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

Abstract

BackgroundProximal muscle rehabilitation is commonly prescribed to address muscle strength and function deficits in individuals with patellofemoral pain (PFP). This review (1) evaluates the efficacy of proximal musculature rehabilitation for patients with PFP; (2) compares the efficacy of various rehabilitation protocols; and (3) identifies potential biomechanical mechanisms of effect in order to optimise outcomes from proximal rehabilitation in this problematic patient group.MethodsWeb of Knowledge, CINAHL, EMBASE and Medline databases were searched in December 2014 for randomised clinical trials and cohort studies evaluating proximal rehabilitation for PFP. Quality assessment was performed by two independent reviewers. Effect size calculations using standard mean differences and 95% CIs were calculated for each comparison.Results14 studies were identified, seven of high quality. Strong evidence indicated proximal combined with quadriceps rehabilitation decreased pain and improved function in the short term, with moderate evidence for medium-term outcomes. Moderate evidence indicated that proximal when compared with quadriceps rehabilitation decreased pain in the short-term and medium-term, and improved function in the medium term. Limited evidence indicated proximal combined with quadriceps rehabilitation decreased pain more than quadriceps rehabilitation in the long term. Very limited short-term mechanistic evidence indicated proximal rehabilitation compared with no intervention decreased pain, improved function, increased isometric hip strength and decreased knee valgum variability while running.ConclusionsA robust body of work shows proximal rehabilitation for PFP should be included in conservative management. Importantly, greater pain reduction and improved function at 1 year highlight the long-term value of proximal combined with quadriceps rehabilitation for PFP.

Factors that predict a poor outcome 5–8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis

“…Longer duration of pain and worse symptoms and function, measured at baseline, remain predictors of poor PFP prognosis up to 8 years later. Education of health practitioners and the general public is recommended, to change the long-held belief that PFP is self-limiting and to improve treatment outcomes 53 54What are the new findings?

A substantial proportion (>50%) of people with patellofemoral pain (PFP) who responded at follow-up still have notable symptoms 5–8 years after a 6-week programme of treatment and education.

The large majority of people with PFP at follow-up did not have signs of radiographic knee osteoarthritis, which does not support the proposition that long-term PFP is associated with structural patellofemoral osteoarthritis changes in younger adults.

How might it impact on clinical practice in the near future?

Medical professionals need to educate patients that PFP is not always self-limiting, especially those with long PFP duration (>12 months) and worse symptoms and function.

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How useful is a single measurement of patellar mobility in the assessment of patients with patellofemoral pain?

“…This mal-tracking leads to reduced patellofemoral joint contact area which increases the load on that joint and, hence, pain (Powers et al 2017). Consequently, many treatments for patellofemoral pain have focused on improving patellofemoral control, through, for example, proximal (hip abductors and quadriceps) strengthening and stretching exercises (Lack et al 2015), patella mobilisations (Rowlands and Brantingham 1999), patella taping (Barton et al 2015). Both hypomobility and hypermobility of the patella are considered to be clinically important.…”

An Acute Bout of Barefoot Running Alters Lower-limb Muscle Activation for Minimalist Shoe Users

“…Interestingly, we have shown that BF running increases the activation of GMax during stance phase, a muscle involved in hip extension and stabilization. With evidence that proximal lower-limb muscle exercise can have rehabilitative value for persons with patellofemoral pain [18], BF running could be a potential training or recovery solution for these individuals.…”