Knee Pain Background
Anterior knee pain is a term used to encompass many conditions affecting structures of the knee. The majority of these cases can be attributed to patellofemoral pain syndrome (PFPS) or an abnormal tracking of the patella on the femoral groove secondary to changes in lower extremity alignment, muscle imbalance, or training errors (2).
PFPS is the most common LE condition seen in orthopedic practice and the most common overuse injury in the active population24 attributed to 25-40% of all knee problems in sports medicine centers and 25% of all injuries in runners (1).
PFPS is more common in females who are 2.2 times more likely to experience PFPS than males (3).
The diagnosis of PFPS can be elusive, but recent evidence suggests our strongest diagnostic test is resisted MMT of the quad (+ Likelihood ratio (LR) 2.2), but 2 of 3 positive tests within a cluster (pain with quad contraction, pain with squatting, and pain with palpation) demonstrated a (+) LR of 4.0 (7).
In addition, the eccentric step down test (+ LR 2.34, – LR .70) offers value for differential diagnosis and identifying precipitating or perpetuating impairments (20).
Physical Therapy Treatments
Medical Evidence Supporting PT Interventions
Manual Therapy: A recent literature review found level B evidence for the utilization of manual therapy on the lower quarter in patients with PFPS (4).
Crossley demonstrated improved stair climbing function following manual therapy to the patellofemoral and tibiofemoral joints (9).
An immediate decrease in quadriceps inhibition following lumbo- pelvic manipulation has been shown in patients with PFPS (25, 26).
Further, Iverson, et al. demonstrated a >50% reduction in pain with functional activities following lumbopelvic manipulation in a subgroup patients with PFPS. One variable associated with success included a side to side difference in hip IR >16 degrees which improves the probability of success from 45% to 80% (+ LR 4.6) (15).
Recently Lowry et al. demonstrated improvements in pain and disability utilizing manual therapy to the lower quarter, exercise, orthotics and taping in a series of patients with PFPS (17).
Exercise: Herrington examined the benefits of open chain compared to closed chain strengthening in patients with PFPS. Both groups improved short term strength and function, but no statistical differences were found between groups (13)
A recent randomized, controlled trial demonstrated improved pain and function in a group of females with PFPS performing knee and hip strengthening compared to a knee strengthening and a control group (11).
Mascal et al. demonstrated improved pain and function in two females with PFPS utilizing a proximal and distal lower quarter strengthening program (18).
Clark et al. examined the efficacy of the individual components of physiotherapy in subjects with anterior knee pain. Patients who were in a group that included exercise were significantly more likely to be discharged at three months than non- exercising patients (5).
Taping: Patellar taping produces a clinically meaningful change in chronic knee pain, but conflicting results indicates a subgroup of patients may be most appropriate for this intervention (29).
Lescher, et al. developed a clinical prediction rule to determine which patients with PFPS would be most likely to benefit frompatellar taping. Two variables, (+) patellar tilt test and >5 degree tibia varum, increased the probability of success from 52 to 83% (16).
Derasari, et al. documented an inferior glide of patella produced through taping increased patellofemoral joint surface contact area and reduced pressure across the joint during functional activities in patients with chronic PFPS (9).
Orthoses: PFPS has been associated with altered foot positioning which can alter mechanics at the knee leading to increased pain with activity. Orthotics have been shown to be effective at improving foot positioning and reducing knee pain in the short term (19).
A randomized study evaluating the effects of custom orthotics for knee pain found custom orthotics were effective at decreasing knee pain and improving running tolerance (14).
Foot orthotics were not superior to physical therapy management, nor was there any additional improvement by adding orthotics to a physical therapy programs (6).
A recent systematic review supported the use of foot orthoses to prevent a first episode of overuse conditions and demonstrated no difference between custom and prefabricated foot orthoses. Evidence was insufficient to recommend foot orthoses for the treatment of lower limb overuse conditions (23).
When To Seek Physical Therapy Care
Patients with anterior knee pain demonstrate improvements in pain and disability when referred to a licensed Physical Therapist with advanced training in manual therapy and exercise prescription.
