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Management of Patellofemoral Pain Syndrome

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  #1  
Old 17th January 2007, 01:44 AM
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Default Management of Patellofemoral Pain Syndrome

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Full text article rom the latest American Family Physician:
Management of Patellofemoral Pain Syndrome
Quote:
Patellofemoral pain syndrome (PFPS) is the most common cause of knee pain in the outpatient setting. It is caused by imbalances in the forces controlling patellar tracking during knee flexion and extension, particularly with overloading of the joint. Risk factors include overuse, trauma, muscle dysfunction, tight lateral restraints, patellar hypermobility, and poor quadriceps flexibility. Typical symptoms include pain behind or around the patella that is increased with running and activities that involve knee flexion. Findings in patients with PFPS range from limited patellar mobility to a hypermobile patella. To confirm the diagnosis, an examination of the knee focusing on the patella and surrounding structures is essential. For many patients with the clinical diagnosis of PFPS, imaging studies are not necessary before beginning treatment. Radiography is recommended in patients with a history of trauma or surgery, those with an effusion, those older than 50 years (to rule out osteoarthritis), and those whose pain does not improve with treatment. Recent research has shown that physical therapy is effective in treating PFPS. There is little evidence to support the routine use of knee braces or nonsteroidal anti-inflammatory drugs. Surgery should be considered only after failure of a comprehensive rehabilitation program. Educating patients about modification of risk factors is important in preventing recurrence. (Am Fam Physician 2007;75:194-202, 204. Copyright © 2007 American Academy of Family Physicians.)
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Old 17th January 2007, 01:58 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Related threads:
Foot pronation and knee pain
Knee abduction impulses and patellofemoral pain
Patellofemoral pain and asymmetrical hip rotation
Patella tracking and patellofemoral pain syndrome
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  #3  
Old 18th January 2007, 08:41 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Dear All

At the Sports and science meeting in Fiji a few months back, some phd physio who has done alot of work in this area was now chansing the gluteus medius as the culpret.

Can't wait for the hyoglossus to be blamed. It will given enough time.

Using Jones' strain counter strain can fix it in 90 seconds. Done it hundreds of times to people in all walks of life wih patellofem pain from a few weeks to years to loss of career due to pain. etc. selling two storey house due to stairs and pain. could go on.

musmed

www.musmed.com.au
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Old 19th January 2007, 04:18 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Quote:
Originally Posted by musmed
Dear All

At the Sports and science meeting in Fiji a few months back, some phd physio who has done alot of work in this area was now chansing the gluteus medius as the culpret.

Can't wait for the hyoglossus to be blamed. It will given enough time.



www.musmed.com.au
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Old 19th January 2007, 03:07 PM
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Default Re: Management of Patellofemoral Pain Syndrome

what is 'Jones strain counter strain'
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Old 19th January 2007, 03:52 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Quote:
Originally Posted by dingo
what is 'Jones strain counter strain'
Counterstrain technique for plantar fasciitis
Jones Counterstrain Technique for sesamoiditis
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  #7  
Old 19th January 2007, 05:08 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Dear All

Jones' strain counterstrain was designed by Lawrence Jones. He was an American Osteopath that found there were many tender points where ligaments or tendons join or cross bones.


You an get his book on Amazon. Itis published by his own company, Jones Publishing.

Jones' points resist all forms of therapy. It does not matter that the sore spot has been rubbed, heated, manipulated, injected etc. It just doen not get better.

There are about 250 Jones' points from the head to the great toe.

What is hard to understand is that the problem is only a Jones' point if the pain is turned off by using his technique/protocol.

Basically the procedure is to place a fingertip on the tender point and then move the joint/limb/head/whatever into flexion/extensio abduction/adduction compression/distraction until the pain stops (CONSTANT feedback from your patient is essential). Once it stops immediately do not move. Hold that place for 90 seconds, return joint etc. to neutral and retest.

There should be a 70+% reduction in pain. Over the following few days it will completely disappear.

I hae posted on my website (pull down on the left hand side) the treatment of sesamoiditis. THis is an unbelievably simple technique that works to the amazement of the patient despite the problem having been there for several years or so.

Have a look. Try it! It works.

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musmed
www.musmd.com.au
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  #8  
Old 1st June 2011, 04:37 PM
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Default Re: Management of Patellofemoral Pain Syndrome

The effect of patellar taping on EMG activity of vasti muscles during squatting in individuals with patellofemoral pain syndrome.
Mostamand J, Bader DL, Hudson Z.
J Sports Sci. 2011 Jan;29(2):197-205.

Quote:
Although patellar taping has been shown to reduce pain in participants with patellofemoral pain syndrome, the mechanisms of pain reduction have not completely been established following its application. The purpose of this study was to evaluate EMG activity of vastus medialis and vastus lateralis following the application of patellar taping during a functional single leg squat. Both vastus medialis obliquus-vastus lateralis onset and vastus medialis obliquus/vastus lateralis amplitude of 18 participants with patellofemoral pain syndrome and 18 healthy participants as controls were measured using an EMG unit. This procedure was performed on the affected knee of participants with patellofemoral pain syndrome, before, during, and after patellar taping during unilateral squatting. The same procedure was also performed on the unaffected knees of both groups. The mean values of vastus medialis obliquus-vastus lateralis onset prior to taping (2.54 ms, s = 4.35) were decreased significantly following an immediate application of tape (-3.22 ms, s = 3.45) and after a prolonged period of taping (-6.00 ms, s = 3.40 s) (P < 0.05). There was also a significant difference between the mean values of vastus medialis obliquus-vastus lateralis onset among controls (-2.03 ms, s = 6.04) and participants with patellofemoral pain syndrome prior to taping (P < 0.05). However, there were no significant difference between the ranked values of vastus medialis obliquus/vastus lateralis amplitude of the affected and unaffected knees of participants with patellofemoral pain syndrome and controls during different conditions of taping (P > 0.05). Decreased values of vastus medialis obliquus-vastus lateralis onset may contribute to patellar realignment and explain the mechanism of pain reduction following patellar taping in participants with patellofemoral pain syndrome.
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Old 10th June 2011, 06:24 AM
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Default Re: Management of Patellofemoral Pain Syndrome

The original McConnell article did not go into the mechanics of the McConnell tapping but rather advocated its use. This evidence gives the background information that EMG-activity is significantly reduced in both the vastus medialis and lateralis muscles. With a medial glide of the patella, if the aciton of the vastii muscles are to keep the patella in position during locomotion, the force vector of the vastus medialis is expected to decrease whilst the vastus lateralis force vector should increase due to an increase in moment arm. Perhaps the main reduction is pain due to an over-working v.medialis that is given a period of rest with the tapping?

