Patellofemoral Pain Syndrome

1. Short-Term Effects of Hip Abductors and Lateral Rotators Strengthening in Females

With Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial

THIAGO YUKIO F, FLAVIO MARCONDES R, EDUARDO M, FLAVIO FERNANDES B,

PAULO ROBERTO GARCIA L, NILZA APARECIDA D. Short-Term Effects of Hip
Abductors and Lateral Rotators Strengthening in Females With Patellofemoral Pain
Syndrome: A Randomized Controlled Clinical Trial. ​J Orthop Sports Phys​.
2010;(11):736.

This study was completed on 70 sedentary women between the ages of 20-40 that had a
diagnosis of patellofemoral pain syndrome (PFPS). This study tested the addition of hip abductor
and external rotator strengthening exercises to a conventional 4 week rehabilitation protocol and
compared pain along with functional testing. The study concluded that both groups showed
significant improvement in pain reduction, and the group that completed the additional hip
exercises resulted in lower pain scale ratings when walking down stairs but showed no
differences in other categories. The adductor and external rotator strengthening exercises should
be included in rehabilitation of PFPS due to the positive results of this study. This article
specifies the exercises that were utilized in this study under the intervention section.

2. A Proximal Strengthening Program Improves Pain, Function, and Biomechanics in

Women With Patellofemoral Pain Syndrome (article saved)

Earl J, Hoch A. A proximal strengthening program improves pain, function, and biomechanics in
women with patellofemoral pain syndrome. ​Am J Sports Med​. January
2011;39(1):154-163.

This study was completed to research the relationship between core and hip strengthening and
pain reduction for patients with PFPS. This study used 19 women from 16 to 40 years old. All of
the women in this study were moderately to highly active. All of the women had been diagnosed
with PFPS. The study utilized an 8 week core and hip strengthening protocol to test this
hypothesis. The study showed significant positive changes in pain, functional ability and core
and hip strength. This article did not include a group that utilized a conventional rehabilitation
protocol for this pathology, therefore the article was unable to conclude if this rehabilitation
technique is more beneficial than the conventional techniques. With the successful results of this
article, one can conclude that this core and hip strengthening concept can be a beneficial
technique to utilize, but due to the unknown comparison between it and a conventional
technique, using both techniques will likely result in the most positive outcome for the patient
until further research has been completed.

3. Hip Posterolateral Musculature Strengthening in Sedentary Women With Patellofemoral

Pain Syndrome: A Randomized Controlled Clinical Trial With 1-Year Follow-up

THIAGO YUKIO F, WILLIAM PAGOTTI M, ROBROY L. M, et al. Hip Posterolateral

Musculature Strengthening in Sedentary Women With Patellofemoral Pain Syndrome: A
Randomized Controlled Clinical Trial With 1-Year Follow-up. ​J Orthop Sports Phys​.
2012;(10):823.

This study is testing to see if adding hip strengthening exercises to a traditional PFPS program
will create better long term effects rather than in the traditional 4 week PFPS program alone. The
study utilized 54 sedentary women between the ages 20-40. All of the women in this study had a
diagnosis of PFPS. The study used pain scales and a functional test to assess the progress
throughout the study as well as at the 3, 6, and 12 month follow-ups. The group that included hip
strengthening exercises showed significant improvements in pain and function from the baseline
at each of the follow-ups while the traditional group did result in some significant improvement
in these areas but not in all areas at all follow-ups. The group that included hip strengthening
exercises recorded greater reduction of pain at all three follow-ups compared to the traditional
group. Hip strengthening exercises should be added to a traditional PFPS rehabilitation program
for long term pain reduction and knee function. This article includes a chart and pictures of the
exercise protocol that was utilized for both groups.

4. The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on
Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A
Randomized Controlled Trial

KHALIL K, ZEYNAB M, KOUROSH G, MARK A. L, CHRISTOPHER M. P. The Effects of

Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status,
and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial.
J Orthop Sports Phys.​ 2012;(1):22.

