The development of an evidence-based clinical checklist for the diagnosis of anterior knee pain

Nearly 40% of adolescent athletes report anterior knee pain regardless of maturation status, age, sex or sport played

OBJECTIVE

To report point prevalence of anterior knee pain (AKP) in adolescent athletes by (1) maturation status, (2) chronological age, (3) sex, and (4) primary sport.

DESIGN

Cross-sectional.

METHODS

Male and female participants aged 11-15 years were recruited from specialised sports programs for basketball, volleyball, Australian Rules Football and tennis. Standing height, sitting height, and body mass were measured and used to calculate maturity status. Past injury history, self-reported physical activity, and Victorian Institute of Sport Assessment Questionnaire Patellar Tendon (VISA-P) questionnaires were completed. Anterior knee pain was defined as any pain experienced on the anterior surface of the knee and recorded using a visual analogue scale (VAS). A single leg decline squat (SLDS) was performed for provocation of AKP.

RESULTS

Two hundred and seventeen male and female adolescent athletes participated in this study. Twenty participants were excluded from data analysis. Point prevalence of AKP was 39% (N = 76). Average self-reported physical activity/week was 7.9 ± 4.1 h of their specialised sport and 2.0 ± 2.0 h of other physical activity/week. Maturation status, chronological age, sex nor primary sporting program was statistically significant in explaining the presence or absence of AKP.

CONCLUSION

Due to the right-skewed maturation sample, the authors cannot state conclusively that maturation status was not associated with AKP. Nearly 40% of this cohort reported AKP during a pain provocation test. The presence of AKP was not explained by maturation status, age, sex or primary sport program. Given the chronic nature of AKP and future morbidity reported, this high prevalence provides rationale for intervention or prevention studies targeting younger athletes.

Joint position sense in individuals with anterior knee pain

BACKGROUND

Anterior knee pain (AKP) commonly affects both physically active and sedentary individuals and the aetiology is unknown. Altered joint position sense (JPS) impacts accurate motor action and knee joint stability. It is unclear whether people with AKP have altered JPS.

OBJECTIVE

The aim of our study was to investigate JPS in the knees of individuals with AKP.

METHOD

A descriptive cross-sectional study measured JPS in 25 participants with unilateral or bilateral AKP. JPS was measured using active JPS testing during single leg squat (SLS) and active knee extension (AKE) in sitting. Target angles (TA) were self-determined based on each participant's capabilities. The absolute error (AE) was the main outcome measure. Impaired JPS was classified as an AE equal to or greater than five degrees.

RESULTS

There were no significant differences in JPS when comparing the affected and unaffected knees in participants with AKP (p > 0.05). However, a subgroup of participants with altered knee JPS was identified. There was a tendency towards greater knee flexion in the TAs of knees without AKP.

CONCLUSION

Our results showed that JPS is not significantly more impaired in knees with AKP compared with knees without AKP in a group of individuals with AKP. A subgroup with altered JPS in knees with and without AKP was identified. This finding could be because of compensatory gait patterns and the precision of the Vicon 3D motion analysis system.

CLINICAL IMPLICATIONS

Joint position sense should be assessed bilaterally in individuals with AKP.

Appraisal and summary of patellofemoral pain clinical practice guideline

OBJECTIVE

The purpose of this commentary was to critically appraise the patellofemoral pain clinical practice guideline published by the Academy of Orthopaedic Physical Therapy in 2019 and to summarize their recommendations for chiropractic practice.

METHODS

Quality and reporting of this guideline was assessed with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Three reviewers independently scored between 1-7 (strongly disagree-strongly agree) for 23 items organized into six quality domains.

RESULTS

AGREE II quality domain scores ranged between 57%-98%, with overall quality of the recommendation rated 89%. The guideline contained evidence summaries and/or recommendations for three topics: impairment/function-based diagnosis; examination; and interventions.

CONCLUSION

Based on its methodological quality, we recommend the use of this guideline for the examination, diagnosis, and management of patellofemoral pain in chiropractic practice. A summary of recommendations from this guideline is presented for use within the scope of chiropractic practice in Canada.

The immediate effects of passive hip joint mobilization on hip abductor/external rotator muscle strength in patients with anterior knee pain and impaired hip function. A randomized, placebo-controlled crossover trial

Background: Anterior knee pain (AKP) is often associated with persistent hip muscle weakness and facilitatory interventions may be beneficial for managing patients with AKP (pwAKP). Physiotherapists often employ passive oscillatory hip joint mobilizations to increase hip muscle function. However, there is little information about their effectiveness and the mechanisms of action involved. Objectives: To investigate the immediate effects of passive hip joint mobilization on eccentric hip abductor/external rotator muscle strength in pwAKP with impaired hip function. Design: A double-blinded, randomized, placebo-controlled crossover design. Method: Eighteen patients with AKP participated in two sessions of data collection with one week apart. They received passive hip joint mobilization or placebo mobilization in a randomized order. Eccentric hip muscle strength was measured immediately before and after each intervention using a portable hand-held dynamometer. Results: An ANCOVA with the sequence of treatment condition as the independent variable, the within-subject post-treatment differences as the dependent variable and the within-subject pre-treatment differences as the covariate was conducted. Patients showed a significant mean increase in eccentric hip muscle strength of 7.73% (p = 0.001) for the mobilization condition, compared to a mean decrease of 4.22% for the placebo condition. Seventeen out of eighteen participants reported having no pain during any of the strength testing. Conclusion: These data suggest that passive hip joint mobilization has an immediate positive effect on eccentric hip abductor/external rotator muscle strength in pwAKP with impaired hip function, even in the absence of current pain.

Patients' perceptions of recovery following a 6-week exercise intervention for the treatment of patellofemoral pain: A mixed methods study

Background

Patellofemoral pain (PFP) is a common and complex condition. The diagnosis and causal mechanisms are not well understood and therefore the long-term prognosis tends to be poor. Exercise is currently the only evidence-based treatment strategy suggested to improve pain and function in the long term. However, no qualitative studies have been conducted to establish patients’ perceptions of recovery in the long term following an exercise intervention.

Objectives

To measure self-reported recovery on a 7-point Likert scale in 31 participants with PFP 6 months after a 6-week physiotherapy intervention. To explore the subjective accounts of patients who received a physiotherapy intervention for PFP, regarding their expectations and perceptions of recovery.

Method

Semi-structured exit interviews were conducted electronically 6 months after intervention to ascertain the patients’ perspectives on whether expectations of treatment were met, and factors that influenced their recovery experience.

Results

Quantitative analysis of self-reported recovery on a 7-point Likert scale showed that 48.4% of participants felt that they were ‘recovered’. Qualitative analysis showed three main categories: expectations of treatment, perceptions of recovery and changes in functional abilities.

Conclusion

Clinicians should address patients’ expectations of treatment and include the patients in decision-making regarding their treatment. Long-term follow-up is essential to ensure that treatment effects have been maintained, and this should include information about patients’ self-reported recovery.

Clinical implications

This study suggests that patients’ expectations of treatment and perceptions of recovery from PFP may influence prognosis. Clinicians need to collaborate with patients and involve them in decision-making to achieve their goals. An individualised treatment approach is essential to adequately address patients’ experiences, priorities and beliefs.