The interesting point is that McConnel strapping seems to have an immediate effect on most indviduals with medial/ peri patella pain related to mal-tracking.

What are other clinicians thoughts?

Shalom.
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Old 29th June 2011, 05:30 PM
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Default Re: Management of Patellofemoral Pain Syndrome

This has been released:

An Update for the Conservative Management of Patellofemoral Pain Syndrome: A Systematic Review of the Literature from 2000 to 2010.

Authors: Bolga LA, Boling MC

Int J Sports Phys Ther. 2011 June; 6(2): 112–125. PMCID: PMC3109895



The PDF of the article is freely available from PubMed:
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Old 1st July 2011, 01:32 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Cheers for that article, should be an interesting read.
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Old 1st July 2011, 04:12 AM
musmed musmed is offline
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Default Re: Management of Patellofemoral Pain Syndrome

Quote:
Originally Posted by Shalom View Post
The original McConnell article did not go into the mechanics of the McConnell tapping but rather advocated its use. This evidence gives the background information that EMG-activity is significantly reduced in both the vastus medialis and lateralis muscles. With a medial glide of the patella, if the aciton of the vastii muscles are to keep the patella in position during locomotion, the force vector of the vastus medialis is expected to decrease whilst the vastus lateralis force vector should increase due to an increase in moment arm. Perhaps the main reduction is pain due to an over-working v.medialis that is given a period of rest with the tapping?

The interesting point is that McConnel strapping seems to have an immediate effect on most indviduals with medial/ peri patella pain related to mal-tracking.

What are other clinicians thoughts?

Shalom.
Dear Shalom
Hello.
what is happening is what Dr. Lawrence Jones of strain counter strain fame described some 50 + years ago, well before McConnell
You will find the answer in his book.
Retropatellar pain is dime a dozen stuff.
Using a Jones counterstrain technique where the patella is moved laterally and tilted medially and held for 90 seconds works a treat in almost all cases. 0ver 70% of pain is gone and within 3 days it has totally gone.
These souls are restricted in crouching, squatting descending stairs in the majority.
After you apply his techniques, your patient can perform these tasks despite the fact that the pain that has been there from 1 to 20+ years.
Like they say, nothing is new, only the packaging.
I teach this in my workshops and you would be suprised how many emails i get back saying they removed retropatellar pain using this extremely simple technique.

I have read the paper and of course Jones never rated a mention
regards
paul Conneely
www.musmed.com.au
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  #13  
Old 16th September 2011, 02:41 PM
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Default Re: Management of Patellofemoral Pain Syndrome

The effect of taping, quadriceps strengthening and stretching prescribed separately or combined on patellofemoral pain.
Mason M, Keays SL, Newcombe PA.
Physiother Res Int. 2011 Jun;16(2):109-19. doi: 10.1002/pri.486. Epub 2010 Jul 14.
Quote:
BACKGROUND AND PURPOSE:
Quadriceps strengthening, quadriceps stretching and patellar taping are commonly prescribed together for patellofemoral pain patients. This study aimed to examine the effectiveness of each of these techniques in isolation for one week and in combination for one week.

METHODS:
A prospective double-blind randomized control study was designed involving 41 subjects with 60 knees diagnosed with patellofemoral pain. The knees were randomized in onto one of four groups (n = 15): infrapatellar taping, quadriceps strengthening, quadriceps stretching and control. The taping was worn continually for the week; the strengthening group followed a programme of non-weight-bearing terminal range quadriceps exercises, the stretching group performed rectus femoris stretches. The control group did not receive treatment. All subjects received advice. Seven pre- and post-treatment measures included isokinetic quadriceps strength, quadriceps length, pain measured during four activities and maximum eccentric, posturally controlled, pain-free knee flexion angle during a step-down. Results showed significant changes over time (p < 0.01) in two out of seven measures for the taping group, in five out of seven for the strengthening group and five out of seven for the stretching group and none in the control group. When the three modalities were combined for one week, (n = 60) all seven measures improved significantly (p < 0.01).

