Several factors may be associated with patellar mal alignment.

An increase in Q angle

(more than 15°) may increase the lateral pull of the patella, causing the patella to glide on

the lateral ridge of the femoral groove and producing pain.22

Tightness of the muscles that cross the knee joint may have an effect on patellar

alignment. A tight rectus femoris muscle can limit patellar movement, reducing the

functional and mechanical efficacy of the patellofemoral joint and a tight IT band may

pull the patella laterally during knee flexion.16

PFPS is mainly due to changes in the normal Patella Alignments. The factors that can

alter the patellar alignment are:

• Vastus medialis obliques insufficiency

• Increased Q angle

• Tight lateral Retinaculum

• Tight iliotibial band. 37

Physical interventions (non pharmacological and nonsurgical) are the main stay of

treatment of PFPS. The rehabilitation program should focus on correcting maltracking of

the patella by addressing the findings identified on the physical examination.

Physiotherapy is the most common of all physical interventions and includes specific

vastus medialis obliqus or general quadriceps strengthening and/or realignment procedure

like manual therapy techniques, taping, bracing and stretching.15 These treatments appear

to be based on sound theoretical rationale and have attained widespread acceptance, but

the evidence for the efficacy of these intervention is not well established. This review

will present the available evidence for physical therapy and manual therapy technique

used for the treatment of Patellofemoral pain.

12
Definition and Pathology:

Paul Ingraham and Lindsay McGee conducted a study on Patellofemoral Pain

Syndrome in which they defined patellofemoral pain syndrome which is also known as

“Runners Knee” as the most common knee injury which causes pain around and under

the kneecap. They also said that PFPS involves pain in the front of the knee and generally

results from an imbalance of forces on the kneecap. PFPS occurs when the kneecap is not

gliding as it should in its groove and abnormal pressure occurs between the kneecap and

the edges of the groove.46

Stephen M. Pribut, DPM (2009) performed a study on Runner's Knee

(Patellofemoral Pain Syndrome) in which described Patellofemoral pain as the most

common knee problem in runners and young adults. They stated that the "patellofemoral

complex" consists of the quadriceps, knee cap and patellar tendon and the patellofemoral

pain syndrome (PFPS) has also been called runner's knee, anterior knee pain, or

chondromalacia of the patella. This essentially means a softening of the cartilage of the

knee cap. The anatomical sources of pain in this area are now considered to be from the

richly innervated subchondral bone (bone below the articular cartilage), infrapatellar fat

pad, or the medial and lateral retinaculum of the joint.47

Hyacinth Nwosu and Odile Saurat (2008) conducted a study on Patellofemoral

Pain Syndrome refers to all disorders related with discomfort on the anterior aspect of the

knee joint and may include a diverse range of injury. It describes a continuum of articular

cartilage changes affecting the under surface of the patella. It is characterized by

13
retropatellar pain (under the kneecap) or peripatellar pain (around the kneecap) when

ascending or descending stairs, squatting or sitting with flexed knees.48

Scott F. Dye (2005) performed a study on The Pathophysiology of Patellofemoral

pain and documented that pathophysiologic processes such as in-flamed peripatellar

synovial lining and fat pad tissues and increased osseous metabolic activity of patellar

bone (similar to the early stages of a stress fracture) have been of etiologic importance in

the genesis of patellofemoral pain. They also came to a conclusion that it is increasingly

evident that a variable mosaic of possible patho- physiologic processes, often caused by

simple overload, best accounts for the etiology of patellofemoral pain in most patients.

