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More research is needed to determine whether any long-term differences in pain or PROMs occur in patients with PFP who receive either hip- or knee-targeted exercise therapy. Added UT National Championship banner. 21, No. A 2018 high-quality RCT indicated that in a subgroup of people with PFP and excessive static rearfoot eversion (greater than 6°), supervised foot-targeted exercises (12 sessions over 3 months) and customized foot orthoses, combined with 3 sessions of physical therapy (education, manual therapy, and knee-targeted exercises), produced superior pain and function outcomes at 4 months compared with 3 sessions of physical therapy alone.197 No between-group differences were found at 12 months. The test has a high −LR of 0.10 to 0.20 (95% CI: 0.1, 0.4) (TABLE 2), indicating that the probability of PFP being present when there is a negative test is moderately decreased.63,215,303, Activity Limitations: Physical Performance Measures. Diagnosis and treatment of patients with patellofemoral pain. Sell KE, Verity TM, Worrell TW, Pease BJ, Wigglesworth J. fThe individual is supine, with the knee in slight flexion (not full extension, as this is reported to possibly cause pinching of the suprapatellar pouch). The recommendation is based on these conflicting studies, A preponderance of evidence from animal or cadaver studies, from conceptual models/principles, or from basic science/bench research supports this recommendation, Best practice based on the clinical experience of the guidelines development team supports this recommendation, Patient-oriented guideline summary available on, Mobile app of guideline-based exercises for patient/clients and health care practitioners, Summary or guideline recommendations available on, Continuing Education Units available for physical therapists and athletic trainers, Webinars: educational offering for health care practitioners, Guideline-based instruction available for practitioners on, Mobile and web-based app of guideline for training of health care practitioners, Physical Therapy National Outcomes Data Registry, Support the ongoing usage of data registry for common musculoskeletal conditions (www.ptoutcomes.com), Logical Observation Identifiers Names and Codes mapping, Publication of minimal data sets and their corresponding Logical Observation Identifiers Names and Codes for the knee region on, Non-English versions of the guidelines and guideline implementation tools, Development and distribution of translated guidelines and tools to JOSPT's international partners and global audience, Patellofemoral disorders, unspecified knee, Unspecified disorder of patella, unspecified knee, Chondromalacia patellae, unspecified knee, Muscle wasting and atrophy, not elsewhere classified, unspecified thigh, Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg, Power of isolated muscles and muscle groups, Other biomechanical lesions of lower extremity, Other specified acquired deformities of unspecified lower leg, Other acquired deformities of unspecified foot, Extra-articular ligaments, fasciae, extramuscular aponeuroses, retinacula, septa, bursae, unspecified, Passive gliding patella: superior/inferior, Unable to calculate due to specificity of 1.00, >20° indicated hamstrings muscle tightness, Systematic review of prospective cohort studies, Systematic review of high-quality diagnostic studies, Systematic review, highquality cross-sectional studies, Systematic review of high-quality cohort studies, Systematic review of retrospective cohort study, Systematic review of exploratory diagnostic studies or consecutive cohort studies, Systematic review of studies that allows relevant estimate, Systematic review of lowerquality prospective cohort studies, Systematic reviews of casecontrol studies, Lower-quality exploratory diagnostic studies, de Moura Campos Carvalho-e-Silva et al 2016. ; (5) Is the disease status of the tested population clearly described? 2004;12:223–228. Does quadriceps atrophy exist in individuals with patellofemoral pain? Although 1 study points to the effectiveness of acupuncture, this was in comparison to no treatment, highlighting the need for a placebo/sham-controlled trial. https://doi.org/10.1177/0363546515599628, Ho KY, Hu HH, Colletti PM, Powers CM. https://doi.org/10.1016/j.aott.2017.09.005, Hains G, Hains F. Patellofemoral pain syndrome managed by ischemic compression to the trigger points located in the peri-patellar and retro-patellar areas: a randomized clinical trial. https://doi.org/10.1080/09593980600724246, Nijs J, Van Geel C, Van der auwera C, Van de Velde B. Exploration of the current evidence base for the incidence and prevalence of patellofemoral pain syndrome. Almeida GPL, Silva AP, França FJ, Magalhães MO, Burke TN, Marques AP. Panken et al219 performed a systematic review to determine which clinical factors were able to predict pain, function, or recovery in patients with PFP. https://doi.org/10.1016/j.apmr.2017.10.014, Décary S, Ouellet P, Vendittoli PA, Desmeules F. Reliability of physical examination tests for the diagnosis of knee disorders: evidence from a systematic review. *Levels of evidence adapted from Phillips et al228: (I) Systematic review of prospective cohort studies; high-quality prospective cohort study; (II) Systematic review of retrospective cohort studies; lower-quality prospective cohort study; high-quality retrospective cohort study; consecutive cohort; outcomes study or ecological study; (III) Lower-quality retrospective cohort study; high-quality cross-sectional study; case-control study; (IV) Case series; (V) Expert opinion. Semin Arthritis Rheum. Ittenbach et al149 evaluated the reliability and validity of the AKPS in 414 girl, adolescent female, and woman athletes (11.0–18.1 years of age). 