CONCLUSION:
In isolation, quadriceps stretching and quadriceps strengthening resulted in more improvements than taping. Combining these treatments is recommended as the initial approach to treating patellofemoral pain but further individualized more functional, global treatment is essential.
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Old 2nd November 2011, 03:33 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Patellofemoral knee pain treatment using neuromuscular retraining of the hip musculature in an adolescent female: a case report.
Frounfelter GG, Stutzriem DE.
J Strength Cond Res. 2011 Oct;25(10):2828-34.
Quote:
The purpose of this case study is to demonstrate the treatment of patella-femoral knee pain in an adolescent female athlete with emphasis on neuromuscular training of the knee and hip in synergy movement strategies. A 1.67-m, 61.5-kg, 15-year-old woman athlete reported to rehabilitation with the complaint of a 1-year history of bilateral knee pain. The patient noted that the symptoms were exacerbated with any sports-specific training. The patient played softball as an infielder. The athlete was referred by her family practice physician. After the patient was assessed, a clinical hypothesis was generated. It was thought that neuromuscular dysfunction of the hips and knees was causing faulty knee mechanics. These abnormal mechanics were presenting as patella-femoral knee pain. Initially, the athlete was assigned a home exercise program of side-lying hip abduction and lateral step-downs. At her first follow-up appointment, she noted increased symptoms that were aggravated with her home program. Upon inspecting her exercise technique, faulty step-down mechanics were contributing to her symptoms. Step-downs were discontinued, and the patient was instructed in and performed a chair squatting exercise, which was added to her home program. At her next follow-up, the patient noted being asymptomatic for 2 days. Her exercises were increased in intensity to include a Stairmaster and hip abduction and adduction on a 4-way hip machine. Eventually, over her treatment course, perturbation and proprioceptive training were initiated. By the sixth visit, the patient reported no symptoms and felt comfortable with self-management. A phone interview 3 months later indicated that the patient had no recurrent symptoms and was participating in sports without difficulty. This case demonstrates effectiveness of using hip and knee joint synergy to treat patella-femoral pain (PFP). The use of this synergy promotes proper patella–femoral alignment and improved knee mechanics. This case also is unique in the lack of physical agents and taping used to improve the patient's condition. It reinforces how exercise technique can carry over to functional athletic activities. This study provides a case for the use of hip and knee mechanical retraining in the treatment of PFP in adolescent female athletes who do not exhibit abnormal foot mechanics in weight bearing. It is important that sports medicine professionals be aware of these treatment options and are able to use them to correct these deficits in order to facilitate return to training and competition as quickly and safely as possible.
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Old 25th March 2012, 01:57 AM
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Default Re: Management of Patellofemoral Pain Syndrome

pardon my ignorance is there any link b.w jones point and trigger point?
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Old 26th March 2012, 05:56 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Quote:
Originally Posted by dragon_v723 View Post
pardon my ignorance is there any link b.w jones point and trigger point?
Hi
There is no direct correlation as to perceived aetiology, but there again..

Most Jones point occur where a tendon or ligament cross or join a bone. Jones thought they were some dysfunction at the neurological level (what ever that meant)

A Jones point is only a Jones point when the pain is turned off using a Jones technique- all revolve around sidebending and rotation of the affected area. Di Giovanni et al added compression and the time needed to produce a &0% reduction in pain went from 90 seconds to 4-6.

A trigger point is in the muscle or fascia of the muscle or periosteum (especially the gluteus medius muscle)

They occur mostly in the middle of the muscle where the motor end plate occurs.

Google Jones' points and there are a few good explanations especially one from his text book.

Travell and Simons is the bible for trigger points.

I was actually teaching Jones' points to the foot and ankle yesterday. They certainly do exist and simple treatment protocols when followed can produce dramatic results.
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paul Conneely
www.musmed.com.au
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Old 13th April 2012, 01:17 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials.
Collins NJ, Bisset LM, Crossley KM, Vicenzino B.
Sports Med. 2012 Jan 1;42(1):31-49.
Quote:
Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain. A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL and Pre-CINAHL, PEDro, PubMed, SportDiscus, Web of Science, BIOSIS Previews, and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models. Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Meta-analysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI 0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD -0.21, 95% CI -0.64, 0.21; 8-12 weeks: SMD -0.22, 95% CI -0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control). Findings suggest that, in implementing evidence-based practice for the nonsurgical management of anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required.
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Old 1st May 2012, 12:22 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Exercise training to prevent anterior knee pain in military recruits.
Divine J.
Clin J Sport Med. 2012 May;22(3):288-9.
Quote:
OBJECTIVE:
: To investigate the incidence of anterior knee pain among new recruits participating in a targeted exercise intervention, as an addition to army basic training, compared with recruits in an unmodified training program.

DESIGN:
: Single-blind, cluster (by troop) randomized, controlled trial, during the 14-week period of basic military training.

SETTING:
: The Army Training Centre (Pirbright, United Kingdom) between July 2006 and February 2007.

PARTICIPANTS:
: Army recruits, who enlisted at the Army Training Centre and passed the entry medical examination, participated in the study (n = 1502). The participants were divided into 50 single-sex troops (mean n = 41; range, 22-48).

INTERVENTION:
: All participants trained for 3 to 4 hours per day in endurance marching, military field exercises, running, weapons and foot drill, strength and conditioning, and classroom lessons. At the beginning of physical training sessions, the troops assigned to prevention of anterior knee pain (n = 759 persons) did 4 closed kinetic chain quadriceps and gluteal strengthening exercises and finished with 4 static stretches of the quadriceps, iliotibial band, hamstring, and gastrocnemius muscles. Position of the hip and knee in relation to the foot was emphasized. The 15-minute daily sessions were supervised by specially trained army instructors. The control group participants (n = 743) were assigned to existing military warm-up and warm-down exercises, including slow running, upper-body and lower-body stretching, abdominal curls, and push-up drills. Attendance at the physical training sessions was 91%.

MAIN OUTCOME MEASURES:
: The primary outcome was the incidence of overuse anterior knee pain during the training period. Recruits with knee pain were examined by a medical officer and diagnosed by experienced physiotherapists. Criteria for the diagnosis were anterior or retropatellar knee pain from ≥2 of prolonged sitting, stair climbing, squatting, running, kneeling, and hopping; insidious onset unrelated to trauma; and presence of pain on palpation of the patellar facets, on step down, or during a double-legged squat. Exclusion criteria were signs and symptoms of intraarticular pathology or other pathologic conditions or a history of patellar dislocation, surgery, or structural damage to the knee. Secondary outcomes were related to the successful completion of training and medical or other discharges from training.