This study tested hip strengthening rehabilitation in women with PFPS. This study utilized 28
women with the diagnosis of PFPS with no previous physical therapy. The study did not indicate
the age of these women, but it did indicate that all of the women included were sedentary. The
subjects were split into an exercise group and a control group. The exercise group performed
rehabilitation 3 times per week for 8 weeks. This rehabilitation protocol focused on hip
abduction and external rotation exercises. This study measured pain, health status, hip abduction
strength and hip external rotation strength before the study, after 8 weeks and after 6 months.
The study reported that pain decreased and health status and hip strength increased at the 8 post
intervention follow up. Pain remained decreased and health status remained increase at the 6
month post intervention follow up. This study included pictures of the exercise and the band
progression that was utilized.

5. The Effects of Quadriceps Strengthening on Pain, Function, and Patellofemoral Joint

Contact Area in Persons with Patellofemoral Pain

Chiu J, Yiu-ming W, Patrick S.H. Y, Gabriel Y.F. N. The Effects of Quadriceps Strengthening
on Pain, Function, and Patellofemoral Joint Contact Area in Persons with Patellofemoral
Pain. ​Am J Phys Med Rehabil​. February 2012;91(2):98-106.

This study compared the effects of hip and knee strengthening and patellar tilt with pain
reduction on patients that have PFPS as well as patients that do not. The study consisted of 15
subjects, 9 of which have PFPS and six of which are seemingly healthy. The subjects completed
3 sessions per week of rehabilitation exercises for 8 weeks. The subjects were tested for knee
strength through the use of an isokinetic machine, patellofemoral joint contact area through the
use of an MRI and patellar tilt angle by manual measurements. Pain was measured on a numeric
pain rating scale. The subjects were tested before and after the rehabilitation occurred. The rehab
protocol consisted of stretching of the leg muscles, leg press and knee extension. Significant
improvements were made between the baseline and post rehabilitation measurements accept the
patella tilt angle in the group with the PFPS subjects. This is a beneficial rehabilitation program
to include in any patient with PFPS. The use of non injured subjects was beneficial because these
subjects showed no difference in the pre and post rehabilitation program which indicates further
that these exercises are safe for all.

6. Traumatic Patellar Dislocation Nonoperative Treatment Compared With MPFL

Reconstruction Using Patellar Tendon

Alexandre Carneiro B, Marco Kawamura D, Caio Oliveira D, Gilberto Luis C. Traumatic

Patellar Dislocation: Nonoperative Treatment Compared With MPFL Reconstruction
Using Patellar Tendon. ​Am J Sports Med.​ 2012;(1):114.

This study compares the conservative treatment of immobilization and physical therapy with a
reconstruction of the medial patellofemoral ligament in patients that experienced a primary,
lateral dislocation. This study utilized 44 patients ranging from of 12-38 years. The patients were
screened to ensure that each patient had damage to the medial retinaculum and that no additional
pathologies such as osteochondral defects were present. The subjects were randomly placed into
one of the two treatment groups. For the exercise group, the patients were immobilized in
extension for 3 weeks and performed hip strengthening exercises during this time. After the
immobilization period, proprioception and closed kinetic chain exercises and then progressed to
open kinetic chain exercises. The exercises for the operative group were very similar to the other
group but included more range or motion. The operative group resulted in better results in
decreased pain and fewer numbers of secondary patella dislocations. This article did not indicate
the length of time of the rehabilitation protocol or set follow up time periods.

7. Posterolateral Hip Muscle Strengthening Versus Quadriceps Strengthening for

Patellofemoral Pain: A Comparative Control Trial

Khayambashi K, Fallah A, Movahedi A, Bagwell J, Powers C. Posterolateral hip muscle

strengthening versus quadriceps strengthening for patellofemoral pain: a comparative
control trial. ​Arch Phys Med Rehabil​. May 2014;95(5):900-907.