2009;39:A1–A25. This model is depicted in the FIGURE. Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. 2016;11:926–935. 2002;16:780–788. 2015;49:923–934. Hinman and colleagues137 compared the presence of radiographic PFOA and tibiofemoral OA in 224 individuals who had chronic PFP who were older than 40 years of age. https://doi.org/10.1080/09638288.2017.1419288, Celik D, Coşkunsu D, Kılıçoğlu Ö. Clinicians commonly observe hip and knee movement during an SLS to identify individuals with PFP and movement coordination deficits. Biofeedback supplementation to physiotherapy exercise programme for rehabilitation of patellofemoral pain syndrome: a randomized controlled pilot study. https://doi.org/10.1136/bjsports-2011-090369. Gwen Stefani on how Blake Shelton helped inspire her latest music video. Fixed: Release in which this issue/RFE has been fixed.The release containing this fix may be available for download as an Early Access Release or a General Availability Release. 2012;17:100–118. However, a recent systematic review of observational studies concluded that age, body mass, height, and body mass index (BMI) were not risk factors for the development of PFP.173 Specific to lower extremity structure, the quadriceps angle (Q angle), assessed either in weight bearing or non–weight bearing, was not a risk factor for the development of PFP.173,223. These tests demonstrated moderate to high sensitivity and −LR (TABLE 2), suggesting that the probability of PFP is moderately decreased when there is a negative test.63,65,205. https://doi.org/10.1007/s00167-014-3004-7, Negahban H, Pouretezad M, Sohani SM, Mazaheri M, Salavati M, Mohammadi F. Validation of the Persian version of Functional Index Questionnaire (FIQ) and Modified FIQ in patients with patellofemoral pain syndrome. Acta Orthop Traumatol Turc. *AMSTAR items: (1) Was an “a priori” design provided? A systematic review on prognostic factors and treatment effect modifiers. 2013;60:A4725. This review reported no additional benefits from these electrophysical agents for the management of PFP. At 1-year follow-up, adolescents and adults had similar levels of pain, self-reported knee function, and medical consumption. The authors also reported values of less than 11° for iliotibial band (measured in the Ober position with the knee flexed to 90°) and 134.0° for quadriceps (measured with prone knee flexion) lengths when measured using an inclinometer. Sports Med. Due to the limited and low quality of evidence available, further research is needed to determine the effectiveness of patient education for individuals with PFP. https://doi.org/10.1016/j.jsams.2017.09.187, Briani RV, Pazzinatto MF, De Oliveira Silva D, Azevedo FM. The KOS-ADLS had a moderate standardized effect size (0.63) and demonstrated excellent discrimination between those whose GROC scores worsened and those whose scores did not (AUC = 0.83). Taping applied with the aim of enhancing muscle function is not recommended. Each body of evidence was synthesized separately and then overall to support the overarching recommendation for each intervention. Chinese translation and validation of the Kujala scale for patients with patellofemoral pain. Br J Sports Med. Guney et al124 investigated the quadriceps-to-hamstrings strength ratio in 44 women with unilateral PFP (using the contralateral limb as the control). sThe individual assumes a sidelying position on a mat table, with the pelvis, trunk, and shoulders aligned in the vertical plane. nThe individual is sidelying, with both legs positioned at 45° of hip flexion and 90° of knee flexion, with the limb to be tested superior to the opposite limb. Thus, the most effective frequency and mode of delivery of patient education are also in need of further study. 2016;17:5. https://doi.org/10.1186/s12891-015-0859-9, Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. Dynamic postural stability and muscle strength in patellofemoral pain: is there a correlation? Adding motor control training to muscle strengthening did not substantially improve the effects on clinical or kinematic outcomes in women with patellofemoral pain: a randomised controlled trial. 2007;8:37–43. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures, 2016 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. The therapist applies posteriorly directed pressure to the superior patella to tilt the patella anteriorly at its inferior pole. https://doi.org/10.1016/j.orthres.2003.08.014, Crossley KM, Stefanik JJ, Selfe J, et al. https://doi.org/10.1177/0269215512459277, Rathleff MS, Roos EM, Olesen JL, Rasmussen S. Exercise during school hours when added to patient education improves outcome for 2 years in adolescent patellofemoral pain: a cluster randomised trial. 2001;87:516–522. Effectiveness of exercise therapy in treatment of patients with patellofemoral pain syndrome: systematic review and meta-analysis. Medial knee displacement during the SLS also has been associated with increased hip adduction and knee external rotation during running and jumping tasks.307 It is noteworthy that these investigators did not assess hip or knee strength,134,307 precluding the ability to discern the effect, if any, of hip and knee strength on the FPPA. Br J Sports Med. J Orthop Sports Phys Ther. Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Several aspects of validity were assessed: content validity, construct validity, discriminant (known-groups) validity, structural (factorial) validity, and floor/ceiling effects. J Sci Med Sport. If prescribed, foot orthoses should be combined with an exercise therapy program. Future high-quality RCTs should utilize appropriately powered sample sizes to more clearly identify subgroups of people, such as individuals with painful resisted knee extension, who may experience greater improvements with blood flow restriction training and across various demographics. 2017;30:299–307. The evidence update was organized from highest level of evidence to lowest level. J Orthop Res. No differences were seen between the PFP and pain-free groups for anxiety, depression, catastrophizing, and kinesiophobia. Sharing decision-making between patient and clinician: the next step in evidence-based practice for patellofemoral pain? ; (2) Was there duplicate study selection and data extraction? It is likely that tailoring various components of combined interventions may result in the best patient outcomes. Br J Sports Med. Anterior knee pain following anterior cruciate ligament reconstruction does not increase the risk of patellofemoral osteoarthritis at 15- and 20-year follow-ups. Osteoarthritis Cartilage. Patellofemoral pain may be experienced following surgical procedures, for example, anterior cruciate ligament reconstruction (ACLR).76,77 Although PFP is common in persons following ACLR, this may present differently from nonsurgical PFP due to alterations in the normal knee biomechanics.77 This guideline does not apply to PFP following surgery to the knee or other musculoskeletal regions of the lower extremity. Interventions to consider combining with exercise therapy include foot orthoses, patellar taping, patellar mobilizations, and lower-limb stretching. https://doi.org/10.3233/BMR-140525, Holden S, Boreham C, Doherty C, Delahunt E. Two-dimensional knee valgus displacement as a predictor of patellofemoral pain in adolescent females. 2009;2:6. https://doi.org/10.1186/1757-1146-2-6. A 2018 moderate-quality RCT reported no added improvements in pain or function when patellar taping was combined with intensive physical therapy (12 sessions over 4 weeks), including knee-targeted exercise and manual therapy.114 However, interpretation of how to apply these findings is challenging because taping methods were poorly described in this study. https://doi.org/10.1007/s00167-004-0577-6, Wolf M. Knee pain in children: part I: evaluation. About a quarter (27%) of athletes experienced complete pain relief, and an additional 38% had decreased pain, leaving 35% with pain that was either unchanged or worse. A multivariate binary regression analysis found significantly greater association between adolescent AKP and PFOA (odds ratio [OR] = 7.5; 95% CI: 1.51, 36.94). 2008;24:146–153. The stationary arm of the goniometer is aligned with the fibular head. J Orthop Sports Phys Ther. Given the absence of a previously established valid classification system for PFP, the CPG group proposes a classification consisting of 4 subcategories associated with the ICF. 1997;78:26–32. Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis. Hoglund LT, Burns RO, Stepney AL, Jr. Do males with patellofemoral pain have posterolateral hip muscle weakness? The cited evidence to support high-volume exercise is from a single cohort and lacked a control group of wait and see. 2017;27:12–16. 2014;66:1252–1257. Clinicians may use tailored patellar taping in combination with exercise therapy to assist in immediate pain reduction, and to enhance outcomes of exercise therapy in the short term (4 weeks). Patients with higher scores have more pronated feet.248,249,261 The reliability and validity of this measure are fair to good (ICCs from 0.52 to 0.93) (TABLE 3).16,66,249. Greater Q angle may not be a risk factor of Patellofemoral Pain Syndrome. In addition, clinicians should identify the level of tissue irritability and should screen for the presence of psychological factors that may impact the patient's response to physical therapy and/or require referral to another health care practitioner. Level of evidence assignment is adjusted based on the overall quality rating: - High quality (high confidence in the estimate/results): study remains at assigned level of evidence (eg, if the randomized clinical trial is rated high quality, its final assignment is level I). provided the final decision for discrepancies that were not resolved by the review team. Br J Sports Med. The effects of Kinesio taping on VMO and VL EMG activities during stair ascent and descent by persons with patellofemoral pain: a preliminary study. https://doi.org/10.1016/j.gaitpost.2009.07.109, Bolgla LA, Earl-Boehm J, Emery C, Hamstra-Wright K, Ferber R. Comparison of hip and knee strength in males with and without patellofemoral pain. 2012;21:7–11. https://doi.org/10.2519/jospt.2012.4184, Fukuda TY, Rossetto FM, Magalhães E, Bryk FF, Lucareli PR, de Almeida Carvalho NA. bThe individual climbs stairs in a manner that feels normal to him or her.

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