MAIN RESULTS:
: The cumulative number of new cases of anterior knee pain in the intervention group was lower (10 cases; incidence, 1.3%; 95% confidence interval [CI], 0.7%-2.4%) than that in the control group (36 cases; incidence, 4.8%; 95% CI, 3.5%-6.7%). The incidence per recruit-month was lower in the intervention group compared with the control group (0.005 vs 0.020; P < 0.01). Adjustment for sex, clustering, and other risk factors did not modify the results. Overall, there was a 75% reduction in risk of anterior knee pain in the intervention group (unadjusted hazard ratio = 0.25; 95% CI, 0.13-0.48; P < 0.001). More of the intervention group than the control group successfully completed training (79.7% vs 67.8%); fewer were medically discharged (0.4% vs 3.4%); and fewer were discharged as "unfit for army service" (0.8% vs 3.1%). A greater proportion of the intervention group who were diagnosed with anterior knee pain during the study, compared with the control group, completed training (90% vs 44.4%).

CONCLUSIONS:
: Daily preventative exercises during a military basic training camp successfully reduced the incidence of anterior knee pain in recruits. More of the intervention group avoided medical discharges and completed their basic training
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Old 16th August 2012, 11:42 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Bracing and taping techniques and patellofemoral pain syndrome.
Jessee AD, Gourley MM, Valovich McLeod TC.
J Athl Train. 2012;47(3):358-9.
Quote:
Clinical Question: Is there an effective bracing or taping technique for treating patellofemoral pain?

Data Sources: The authors searched the Cochrane Musculoskeletal Injuries Group specialized register (December 2001), the Cochrane Controlled Trials Register (2000, issue 2), MEDLINE (January 1966 to March 2000), EMBASE (January 1988 to March 2000), CINAHL (January 1982 to March 2000), and PEDro (up to March 2000) without language limitations. They also contacted relevant orthotic companies and searched the included reference lists of the retrieved articles. The search terms for MEDLINE were anterior knee pain, arthralgia, knee joint, patella, and patellofemoral pain. The search terms for EMBASE were brace, chondropathy, dynamic splint, knee, orthosis, orthotics, patella, patella chondromalacia, patellofemoral joint, randomized control trial, and strap. The search terms for CINAHL were anterior knee pain, brace, orthot, orthos, randomi, strap, tape, patell, and patellofemoral. In PEDro, the subsequent composite of search terms was therapy: manipulation, massage, mobilization, orthoses, splinting, stretching, strength training, taping(; subdiscipline:) musculoskeletal, orthopaedics, sports; method: clinical trial; problem: muscle weakness, pain, reduced joint compliance; body part: foot or ankle, lower leg or knee.

STUDY SELECTION:
All randomized and quasi-randomized trials comparing the effectiveness of knee or foot orthotics for treatment of patellofemoral pain syndrome were included. Any trials that described the use of orthotic devices in conjunction with operative treatment were excluded from this review. Using these inclusion criteria, 2 reviewers independently assessed the potentially eligible studies and resolved any disagreements through conversation and negotiation by a third reviewer. Although the authors mentioned that the review's purpose was to assess knee and foot orthoses, none of the included studies assessed foot orthoses. Therefore, all trials that examined foot orthotics were excluded.

DATA EXTRACTION:
Using a preset extraction form, 2 reviewers independently entered data into a review manager software program (RevMan 2000; The Cochrane Collaboration, Oxford, United Kingdom). This program was produced by the Cochrane Collaboration to support systematic reviews. Any further information needed regarding methods and data was requested from the authors. Because of heterogeneity of the study population, interventions, and follow-up periods, statistical pooling was not conducted. In place of statistical pooling, the strength of scientific evidence was graded based on a scale of A through D, with A being the strongest evidence-based research and D being the weakest evidence-based research.

MAIN RESULTS:
The search strategy identified 15 trials, of which only 5 trials met all the inclusion criteria and had enough data to be considered for pooling. The 5 trials involved 362 participants who were assessed for pain, functional improvement, isokinetic muscular strength, motivation, subjective success, worst pain, usual pain, subjective clinical pain, and patellofemoral congruence angle. Of the 5 studies included in the review, only the following statistically significant differences were found. The Protonics orthosis significantly decreased pain and improved function based on the Kujala score versus no treatment. A home exercise program with McConnell taping and biofeedback decreased pain and improved function based on the Functional Index Questionnaire versus home exercise and monitored therapy. In addition, the Protonics orthosis versus no treatment resulted in a patellofemoral congruence angle change; McConnell taping versus Couman bandage improved satisfaction with applied therapy and isokinetic muscle strength at 300 6 /s of knee flexion. No other findings included in the review studies were statistically significant. The included studies were inadequate in their methodologic quality and incomplete in their research-based evidence, which was obtained by their investigators.

CONCLUSIONS:
According to the systematic review by D'hondt et al, the strength of retrieved research-based evidence of effectiveness of orthotic devices in the treatment of patellofemoral pain syndrome was graded C. This grade was appropriate because all trials had low-quality methodologic evidence to support or reject the effectiveness of orthotics and taping techniques in reducing pain. Although very little scientific evidence is available regarding the use of orthotics and taping techniques, D'hondt et al identified trends in orthotics and taping techniques that should be considered in clinical practice. A comprehensive exercise and stretching program with tape application was more effective in decreasing worst pain and usual pain and increasing functional improvement. This finding indicates that patellofemoral pain syndrome is best treated by using more than 1 intervention. In addition, no difference was apparent in pain outcomes between McConnell taping technique and Couman bandage: neither technique resolved pain. The Protonics orthosis actively affected patellar tracking by reducing internal rotation of the femur and compression on the lateral aspect of the patella. As a result, the Protonics orthosis reduced pain compared with no treatment. In contrast, the Couman bandage is used only to guide the patellar tracking pattern and massage the structures around the patella during motion. Yet a home exercise program with the addition of a stretching program and McConnell taping decreased pain and increased function, which may suggest that a combination of treatment approaches is needed to effectively treat the condition, as found in previous studies.
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Old 8th October 2012, 09:40 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Effectiveness of different exercises and stretching physiotherapy on pain and movement in patellofemoral pain syndrome: a randomized controlled trial
F Revelles Moyano et al.
Clin Rehabil October 4,
Quote:
Objective: To compare the effectiveness of proprioceptive neuromuscular facilitation combined with exercise, classic stretching physiotherapy intervention, and educational intervention at improving patient function and pain in patients with patellofemoral pain syndrome.