Inflamed synovial lining and fat pad tissues, retinacular neuromas, increased intra-

osseous pressure, and increased osseous metabolic activity of the patella all have been

documented as contributing to the perception of anterior knee pain.49

Hans Ulrich Stäubli, Roland M. Biedert et al (2005) performed a study on The

mosaic of pathophysiology causing patellofemoral pain: Therapeutic implications and

said that their view of the genesis of patellofemoral pain is that the loss of homeostasis of

innervated patellofemoral tissues often unimagable by standard radiographic studies,

including magnetic resonance imaging, is a more important factor than the presence of

abnormal structural characteristics. The most likely sources of nociceptive output in

patients with patellofemoral pain are the innervated peripatellar soft tissues, including

synovium, and the intra-osseous environment of the patella.50

MS Juhn (1999) conducted a study on Patellofemoral Pain Syndrome: A review

and guidelines for Treatment and stated that excessive stress or normal stress applied in

an abnormal direction to the cartilage, with resultant deformation, can transmit abnormal

14
sheer stress to the subchondral bone. Nerves are associated with a blood supply to the

subchondral bone, and the increase in pressure between the patella and femur is likely to

be transmitted to these nerve receptors and perceived as patellar pain. They also said that

the lateral retinaculum also plays an important role in patellofemoral pain. The chronic

lateral subluxation of the patella can lead to shortening of the retinaculum with secondary

nerve damage, resembling the histopathological picture of a Morton neuroma.18

Incidence and Prevalence:

Jan Nusland (2006) performed a study on Patellofemoral Pain Syndrome: Clinical

and Pathophysiological Considerations. In his study he reported that the patellofemoral

pain syndrome affects 15% - 33% of the active adult population and 21% - 45% of the

adolescents. He also added that amongst the adolescents, the incidence is reported to be

higher in the girls. It is consistently reported in the activities such as ascending or

descending stairs and squatting or subsequent long periods of sitting still.51

Michael J. Callaghan and James Selfe (2006) conducted a study on Incidence or

Prevalence of Patellofemoral pain in the general population and they came to a

conclusion that an incidence rate for PFPS ranged from 3% to 40% in the young adults

with a higher prevalence rate in the females.52

Arlene M. Goodman, Jon G. Divine et al (2009) conducted a study on Incidence

and Prevalence of Patellofemoral Pain in Middle School and High School Basketball

Athletes. Their current study results supported the hypothesis that middle & high school–

aged female basketball players have a higher prevalence of developing PFP during the

15
season than male athletes. The prevalence of PFP is as high as 1 in 4 female athletes and

female athletes are 2 times more likely to demonstrate PFP symptoms than male

athletes.53

J Phillips and M F Coetsee (2007) performed a study on Incidence of Non

Traumatic anterior knee pain among 11 – 17 years old. In this study they concluded that

anterior knee pain is commonest amongst 10 -17 year olds, with the peak during the ages

12 – 15 years old for the girls, while the boys showed a more even distribution.54

Tállay, András (A); Kynsburg, Akos et al (2004) conducted a study on Prevalence

of patellofemoral pain syndrome and Evaluation of the role of biomechanical

malalignments and the role of sport activity. In their study they evaluated the prevalence

of PFPS in a group of adolescents aged 12-20 years. The authors concluded that the

prevalence of PFPS among the adolescents is 20.65%.55

Pathomechanics:

Myer, Gregory D; Ford, Kevin R et al (2009) conducted a study on Incidence and

Pathomechanics Related to Patellofemoral Pain in Female Basketball Players. The

purpose of their study was to evaluate prospective measures of lower extremity strength,

motions and loads to determine their relationship to development of Patello Femoral pain.

They hypothesized that increased dynamic valgus and decreased hip abduction strength

would be associated with development of new PF (NPF) in female basketball players

relative to teammates with unilateral active PF (APF) and without PF (CTRL) at baseline

and they came into a conclusion that there was increased knee abduction in APF, and also

an increase in NPF.56

16
Fulkerson, John P (1983) performed a study on The Etiology of Patellofemoral

Pain in Young, Active Patients: A Prospective Study. In their study they conducted

a prospective clinical examination of 78 knees in 60 young patients with

patellofemoral pain, pain occured frequently in the lateral peripatellar retinaculum,

sometimes in association with milder, less well defined medial patellar discomfort.

Patellofemoral pain in the young person is frequently a soft tissue problem initially,

but aberrant mechanics (particularly lateral tracking) that cause this retinacular

overuse and pain may eventually lead to synovial irritation and chondromalacia.