This study compared rehabilitation programs that focused on posteriolateral hip strengthening
versus quadriceps strengthening in patients with PFPS. This study utilized 18 men and 18
women with patellofemoral pain. The subjects were screened to ensure no other knee pathology
was the cause of his/her pain. The subjects received treatment 3 times per week for 8 weeks. The
rehab was not performed bilaterally unless the patient was present with bilateral pain.
Progressions to the rehab were made every two weeks. Patients in the hip exercise group
performed exercises to strengthen hip abductors and external rotators. Patients in the quadricep
exercise group performed exercises only to strengthen the quadriceps. This study measured pain
and self reported health status. These measurements were taken prior to the rehabilitation
program, directly after and 6 months after the rehabilitation program was completed. Greater
reductions of pain was found in the hip exercise group, but high scores on the health status were
reported in the quadriceps exercise group. Both rehabilitation techniques should be used in
protocols for PFPS.

8. Strengthening of the Hip and Core Versus Knee Muscles for the Treatment of
Patellofemoral Pain: A Multicenter Randomized Controlled Trial

de la Motte S, Arnold B, Ross S. Strengthening of the Hip and Core Versus Knee Muscles for
the Treatment of Patellofemoral Pain: A Multicenter Randomized Controlled Trial. ​J Athl
Train​. April 2015;50(4):366-377.

This study utilized two 6 week rehabilitation protocols to assess pain, function, hip and knee
muscle strength and core endurance. One of the protocols focused on the knee and the other
focused on hip exercises. This study included 199 participants with patellofemoral pain. Pain
was measured using the visual analog scale and physical function was measured using the
anterior knee pain scale. These measurements were taken prior to the research, once a week
during the study and after the rehabilitation program was completed. The patients were given
at-home exercises, and the rehabilitation progression was decided by the athletic trainer based on
the patient’s individual improvements, signs and symptoms. All exercises in both protocols were
performed on both sides. The study resulted in 80.2% of the hip exercise group to have
successful results while the knee exercise group only resulted in 77% success rate. Both groups
showed significantly positive results therefore one can hypothesis that combining the hip and
knee exercises can further increase the success rate. Further studies should be completed on this
hypothesis. This study included good explanations for the specific protocol that was used.

9. Patellofemoral pain: an update on diagnostic and treatment options

McCarthy M, Strickland S. Patellofemoral pain: an update on diagnostic and treatment options.

Curr Rev Musculoskelet Med​. June 2013;6(2):188-194.

This article provides a clear and detailed history, examination, imaging, treatment and operative
insight. When asking history questions, consider any previous patellar issues or instability even
if it was not recent as a significant piece of diagnosing PFPS. during an examination be sure to
assess the patella tracking, specifically the medial and lateral movement. This article explains
how valuable an X-ray in the sulcus angle view is. It gives the examiner the ability to see and
quantify the degree of lateral shift that a patient has. This would also be beneficial to use before
rehabilitation to see the progression of the improvements that the patient is making. This could
also be used to help with a patient’s psychological outlook if he/she is able to physically see the
progress that is being made through his/her hard work. Rehabilitation recommendations in this
article include quadriceps stretching and strengthening, hamstring stretching and lateral
retinacular manual stretching. This article is beneficial because it allows its reader to remain
updated on the newest findings on PFPS in all areas.

10. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review
with meta-analysis

Simon L, Christian B, Oliver S, Kay C, Dylan M. Proximal muscle rehabilitation is effective for
patellofemoral pain: a systematic review with meta-analysis. ​Br J Sports Med.​
2015;(21):1365.

This study focuses on the evaluation of the effectiveness of strengthening the musculature
proximal to the knee in patients with patellofemoral pain. This article combined 14 studies to
compare rehabilitation protocols to determine the most effective combination. The article found
that proximal strengthening when combined with quadriceps strengthening showed better results
that protocols that solely consist of quadriceps strengthening short term. Studies that included
results in a medium term indicated that proximal strengthening or proximal and quadriceps
strengthening is more effective than solely quadriceps strengthening exercises for patients with
PFPS. Proximal and quadriceps strengthening is more effective at reducing pain that just
quadriceps strengthening in the long term studies as well. This study is very beneficial because
of the quantity of results that it was able to combine. This gives the audience a high confidence
to believe and utilize the results that were indicated in this study. Proximal and quadricep
strengthening should be used in all PFPS rehabilitation protocols.