Design: Randomized, controlled, blind trial over four months.

Setting: Urban population, Spain.

Participants: Patients undergoing primary care for retropatellar pain.

Intervention: Subjects were allocated on three different treatment options: a proprioceptive neuromuscular facilitation and aerobic exercise group, a classic stretching group, and a control treatment were applied over four months under the supervision of a physiotherapist.

Main outcome: Knee Society Score, pain reported (Visual analogue scale) and knee range of motion. Assessments were completed at baseline and after four months.

Results: 74 patients were enrolled in the study and distributed between groups. Both the proprioceptive neuromuscular facilitation and classic stretching group showed significant changes in all variables after four months intervention (p < 0.001). The difference in mean Kujala knee score changes between groups (classic stretching group vs. proprioceptive neuromuscular facilitation group vs. control group) at four months was −24.05 (95% confidence interval (CI) −30.19, −17.90), p ≤ 0.001; vs. −39.03 (95% confidence interval (CI) −42.5, −35.5), p ≤ 0.001; vs. −0.238 (95% confidence interval (CI) −1.2, 0.726), p = 0.621, respectively.

Conclusions: A proprioceptive neuromuscular facilitation intervention protocol combined with aerobic exercise showed a better outcome than a classic stretching protocol after four months.
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Old 16th November 2012, 07:39 PM
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Default Re: Management of Patellofemoral Pain Syndrome

NEW INSIGHTS IN MUSCLE MORPHOLOGY, MUSCLE ACTIVATION AND FUNCTIONAL OUTCOME IN PATIENTS WITH PATELLOFEMORAL PAIN
ELS PATTYN
Thesis, Univeristy of Ghent; 2012 (PDF)
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Summary
Patellofemoral pain (PFP) is a common knee disorder in physically active adolescents as well as in a general population. PFP accounts for 25% of all knee injuries in a sports medicine clinic. The main symptom of PFP is retro and/or peripatellar pain aggravated by loading activities such as going up and downs stairs, squatting, running and prolonged sitting with the knees flexed. It has a debilitation effect on patients’ daily life. Most patients with PFP respond well to conservative treatment although there is a considerable individual variation in treatment response. Non-operative treatment implies exercise interventions along with soft tissue techniques, relative rest and orthotic interventions if needed. A third to a quarter of the patients with PFP however, will be confronted with recurrent or chronic pain.

There is general agreement that the etiology of PFP has a multifactorial origin, although the exact underlying mechanisms are not well understood. Overloading of entirely normal positioned patella as well as normal loading upon patellar malalignment may lead to symptoms. Patellar malalignment or maltracking is thought to be one of the primary precursors of PFP. It may increase patellofemoral contact pressure and causes unfavorable stresses and shearing forces. Patellar malalignment without lower extremity malalignment may be caused by insufficiency of static and/or dynamic stabilizers of the patellofemoral joint.

A dysfunction of the dynamic stabilizers may imply quadriceps strength deficit due to atrophy, neuromuscular dysfunction concerning either timing or amount of activity, and decreased muscle flexibility.

A thorough understanding of the underlying mechanisms of PFP and the factors determining the functional outcome is imperative for selecting the most appropriate rehabilitation program in view of a permanent treatment result. This dissertation attempts to provide clarification regarding muscle morphology and muscle activation linked to functional outcome in patients with PFP.

The vastus medialis obliquus (VMO) is seen as the most important medial stabilizer of the patellofemoral joint. Atrophy of the VMO has been often associated with PFP. However, it is striking to observe the scarcity of objective data and studies concerning VMO atrophy along with patellofemoral disorders. Our first study investigated if atrophy of the VMO is present in patients with PFP measured by magnetic resonance imaging (MRI). Patients with PFP showed a significantly smaller CSA of the VMO compared with healthy controls, while there was no difference in VL size and a borderline significance for general atrophy of the total quadriceps.

As the study had a cross-sectional design, the cause-effect issue can not be resolved. Either the patients had VMO hypoplasia before the start of their symptoms, or the VMO atrophy might be caused by muscle reflex inhibition due to pain.

There is no consensus in the literature whether the recruitment pattern of the quadriceps in individuals with PFP is disturbed or not. Contrary to electromyography studies, we investigated the activity pattern of the quadriceps during a functional activity by means of ‘muscle functional magnetic resonance imaging’ (mfMRI). The results of this study showed that all the vasti muscles of the patients were active to the same extent in comparison with healthy individuals during a functional task. This implied that that there is no need to stimulate and teach patients to exploit more intensively the VMO during functional activities, which is in contrast to the current treatment guidelines. It might be possible to explain these apparently contradictory results - atrophy of the VMO while equal activation - by a temporary reflex inhibition due to pain and inducing a permanent atrophy.

Several attempts have been made to determine which factors may predict the outcome and account for the variation often seen in the conservative treatment of PFP. Considering the VMO atrophy and the eccentric strength deficit in patients with PFP, we have included the quadriceps muscle size and eccentric strength in the predicting model. The results indicated that the combination of low frequency of pain before treatment with normal quadriceps muscle size and a low average peak eccentric torque at 60°/sec, predisposed a patient to a good functional outcome after seven weeks of therapy. It is probably easier to restore a neuromuscular disorder than to gain muscle volume in the same time period.

