedure.

METHODS

We propose to recruit expert clinicians with a special interest in LBP from across a range of medical specialties, such as orthopedics, rheumatology, and sports medicine. The procedure will consist of four stages. Stage 1 is an online elicitation of variables to be considered by the model, followed by a face-to-face workshop. Stage 2 is an online elicitation of the structure of the model, followed by a face-to-face workshop. Stage 3 consists of an online phase to elicit probabilities to populate the Bayesian network. Stage 4 is a rudimentary validation of the Bayesian network.

RESULTS

Ethical approval has been obtained from the Research Ethics Committee at Queen Mary University of London. An internal pilot of the procedure has been run with clinical colleagues from the research team. This showed that an alternating process of three remote activities and two in-person meetings was required to complete the elicitation without overburdening participants. Lessons learned have included the need for a bespoke online elicitation tool to run between face-to-face meetings and for careful operational definition of descriptive terms, even if widely clinically used. Further, tools are required to remotely deliver training about self-identification of various forms of cognitive bias and explain the underlying principles of a Bayesian network. The use of the internal pilot was recognized as being a methodological necessity.

CONCLUSIONS

We have proposed a method to construct Bayesian networks that are representative of expert clinical reasoning for a musculoskeletal condition in this case. We have tested the method with an internal pilot to refine the process prior to deployment, which indicates the process can be successful. The internal pilot has also revealed the software support requirements for the elicitation process to model clinical reasoning for a range of conditions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21804.

Proximal, Local, and Distal Muscle Morphology in Women With Patellofemoral Pain

Objective:

The objective of this study was to compare proximal, local, and distal muscle morphology in women with and without patellofemoral pain (PFP).

Materials and Methods:

Proximal, local, and distal muscle thicknesses (MTs) were obtained with B-mode sonography in healthy (control group [CG], n = 20) and PFP (PFP group, n = 20) women. In addition, muscle mass was measured by the sum of the synergistic MTs. Data were analyzed by independent t-test, Mann-Whitney U test, and effect size.

Results:

PFP women had smaller gluteus medius ( P = .02, d = 0.7), vastus medialis ( P < .01, d = 1.0), and flexor digitorum brevis ( P < .01, d = 1.0) MT and greater gastrocnemius medialis ( P = .04, d = 0.6) MT than CG. Quadriceps muscle mass ( P = .01, d = 0.8) and foot muscle mass ( P = .008, d = 0.9) were smaller, while plantar flexor muscle mass was greater in the PFP group than in CG ( P = .01, d = 0.8).

Conclusion:

PFP women have proximal, local, and distal MT alterations in comparison with CG, which may explain possible changes in muscle strength and functionality.

Telerehabilitation for Knee Osteoarthritis in Brazil: A Feasibility Study

BACKGROUND

The effectiveness of telerehabilitation for a patient with knee osteoarthritis may depend upon the person's adherence to intervention. Thus, the aim of this study was to investigate whether people with knee osteoarthritis would adhere to exercise-therapy facilitated via multiple media in Brazil, a newly industrialized country.

METHOD

This is a feasibility study, pre-post intervention. Middle aged (40-50 years) and elderly (≥70 years) people with knee osteoarthritis received in-person exercise-therapy instructions on the first day, along with a booklet and DVD (videos) to take home. Participants also received six motivational phone calls throughout the 12-week treatment. Satisfaction and adherence were assessed one week after intervention with the Exercise Adherence Rating Scale (EARS), sections B and C. Preference on the method used to adhere to exercises was recorded.

CONCLUSION

Telerehabilitation was well accepted by middle-aged and elderly Brazilians with knee osteoarthritis. The preferred media to enhance adherence, was a booklet with descriptions of the exercises, especially for the elderly cohort.

Effect of gait retraining on segment coordination and joint variability in individuals with patellofemoral pain

BACKGROUND

Gait retraining is advocated for the management of patellofemoral pain. This case series examined changes in lower limb variability following 6-weeks of gait retraining in individuals with patellofemoral pain.

METHODS

Six runners with patellofemoral pain completed a 6-week physiotherapist-guided gait retraining program using minimalist footwear and increased cadence. Approximate entropy joint variability and segment coordination variability were calculated across the entire gait cycle during running at baseline, 6 and 12 weeks and compared using repeated measures analysis of variance and the standardised mean difference (SMD).

FINDINGS

Compared to baseline, there were large increases in hip joint transverse plane kinematic variability at 6 (SMD = 1.7) and 12 weeks (SMD = 1.3). Moderate increases in hip joint frontal plane and knee joint sagittal plane kinematic variability were also observed at 6 (SMD = 1.1 & 0.96) and 12 weeks (SMD = 1.1 & 0.89). Knee joint frontal plane and hip joint transverse plane kinetic variability demonstrated large increases from baseline at 6 (SMD = 1.3 & 0.9) and 12 weeks (SMD = 0.9 & 1.0). There was no main effect of time for segment coordination variability. All participants had clinically meaningful improvements in pain (visual analogue change score > 20 mm).

INTERPRETATION

Gait retraining increased joint kinematic and kinetic variability in those with patellofemoral pain and these changes persisted over 12 weeks. Increased variability was observed in joint kinematics and kinetics known to influence patellofemoral joint stress, which may vary patellofemoral joint loading patterns and partly explain the clinical effect.

Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review

BACKGROUND

Musculoskeletal (MSK) pain is one of the most common reasons for primary care consultation, particularly pain in the lower back (LBP), knee and shoulder. The use of diagnostic imaging for MSK pain is increasing, but it is unclear whether this increase is justified on the basis of clinical practice guideline (CPG) recommendations.