11. Mirror gait retraining for the treatment of patellofemoral pain in female runners

Willy R, Scholz J, Davis I. Mirror gait retraining for the treatment of patellofemoral pain in
female runners. ​Clin Biomech.​ December 1, 2012;27:1045-1051.1

This study studied the technique of gait retraining with the use of mirrors and verbal cueing for
patients with PFPS and abnormal hip mechanics. This study utilized 10 females between the ages
of 18-40. All subjects were highly active runners. The subjects completed 8 sessions of gati
retraining. A baseline video was taken for the subjects to watch. The subjects would then walk
on a treadmill for 15-30 minutes and would receive verbal cueing. The cueing was originally
scripted and then progressed to cueing of what was necessary of the subject to perform to ensure
that their gait was satisfactory. The study indicated successful results. Gait retraining with the
use of a mirror was effective in reducing abnormal gait trends and reducing pain. This study is
very beneficial because it talks about the simple ways to detect and correct a problem. This
technique is also useful because it requires very little equipment and serve as a very practical
rehabilitation technique that is commonly overlooked.

12. The effect of hip and knee exercises on pain, function, and strength in patients with
patellofemoral pain syndrome: a randomized controlled trial

ŞAHİN M, AYHAN F, BORMAN P, ATASOY H. The effect of hip and knee exercises on pain,
function, and strength in patients with patellofemoral pain syndrome: a randomized
controlled trial. ​Turk J Med Sci.​ March 2016;46(2):265.

This study compares quadriceps rehabilitation alone verses the addition of hip exercises in a
protocol to reduce pain, increase function and muscle strength in patients with PFPS. This study
used 55 women with PFPS. The rehabilitation sessions lasted 12 weeks in which 3 sessions per
week were completed. Pain and muscle strength was measured prior to the rehabilitation, after 6
weeks and after 12 weeks of the rehabilitation program. The quadriceps exercises included in
this study are ‘lower extremity stretches, isometric quadriceps-strengthening exercise, straight
leg raises, mini squat exercises and knee extensor-strengthening exercises.” The additional
exercises that were performed by the group including hip and knee strengthening are “hip
abductor-strengthening exercises and hip external rotator-strengthening exercises.” Both groups
resulted in significant improvements in pain reduction and function increase. The hip and knee
group did result in a higher significance for pain reduction and function increase. The addition of
hip exercises in a rehabilitation protocol for PFPS is beneficial for the best results possible.

13. Comparative evaluation of ambulation patterns and isokinetic muscle strength for the
application of rehabilitation exercise in patients with patellofemoral pain syndrome

SOONYOUNG K. Comparative evaluation of ambulation patterns and isokinetic muscle

strength for the application of rehabilitation exercise in patients with patellofemoral pain
syndrome. ​J Phys Ther Sci​. December 2016;28(12):3279-3282.

This study is looking at the cause of PFPS by observing abnormal movements or gait patterns
and the joint performance in patients with and without PFPS. This study utilized 52 females from
the age 20-29 (32 with PFPS and 20 seemingly healthy). The use of a treadmill with pressure
plate sensors measured the rotation of each section of the foot as the patient was walking. The
isokinetic muscle function was measure by the Humac Norm Testing and Rehabilitation system.
The foot rotation and muscle function measurements were statistically different in the group with
PFPS. The strength produced in the affected leg was significantly lower than that of the
unaffected leg. The article explains that these changes occur very slowly over time and can then
lead to muscle weakness and atrophy which lead to abnormal movements. The study suggests
quadriceps and hamstring strengthening along with proprioception and flexibility.

14. THE EFFECTS OF A MULTIMODAL REHABILITATION PROGRAM ON PAIN,

KINESIOPHOBIA AND FUNCTION IN A RUNNER WITH PATELLOFEMORAL
PAIN.