The results of the studies have major implications for the treatment of PFP. If VMO atrophy is present, tonification in view of volume gain is recommended. If no atrophy is present a functional neuromuscular training program aiming at ameliorating the eccentric control is recommended. Based on the finding of equal vasti activity, the “myth of selectively contracting the VMO more during functional activities” should be abandoned.
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Old 13th December 2012, 12:18 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Prognostic factors for patellofemoral pain: a multicentre observational analysis
Natalie J Collins, Sita M A Bierma-Zeinstra, Kay M Crossley, Robbart L van Linschoten, Bill Vicenzino, Marienke van Middelkoop
Br J Sports Med doi:10.1136/bjsports-2012-091696
Quote:
Objectives Describe proportions of individuals with patellofemoral pain (PFP) with an unfavourable recovery over 12 months; identify clinical predictors of poor recovery at 3 and 12 months; and determine baseline values of predictors that identify those with poor 12-month prognosis.

Methods An observational analysis utilised data from 310 individuals with PFP enrolled in two randomised clinical trials. Thirteen baseline variables (participant, PFP, study characteristics) were investigated for their prognostic ability. Pain, function and global recovery were measured at 3 and 12 months. Multivariate backward stepwise regression analyses (treatment-adjusted, p<0.10) were performed for each follow-up measure. Receiver operator characteristic curves identified cut-points associated with unfavourable recovery at 12 months.

Results 55% and 40% of participants had an unfavourable recovery at 3 and 12 months, respectively. Longer baseline pain duration was significantly associated with poor 3-month and 12-month recovery on measures of pain severity (β 11.36 to 24.94), Anterior Knee Pain (AKP) Scale (−4.44 to −11.33) and global recovery (OR: 2.32 to 6.11). Greater baseline pain severity and lower AKP Scale score were significantly associated with poor recovery on multiple measures (p<0.05). Baseline duration >2 months and AKP Scale score <70/100 were associated with unfavourable 12-month recovery.

Conclusions A substantial number of individuals with PFP have an unfavourable recovery over 12 months, irrespective of intervention. Knee pain duration >2 months is the most consistent prognostic indicator, followed by AKP Scale score <70. Sports medicine practitioners should utilise interventions with known efficacy in reducing PFP, and promote early intervention to maximise prognosis.
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Old 14th December 2012, 09:13 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Clinical test for diagnosis of patellofemoral pain syndrome: Systematic review with meta-analysis
Guilherme S. Nunes, Eduardo Luiz Stapait, Michel Hors Kirsten, Marcos de Noronha, Gilmar Moraes Santos
Physical Therapy in Sport (Article in Press)
Quote:
The high incidence and diversity of factors attributed to the etiology of patellofemoral pain syndrome (PFPS) makes the diagnosis of this problem somewhat complex and susceptible to misinterpretation. Currently, there is not a defined set of procedures considered as ideal to diagnose PFPS. To investigate the diagnostic accuracy of clinical and functional tests used to diagnose PFPS through a systematic review. We searched relevant studies in the databases Medline, CINAHL, SPORTDiscus and Embase. The QUADAS score was used to assess the methodological quality of the eligible studies. We analyzed data that indicated the diagnostic properties of tests, such as sensibility, specificity, positive (LR+) and negative (LR−) likelihood ratio, and predictive values. The search identified 16,169 potential studies and five studies met the eligibility criteria. The 5 studies analyzed 25 tests intending to accurately diagnose PFPS. Two tests were analyzed in two studies and were possible to perform a meta-analysis. Within the five studies included, one study had high methodological quality, two studies had good methodological quality and two studies had low methodological quality. Two tests, the patellar tilt (LR+ = 5.4 and LR− = 0.6) and squatting (LR+ = 1.8 and LR− = 0.2), had values that show a trend for the diagnosis of PFPS (LR+ >5.0 and LR− <0.2), however their values do not represent clear evidence regarding diagnostic properties as suggested in the literature (LR+ >10 and LR− <0.1). Future diagnostic studies should focus on the sample homogeneity and standardization of tests analyzed so future systematic reviews can determine with more certainty the accuracy of the tests for diagnosis of PFPS.
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Old 5th February 2013, 11:12 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Different Relationships Between the Level of Patellofemoral Pain and Quality of Life in Professional and Amateur Athletes
Roy T.H. Cheung, Zhijie Zhang, Shirley P.C. Ngai
PM&R; Available online 29 January 2013
Quote:
Background
Patellofemoral pain is a common orthopedic condition in the athletic population. Previous investigators focused on exploring the etiology and investigating the effectiveness of different treatment approaches for patellofemoral pain. However, the severity of symptoms and its corresponding impact on quality of life (QOL) in athletes at different elite levels have not been explored. Such information may help in formulating rehabilitation strategies targeting different levels of athletes.

Objective
To compare the perception of patellofemoral symptoms and its impact on QOL between professional and amateur athletes with patellofemoral pain.

Design
Cross-sectional study.

Participants
Thirty-eight athletes with patellofemoral pain: 19 professional athletes from the Chinese national track and field team and 19 matched amateur participants recruited from a local track and field club.

Main Outcome Measures
All participants completed the Chinese version of Kujala scale and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), which we used to quantify the severity of patellofemoral symptoms and QOL, respectively.

Results
Professional athletes demonstrated a significantly higher level of patellofemoral symptoms (P < .001) and lower physical functioning subscore of SF-36 (P < .014) than did the amateur athletes. We also found a trend of a lower mental health subscore of SF-36 in professional athletes than in the amateurs (P = .07). The Kujala scale score was positively correlated with the subscore of “physical functioning” in both professional athletes (rs = 0.688, P = .001) and amateurs (rs = 0.751, P < .001). We also observed a trend of correlation between the subscore in the mental health domain and the severity of patellofemoral symptoms in professional athletes.