Chondromalacia, however, may not be the primary cause of patellofemoral pain in

many young people.57

Pagenstert GI, Bachmann M. (2008) conducted a study on Clinical examination

for patellofemoral problems. In their study they concluded that one of the reasons

for the patellofemoral pain may be the complex pathomechanics of the

patellofemoral joint which is suspended between the pelvis, the femur, and the tibia

and subsequently is influenced by the whole lower extremity from the hip down to

the foot.58

Mark S. Juhn (1999) performed a study on Patellofemoral Pain Syndrome: A

Review and Guidelines for Treatment. He reported that there were 4 biomechanical

reasons for the Patellofemoral pain, i.e., foot pronation, Pes Cavus, Q angle and

muscular causes. Foot pronation causes a compensatory internal rotation of the

tibia or femur (femoral anteversion) that upsets the patellofemoral mechanism.

Compared with a normal foot, a high-arched foot provides less cushioning for the

17
 leg when it strikes the ground. This places more stress on the patellofemoral

mechanism, particularly when a person is running. "Large" Q angle is a

predisposing factor for patellofemoral pain. Weakness of the quadriceps muscles is

the most often cited area of concern.18

David Tiberio (1987) conducted a study on the Effect of excessive subtalar joint

pronation on patellofemoral mechanics: A theoretical Model. In this study he stated

that the effect of excessive subtalar joint pronation on the tibiofemoral joint, a

possible compensatory action of the femur to deal with excessive pronation, and the

resulting pathomechanics at the patellofemoral joint.59

Risk Factors:

Erik Witvrouw, Roeland Lysens et al (2000) performed a study on Intrinsic Risk

Factors For the Development of Anterior Knee Pain in an Athletic Population:A Two-

Year Prospective Study. The purpose of their study was to determine the intrinsic risk

factors for the development of anterior knee pain in an athletic population. They

concluded that only a shortened quadriceps muscle, an altered vastus medialis obliquus

muscle reflex response time, a decreased explosive strength, and a hypermobile patella

had a significant correlation with the incidence of patellofemoral pain.32

Gregory R Waryaszand Ann Y McDermott (2008) conducted a study on

Patellofemoral pain syndrome (PFPS): a systematic review of anatomy and potential risk

factors. In this study they documented that the positive potential risk factors identified

included: weakness in functional testing; gastrocnemius, hamstring, quadriceps or

iliotibial band tightness; generalized ligamentous laxity; deficient hamstring or

18
quadriceps strength; hip musculature weakness; an excessive quadriceps (Q) angle;

patellar compression or tilting; and an abnormal VMO/VL reflex timing.60

Y Thijs, D De Clercq et al (2008) conducted a study on Gait-related intrinsic risk

factors for patellofemoral pain in young adults. In their study they reported that an

excessive impact shock during heel strike and at the propulsion phase of running may

contribute to an increased risk of developing patellofemoral pain.61

Shawn Maloney (2008) performed a study on Physical Therapy for Patellofemoral

Pain Syndrome. In his study he stated that the risk factors can be divided into anatomical

and physiological. There are numerous anatomical risk factors that may potentially

contribute to the development of PFPS. These include femoral anteversion, the trochlear

notch sulcus angle, tibial torsion, patella alta or baja, and foot and ankle alignment.

Physiologic factors can be divided into muscle performance and range of motion or

flexibility. Muscle performance included strength, endurance, and motor control.62

Clinical Presentation:

Augustsson J; Karlsson et al (1999) conducted a study on Patellofemoral Pain

Syndrome: A Review of Current Issues. In their study they reported that the most

common symptoms in patients with PFPS are pain during and after physical activity,

during bodyweight loading of the lower extremities in walking up/down stairs and

squatting, and in sitting with the knees flexed.63

Mark S. Juhn (1999) performed a study on Patellofemoral Pain Syndrome: A

Review and Guidelines for Treatment. In this study he documented that the patients with

patellofemoral pain syndrome have anterior knee pain that typically occurs with activity

19
and often worsens when they are descending steps or hills and it can also be triggered by

prolonged sitting. He also added that it can affect either one or both knees.18

Casey G. Batten; Christina R. Allen et al (2007) conducted a study on

Patellofemoral Pain Syndrome: Signs and Symptoms and concluded that the most

common symptom of patellofemoral pain syndrome is a dull ache underneath the kneecap

while walking down stairs, squatting or getting up after sitting for long periods of time. In

addition, your knee may catch when bending, and you may experience a painful grating

or creaking sensation.14

Stephen M. Pribut (2009) conducted a study on Runner's Knee

(Patellofemoral Pain Syndrome). In his study he stated that the symptoms of runner’s

knee include pain near the knee cap usually at the medial (inner) portion and below it.