Passigli S, Capacci P, Volpi E. THE EFFECTS OF A MULTIMODAL REHABILITATION

PROGRAM ON PAIN, KINESIOPHOBIA AND FUNCTION IN A RUNNER WITH
PATELLOFEMORAL PAIN. ​Int J Sports Phys Ther.​ August 2017;12(4):670-682.

This study included “pain education,... lower limb strengthening, running retraining… and
function in a runner with patellofemoral pain.” This was a case study on a 37 year-old female.
The patient is a runner with PFP that has lasted a year. The patient is highly active and typically
runs on a hard surface. The patient first completed 8 weeks of at home rehabilitation and one
session at the clinic per week. This phase of the program focused on glute, quadriceps and core
strengthening. The second phase of this program was 12 weeks long and consisted of gait
retraining and running mechanics. The patient was recorded while running an many
measurements such as cadence, ground contact time and vertical oscillation were taken. The
running was painful so the patient was asked to increase her step rate to evaluate if this affected
her pain level. The patient was pain free at the end of the 12 weeks. These effects were long
lasting as well because the patient completed a marathon 9 months later with no pain. This article
shows the importance and effectiveness of gait retraining in a rehabilitation protocol in patients
with PFP.

15. Carryover effect of hip and knee exercises program on functional performance in
individuals with patellofemoral pain syndr.

HAMADA H, DRAZ A, KOURA G, SAAB I. Carryover effect of hip and knee exercises
program on functional performance in individuals with patellofemoral pain syndr. ​J Phys
Ther Sci​. August 2017;29(8):1341-1347.

This study looks at the “carryover effect” on the hip and knee protocols for patients with PFPS.
This study utilized 30 subjects between the ages of 18-35. All of the subjects have been
diagnosed with PFPS. The subjects were split into 2 groups. The first group focused on hip
strengthening exercises for the first 4 weeks of the study and then focused on knee strengthening
exercises and lower extremity stretching for the next 4 weeks of the study. The second group
completed these same exercises in the reverse order. Pain and functional movements were test
prior to the rehabilitation program, after 4 weeks and after 8 weeks. After 4 weeks that statistics
indicated a greater improvement in functional tests by group in comparison to group 2, but
group 2 showed a higher reduction of pain at the 4 week mark than group 1. These results
indicate that for the best protocol for PFPS, one would include hip and knee strengthening
exercises simultaneously throughout the rehabilitation program.

16. A feasibility study of a novel, task-specific movement training intervention for women
with patellofemoral pain.

Salsich G, Yemm B, Steger-May K, Lang C, Van Dillen L. A feasibility study of a novel,

task-specific movement training intervention for women with patellofemoral pain. ​Clin
Rehabil​. February 2018;32(2):179-190.

This study was completed to assess the effectiveness of a task specific movement training
program in patients with PFPS. The study utilized 25 females with PFPS between 18-40 years of
age. The subjects all had a BMI less than 30. The rehabilitation was completed 2 times per week
for 6 weeks and began with functional movements that include walking up and down stairs,
“single-limb squats, double-limb squats and standing up from/sitting in a chair.” The patients are
cued on specific mechanics to fix while completing these movements. After the patient has
mastered these movements and they are pain free during these movements, new movements are
added. The study did indicate positive results in range of motion for the hip and knee. The study
did not indicate how pain was affected by this rehabilitation protocol. The study explained that
further research with larger sample sizes should be conducted in the future. This rehabilitation
technique did not seem to be as successful or as researched, therefore I would not include this
into my protocol for PFPS until further research is done.

17. Lasting Improvement of Patient-Reported Outcomes 6 Months After Patellofemoral Pain

Rehabilitation.

Hamstra-Wright K, Aydemir B, Earl-Boehm J, Bolgla L, Emery C, Ferber R. Lasting

Improvement of Patient-Reported Outcomes 6 Months After Patellofemoral Pain
Rehabilitation. ​J Sport Rehabil.​ July 2017;26(4):223-233.