Conclusions
Athletes at different elite levels might have varied perceptions of patellofemoral pain and the corresponding impact on physical aspects of quality of life. The results of this study may highlight the necessity of addressing psychosocial factors when formulating rehabilitation strategies in the athletic population with patellofemoral pain.
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Old 18th February 2013, 08:34 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome and Modifiable Intrinsic Risk Factors;
How to Assess and Address?

Farzin Halabchi; Reza Mazaheri; Tohid Seif-Barghi
Asian Journal of Sports Medicine, Volume 4 (Number 2), June 2013, (Full text pdf)
Quote:
Patellofemoral pain syndrome (PFPS) is a very common disorder of the knee.
Due to multiple forces influencing the patellofemoral joint, clinical management
of this ailment is particularly intricate. Patellofemoral pain syndrome has a
multifactorial nature and multiple parameters have been proposed as potential
risk factors, classified as intrinsic or extrinsic. Some of the intrinsic risk factors
are modifiable and may be approached in treatment. A number of modifiable
risk factors have been suggested, including quadriceps weakness, tightness of
hamstring, iliopsoas and gastrosoleus muscles, hip muscles dysfunction, foot
overpronation, tightness of iliotibial band, generalised joint laxity, limb length
discrepancy, patellar malalignment and hypermobility. In general, the routine
approach of physicians to this problem does not include assessment and
modification of these risk factors and therefore, it may negatively affect the
management outcomes. Changing this approach necessitates an easy and
practical protocol for assessment of modifiable risk factors and effective and
feasible measures to address them. In this review, we aimed to introduce
assessment and intervention packages appropriate for this purpose.
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Old 23rd March 2013, 12:17 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Neuromuscular Activity and Knee Kinematics in Adolescents with Patellofemoral Pain
Rathleff, Michael S.; Samani, Afshin; Olesen, Jens L.; Roos, Ewa M.; Rasmussen, Sten; Christensen, Birgitte H.; Madeleine, Pascal
Medicine & Science in Sports & Exercise: 21 March 2013
Quote:
Purpose: To investigate neuromuscular control of the knee during stair descent among female adolescents with Patellofemoral Pain (PFP) and report its association with self-reported clinical status assessed by the Knee injury and Osteoarthritis Outcome Score (KOOS).

Methods: Fifty-seven previously untreated female adolescents diagnosed with PFP aged 15 to 19 years were recruited from schools. The control group consisted of 29 age-matched healthy female adolescents. Bipolar surface electrodes were placed on VM and VL and an electronic knee goniometer was placed at the knee to collect knee flexion/extension kinematics. The participants walked down a stairway consisting of 24 steps at their normal pace. Sample Entropy was used to quantify the complexity of the time series from surface electromyography (sEMG) and kinematics during the stance phase. Self-reported clinical status was assessed by the KOOS and maximal quadriceps torque measured using strap-mounted handheld dynamometry.

Results: Female adolescents with PFP were characterized by altered neuromuscular knee control during stair descent, lower maximal quadriceps torque, and poorer KOOS scores across all five domains. Furthermore, a positive association was found between the complexity of sEMG from VL and self-reported pain determined by KOOSpain indicating larger impairments in neuromuscular knee control among those with the highest pain levels.

Conclusion: The current findings show that female adolescents with PFP are characterized by altered neuromuscular control of the knee during stair descent and lower maximal quadriceps torque. These results suggest that rehabilitation is needed, and should focus on restoring neuromuscular control and muscle strength.
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Old 14th June 2013, 05:50 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: Results from a single-blinded randomized controlled trial with 12 months follow-up
Berit Østerås, Håvard Østerås, Tom Arild Torsensen
Physiotherapy; Available online 10 June 2013
Quote:
Objectives
To evaluate the long-term effect of high-dose, high-repetition medical exercise therapy (MET) in patients with patellofemoral pain syndrome (PFPS).

Design
Follow-up study one year after completion of a randomized, controlled trial.

Setting
Follow-up testing in the primary healthcare physiotherapy clinics, where intervention was undertaken.

Participants
Twenty-eight patients with PFPS completed follow-up testing, fourteen in each group.

Interventions
The groups received three treatments per week for 12 weeks: high-dose, high-repetition MET for the experimental group, and low-dose, low-repetition exercise therapy for the control group.

Main outcome measures
Pain measured using a visual analogue scale (VAS: 0–10 cm), and function measured using a step-down test (numbers of completed step-downs in 30 seconds) and the modified Functional Index Questionnaire (FIQ: 0 points indicates maximal disability, 16 points no disability).

Results
At baseline there were no differences between groups. After intervention, there were statistically significant (p < 0.05) and clinically important differences between groups for all outcome parameters, also when adjusting for gender and duration of symptoms: −1.6 for mean pain [95% confidence interval (CI) −2.4 to −0.8], 6.5 for step-down test (95% CI 3.8 to 9.2), and 3.1 for FIQ (95% CI 1.2 to 5.0). At follow-up the differences between groups were maintained and even increased for mean pain and step-down with significant differences (p < 0.05) between groups; −1.8 for mean pain (95% CI: −2.7 to −1.0) and 4.5 for step-down test (95%CI: 2.4 to 6.5). The difference between groups for FIQ at follow-up: 1.1 (95% CI: −1.1 to 3.3).

Conclusion
There appear to be long-term effects of high-dose, high-repetition MET in patients with PFPS with respect to pain and functional outcomes. One year after completed intervention the experimental group has continued to improve, while the control group has relapsed.
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Old 8th July 2013, 11:34 PM
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Default Re: Management of Patellofemoral Pain Syndrome

Closed Kinetic Chain exercises with or without additional hip strengthening exercises in management of Patellofemoral pain syndrome: a randomized controlled trial.
Ismail MM, Gamaleldein MH, Hassa KA
European Journal of Physical and Rehabilitation Medicine [2013]
Quote:
Background: Patellofemoral pain syndrome (PFPS) is a common musculoskeletal pain condition, especially in females. Decreased hip muscle strength has been implicated as a contributing factor. Isolated open kinetic chain hip abductors and lateral rotators exercises were added by many authors to the rehabilitation program. However, Closed Kinetic Chain (CKC) exercises focusing on hip and knee muscles were not investigated if they can produce similar effect of hip strengthening and decreasing pain without the need of isolated exercises for hip musculature. Aim: The aim of the present study was to determine the effect of a CKC exercises program with or without additional hip strengthening exercises on pain and hip abductors and lateral rotators peak torque. Design: Prospective randomized clinical trial.