AIM

To identify and map the content of CPGs that informs the use of diagnostic imaging in those with nontraumatic LBP, knee and shoulder pain in primary and intermediate care in the UK.

DESIGN AND SETTING

A scoping review of CPGs.

METHODS

This scoping review was conducted and is reported in accordance with PRISMA guidance. A broad search strategy included electronic searches of MEDLINE, CINAHL, PsychINFO and SPORTDiscus from 2009 to 17 April 2019. This was conducted alongside a search of guideline repositories and was combined with a snowball search of Google, relevant professional bodies and use of social media.

RESULTS

31 relevant CPGs were included. Routine use of diagnostic imaging for those with nontraumatic LBP, knee or shoulder pain is generally discouraged in primary care or intermediate care. Diagnostic imaging should be reserved for when specific or serious pathology is suspected or where the person is not responding to initial nonsurgical management and the imaging result is expected to change clinical management decisions.

CONCLUSION

Diagnostic imaging should not be routinely requested in primary or intermediate care for nontraumatic LBP, knee or shoulder pain. CPGs do not justify the increasing imaging rates in the UK for MSK pain.

Physical Therapist Management of Anterior Knee Pain

PURPOSE OF REVIEW

Anterior knee pain is a common musculoskeletal complaint among people of all ages and activity levels. Non-operative approaches with an emphasis on physical therapy management are the recommended initial course of care. The purpose of this review is to describe the current evidence for physical therapist management of anterior knee pain with consideration of biomechanical and psychosocial factors.

RECENT FINDINGS

The latest research suggests anterior knee pain is a combination of biomechanical, neuromuscular, behavioral, and psychological factors. Education strategies to improve the patient's understanding of the condition and manage pain are supported by research. Strong evidence continues to support the primary role of exercise therapy and load progression to achieve long-term improvements in pain and function. Preliminary studies suggest blood flow restriction therapy and movement retraining may be useful adjunct techniques but require further well-designed studies. Anterior knee pain includes multiple conditions with patellofemoral pain being the most common. An insidious onset is typical and often attributed to changes in activity and underlying neuromuscular impairments. A thorough clinical history and physical examination aim to identify the patient's pain beliefs and behaviors, movement faults, and muscle performance that will guide treatment recommendations. Successful physical therapist management involves a combination of individualized patient education, pain management, and load control and progression, with an emphasis on exercise therapy.

Medical Interventions for Patellofemoral Pain and Patellofemoral Osteoarthritis: A Systematic Review

Patellofemoral pain (PFP) and patellofemoral osteoarthritis (PFOA) are common, persistent conditions that may lie along a pathological spectrum. While evidence supports exercise-therapy as a core treatment for PFP and PFOA, primary care physicians commonly prescribe medication, or refer for surgical consults in persistent cases. We conducted a systematic review of medical interventions (pharmaceutical, nutraceutical, and surgical) for PFP and PFOA to inform primary care decision making. Methods: Following protocol registration, we searched seven databases for randomized clinical trials of our target interventions for PFP and PFOA. Our primary outcome was pain. We assessed risk of bias, calculated standardized mean differences (SMDs) and determined the level of evidence for each intervention. Results: We included 14 publications investigating pharmaceutical or nutraceutical interventions, and eight publications investigating surgical interventions. Two randomized control trials (RCTs) provided moderate evidence of patellofemoral arthroplasty having similar pain outcomes compared to total knee arthroplasty in isolated PFOA, with SMDs ranging from −0.3 (95% CI −0.8, 0.2, Western Ontario McMaster Pain Subscale, 1 year post-surgery) to 0.3 (−0.1, 0.7, SF-36 Bodily Pain, 2 years post-surgery). Remaining studies provided, at most, limited evidence. No efficacy was demonstrated for oral nonsteroidal anti-inflammatories or arthroscopic surgery. Conclusions: Pharmaceutical and nutraceutical prescriptions, and surgical referrals are currently being made with little supporting evidence, with some interventions showing limited efficacy. This should be considered within the broader context of evidence supporting exercise-therapy as a core treatment for PFP and PFOA.

The effects of McConnell patellofemoral joint and tibial internal rotation limitation taping techniques in people with Patellofemoral pain syndrome

BACKGROUND

Taping is frequently used as part of the multi-modal management for patellofemoral pain syndrome (PFPS). McConnell Patellofemoral Joint Taping (PFJT) and Tibial Internal Rotation Limitation Taping (TIRLT) are proposed to be useful adjuncts to the management of PFPS. However, it is unclear if TIRLT offers similar benefits to PFJT, and its effect on pain and lower limb kinematics have not been investigated previously.

RESEARCH QUESTION

What are the effects of TIRLT, PFJT and no taping on perceived pain and lower limb kinematics during a lunge and single leg squat (SLS) in people with PFPS?

METHODS

This cross-sectional study compared the effects of TIRLT, PFJT and no taping, on knee pain and lower limb kinematics during two pain-provoking movements in people with PFPS. Participants with PFPS (n = 23) performed a lunge and SLS under three randomised conditions: TIRLT, PFJT and no taping. The Codamotion system captured and analysed lower limb kinematic data in the sagittal, transverse and coronal planes. Peak knee pain intensity during the movement was assessed using the Numerical Rating Scale (NRS).

RESULTS

Participants reported significantly less pain with the TIRLT and PFJT techniques compared with no tape during the lunge (p = 0.005 and p = 0.011, respectively) and SLS (p= 0.002 and p = 0.001, respectively). There was no evidence of altered lower limb kinematics accompanying pain reductions with either taping technique.

SIGNIFICANCE

Both forms of taping may be useful adjuncts as the short-term benefit of pain relief may enable participation in more active forms of rehabilitation.