This study looked at the medium to long term effectiveness of hip and knee strengthening
rehabilitation on patients with PFP. This study utilized 157 subjects diagnosed with PFP. This
study used a 6 week rehabilitation program that focused on hip and knee strengthening. Pain,
functional ability, strength and core endurance were measured before the rehabilitation, directly
after, 6, 12, 18 and 24 months after the rehabilitation was completed. The study indicated
significant pain reduction and function increase at the post rehabilitation and 6 month
measurement follow ups. The subjects resulted in significant strength and core endurance post
rehabilitation but these strengths did not remain significant at the 6 month follow up. The
muscular results would be expected, but the pain reduction and function increase results were
interesting. Although the results show that the musculature returns to its previous state, the
positive effects are maintained through a 6 month time period. Only 5% of the subjects had a
return of pain and function symptoms at the 24 month follow up.

18. PATELLOFEMORAL PAIN SYNDROME: A Practical Treatment Approach.

NORRIS C. PATELLOFEMORAL PAIN SYNDROME: A Practical Treatment Approach.

Co-Kinetic J​. July 2017;(73):14-17.

This article educates its reader on the prevalence and physiology of PFPS. The patella sustains
up to 9 times one’s own body weight when descending the stairs. This article provides different
treatment options such as patellar taping, foot orthotics and physical therapy. This article
recommends hip and knee exercises to treat PFPS. It explains that closed kinetic chain exercises
typically exacerbate the pain as weight bearing activities therefore it may be better in the case of
PFPS to begin with open kinetic chain exercises. Progressing the degree of weight that is being
bear in the early stages of the rehabilitation program may also be beneficial. This article includes
videos of the patellar taping and various exercises. This article was very simple but provided
practical ideas that could be used for PFPS. More studies should be conducted on the
effectiveness of the orthotics and patellar taping.

19. Individualized Physiotherapy in the Treatment of Patellofemoral Pain.

This study focused on the effects of an individualized rehabilitation program compared to a

traditional hip and knee strengthening approach. This study tried a more holistic view of treating
PFP. This study included 41 patients with PFP. Pain, quadriceps strength, quadriceps length and
quadriceps eccentric control was measured before and after the rehabilitation. The rehabilitation
for each patient was determined by assessing postural alignment, lower limb movements, muscle
tightness and range of motion. This study resulted in significant pain reduction in all 7 of the
functional movement tests. This study provided a unique philosophy that is often overlooked. I
enjoyed the individualization of the protocols for these patients. I will definitely take this into
account with my rehabilitation in the future. This article provided good visual aids of the
exercises and of common improper mechanics as well as the proper mechanics for these
exercises.

Keays S, Mason M, Newcombe P. Individualized Physiotherapy in the Treatment of

Patellofemoral Pain. ​Physiother Res Int​. March 2015;20(1):22-36.

20. Acute Responses of Strength and Running Mechanics to Increasing and Decreasing Pain
in Patients With Patellofemoral Pain

Bazett-Jones D, Huddleston W, Cobb S, O'Connor K, Earl-Boehm J. Acute Responses of

Strength and Running Mechanics to Increasing and Decreasing Pain in Patients With
Patellofemoral Pain. ​J Athl Train.​ May 2017;52(5):411-421.

This study assessed pain in relation with muscular strength and biomechanics of running. This
article included 17 active, college students that had been diagnosed with PFP. Pain
measurements, self evaluation of function, ground reactive force and joint kinematics were taken
prior to the rehabilitation program. The patients were asked to perform 20 nonstop, single leg
squats; pain was assessed before and after the exercise. The patients were then given a 15 minute
TENS unit treatment at the maximum intensity that could be tolerated by the patient. The patient
was then asked to run on the treadmill for 30 seconds, complete a running analysis and a strength
test. The study resulted in significant pain reduction after the TENS unit treatment. This
treatment did not have any effects on the patient’s muscular strength or biomechanics of running.
This was an interesting study due to the use of the TENS unit but further research needs to be
conducted to see the effects of long term use of this technique of pain reduction can be damaging
the patient’s anatomical structures. I feel that changing a patient’s gait or strength would be a
better form of rehabilitation.