Setting: Patients with patellofemoral pain syndrome referred to the outpatient physical therapy clinic of the faculty of physical therapy, cairo university.

Population: Thirty two patients who had patellofemoral pain syndrome with age ranged from eighteen to thirty years.

Methods: Patients were randomly assigned into two groups: CKC group and CKC with hip muscles strengthening exercises as a control (CO) group. Treatment was given 3 times/week, for 6 weeks. Patients were evaluated pre- and post-treatment for their pain severity using VAS, function of knee joint using Kujala questionnaire, hip abductors and external rotators concentric/eccentric peak torque.

Results: There were significant improvements in pain, function and hip muscles peak torque in both groups (P<0.05). However, there was no statistically significant difference between groups in hip muscles torque (P<0.05) but pain and function improvements were significantly greater in the CO group (P<0.05).

Conclusion: Six weeks CKC program focusing on knee and hip strengthening has similar effect in improving hip muscles torque in patients with PFPS as a CKC exercises with additional hip strengthening exercises. However, adding isolated hip strengthening exercises has the advantage of more pain relief. Clinical Rehabilitation

Impact: CKC exercises with additional hip strengthening could be more beneficial in decreasing pain in PFPS than CKC exercises alone.
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Old 12th September 2013, 05:07 AM
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Default Re: Management of Patellofemoral Pain Syndrome

Does quadriceps atrophy exist in individuals with patellofemoral pain? A systematic literature review with meta-analysis
Lachlan S. Giles, Kate E. Webster, Jodie A. McClelland, Jill Cook
Journal of Orthopaedic & Sports Physical Therapy, 0, Volume: Early Access
Quote:
Study design
Systematic literature review.

Objectives
To investigate whether quadriceps atrophy is present in the affected limb of individuals with patellofemoral pain (PFP).

Background
PFP is a common condition. Atrophy of the quadriceps femoris, in particular the vastus medialis oblique (VMO), is often assumed to be present by clinicians and its resolution may underpin the reported effectiveness of quadriceps strengthening intervention in PFP rehabilitation.

Methods
A systematic search of the literature was conducted to identify studies that measured the size of the quadriceps in individuals with PFP. Meta-analyses were performed to determine whether a difference was present in quadriceps size between the limb with PFP and comparison limbs. Separate meta-analyses were performed for quadriceps size measured as girth and quadriceps size measured with imaging (thickness, cross sectional area, and volume).

Results
Ten studies were included in this review. Meta-analysis of girth measurements (3 studies) found no atrophy in limbs with PFP (P=.638). Meta-analyses for imaging (thickness, cross sectional area, or volume measurements) showed atrophy in the limb with PFP compared to both the asymptomatic limb (3 studies) (P=.036) and limbs from a comparison group (3 studies) (P=.001). The single study that compared VMO and vastus lateralis (VL) in individuals with PFP found atrophy of both VMO and VL but no significant difference in the amount of atrophy between them (P=.179).

Conclusion
Quadriceps muscle atrophy was shown to be present in PFP when analysed by imaging, but not girth measures. Insufficient data were available to determine if there is greater atrophy of VMO than VL. These findings support the rationale for use of quadriceps strengthening as part of the rehabilitation for PFP.
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Old 12th October 2013, 12:11 PM
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Default Re: Management of Patellofemoral Pain Syndrome

A review of the management of patellofemoral pain syndrome.
Rixe JA, Glick JE, Brady J, Olympia RP.
Phys Sportsmed. 2013 Sep;41(3):19-28.
Quote:
Objective: Patellofemoral pain syndrome (PFPS) is one of the most frequently diagnosed knee conditions in the primary care, orthopedic, and sports medicine settings. Although strength training and stretching programs have traditionally been the mainstay of patient treatment, there are no consensus recovery protocols for runners experiencing PFPS. The purpose of our review is to examine recent literature regarding the efficacy of various treatment modalities in the management of patients with PFPS. Methods: Our review included 33 articles from a PubMed literature search using the search term PFPS treatment. The search was limited to randomized controlled trials, crossover case-controlled studies, and cohort studies with ≥ 10 participants, with trial data that were published within the last 5 years. Results: Strength training and stretching exercises continue to be strongly supported by research as effective treatment options for runners with PFPS. Recent studies have confirmed that quadriceps and hip strengthening combined with stretching in a structured physiotherapy program comprise the most effective treatment for reducing knee pain symptoms and improving functionality in patients with PFPS. As previous studies have shown, therapies such as proprioceptive training, orthotics, and taping may offer benefits as adjunctive therapies but do not show a significant benefit when they are used alone in patients with PFPS. Additionally, recent research has confirmed that surgical and pharmacologic therapies are not effective for the management of patients with PFPS. Conclusion: A large number of athletes are impacted by PFPS every year, particularly young runners. Sports medicine researchers have investigated many possible therapies for patients with PFPS; however, no clear guidelines have emerged regarding the management of the syndrome. Our review analyzes recent literature on PFPS and identifies specific treatment recommendations. The most effective and strongly supported treatment modality for patients with PFPS is a combined physiotherapy program, including strength training of the quadriceps and hip abductors and stretching of the quadriceps muscle group. Adjunctive therapies, including taping, biofeedback devices, and prefabricated orthotic inserts, may provide limited additive benefits in select populations. Surgery should be avoided in all patients with PFPS.
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