1. Bizzini, M. et al. A systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. JOSPT. 2003; 33(1):4-20.
2. Bolgla, L. et al. An update for the conservative management of patellofemoral pain syndrome: A systematic review of the literature. The International Journal of Sports Physical Therapy. 2011; 6(2):112-125.
3. Boling, M. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010; 20(5):720-725.
4. Brantingham, J. Manipulative therapy for lower extremity conditions. Expansion of literature review. Journal of Manipulative and Physiological Therapeutics. 2009; 32(1):53-71.
5. Clark D, Downing N, Mitchell J, et al. Physiotherapy for anterior knee pain: a randomized controlled trial. Ann Rheum Dis. 2000; 59: 700-704.
6. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med 2009; 43(3):163-168.
7. Cook, C. et al. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy. 2011; 1-8.
8. Creighton, D. et al. Use of Anterior Tibial Translation in the Management of Patellofemoral Pain Syndrome in Older Patients: A Case Series. J Man Manip Ther. 2007; 15(4): 216–224
9. Crossley, K. et al. Physical Therapy improves knee flexion during stair ambulation in patellofemoral pain. Med Sci Sp Ex. 2005; 37:176-183.
10. Derasari A, et al. McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study. Phys Ther. 2010; 90(3):411-419.
11. Fukuda, T. et al. Short-Term Effects of Hip Abductors and Lateral Rotators Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial. JOSPT. 2010; 40(11):736-742
12. Gross MT, Foxworth JL. The role of foot orthoses as an intervention for patellofemoral pain. JOSPT. 2003; 33:661-670.
13. Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weight-bearing exercises for patellofemoral pain. JOSPT. 2007; 37:155-160.
14. Hirschmuller A, Baur H, Muller S, Helwig P, Dickhuth HH, Mayer F, et al. Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. Br J Sports Med 2011; 45(12):959- 965
15. Iverson CA, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. JOSPT. 2008; 38:297-309.
16. Lesher J, et al. A clinical prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping. J Orthop Sports Phys Ther. 2006; 36:854-866.
17. Lowry, C. et al. Management of Patients With Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series. JOSPT. 2008; 38(11):691-702
18. Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. JOSPT. 2003; 33:647-660.
19. Munuera PV, Mazoteras-Pardo R. Benefits of custom-made foot orthoses in treating patellofemoral pain. Prosthet Orthot Int 2011; 35(4):342-349.
20. Nijs, J. et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther. 2006; 11:69-77
21. Powers, C. et al. Patellofemoral kinematics during weight-bearing and non-weight- bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. JOSPT. 2003; 33:677-685.
22. Rabin, A. et al. Measures of Range of Motion and Strength Among Healthy Women With Differing Quality of Lower Extremity Movement During the Lateral Step-Down Test. JOSPT. 2010; 40(12):792-800
23. Souza, R. et al. Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain. JOSPT. 2009; 39(1):12-19.
24. Suter, E. et al. Conservative lower back treatment reduces inhibition in knee extensor muscles: a randomized controlled trial. J Manipulative Physiol Ther. 2000; 23:76-80.
25. Suter, E. et al. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. J Manipulative Physiol Ther. 1999; 22:149-153.
26. Taunton, J. et al. A retrospective case control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95-101.
27. Tiggelen D.V. et al. Effect of bracing on the prevention of anterior knee pain – a prospective randomized study.
28. Warden S. J. et al. Patellar taping and bracing for the Treatment of Chronic Knee Pain: A Systematic review and Meta-Analysis. Arthritis and Rheumatology(Arthritis Care & Research). Vol. 59, NO.1, January 15, 2008, pp73-83. DOI 10, 1002/art.23242. 2008 American College of Rheumatology.
29. Wilk KE, George JD, Mangine RE and Malone TR. Patellofemoral disorders: A classification system and clinical guidelines for nonoperative rehabilitation. Journal of Ortho and Sports Phys Ther. 1998; 28(5): 307-322.