Pain is usually also felt after sitting for a long period of time with the knees bent.

Running downhill and sometimes even walking down stairs can be followed by pain. The

symptoms are aggravated when the knee is bent since (with increased vectors of force)

increased pressure exists between the joint surface of the knee cap and the articular

surface of the femur (thigh bone). This increase in force over-stresses the injured area and

leads to pain.47

Diagnosis:

John P. Fulkerson (2002) conducted a study on Diagnosis and Treatment of

patients with Patellofemoral Pain. In his study he concluded that the patient-athlete with

patellofemoral pain requires precise physical examination based on a thorough history.

20
The nature of injury and specific physical findings, including detailed examination of the

retinacular structure around the patella, will most accurately pinpoint the specific source

of anterior knee pain or instability. He also said that the radiographs should include a

standard 30° to 45° axial view of the patellae and a precise lateral radiograph.31

Patrick J Potter et al (2009) conducted a study on Patellofemoral Syndrome:

Differential Diagnoses & Workup in which they concluded that imaging studies could be

used to diagnose or recommend treatment for patellofemoral syndrome (PFS). They said

that skyline views should be included with anterior-posterior (AP) and lateral

radiographic imaging of the knee. They also added that lateral patellar tilt and a high-

riding patella (patella alta) may be observed. Computed tomography (CT) scanning and

magnetic resonance imaging (MRI) are very helpful in diagnosing this syndrome. They

also concluded that arthroscopy helps to confirm the diagnosis patellofemoral syndrome

(PFS) by allowing direct visualization of the cartilage surface. Arthroscopic evaluation

also provides assessment of joint structures that may cause symptoms that mimic PFS

when they are impaired.64

W. Dilworth Cannon; Brian Feeley et al (2007) performed a study on

Patellofemoral pain Syndrome: Diagnosis. In their study they evaluated the diagnostic

process for this syndrome. They came into a conclusion that X-ray (These can be taken

from different angles to show when your kneecap is off-track), Magnetic Resonance

Imaging (MRI) (This is an effective tool that may be used to see if your pain is due to

bone, cartilage or muscle problems) and Arthroscopy are the useful diagnostic tools for

the patellofemoral pain syndrome.14

21
 Elizabeth Harrison et al (2001) conducted a study on Patellofemoral Pain

Syndrome: The Ongoing Challenges in Etiology, Diagnosis, and Management. In this

study he reported that the diagnosis is established during a physical examination and is

based on frequency of symptoms and confirmed by X rays of the knee. She also said that

this can also be seen on an MRI, although this type of scan is not routinely performed for

this purpose.65

Treatment:

Carina D Lowry; Joshua A Cleland et al (2008) performed a study on

Management of patients with Patellofemoral Pain syndrome using Multimodal Approach:

A Case Series. The purpose of this series was to describe the outcomes of the patients

referred to physical therapy with PFPS who were treated with a multimodal approach.

The patients were treated with manual therapy techniques, exercises, stretching and

orthotics. They came into a conclusion that four out of the five patients demonstrated a

decrease in pain and an increase in functional ability over a median 11 sessions course of

care, and these gains were maintained at 6-month follow up.66

Jenny McConnell and Kim Bennell (2006) conducted a study on Conservative

Management of Patellofemoral pain Syndrome: The McConnell Program. The purpose of

their study was to know the treatment modes of Patellofemoral Pain Syndrome. They

developed a Multi-faceted treatment known as the Mc Connell program which included

manual therapy, tapping, and stretching and patellar mobilizations. They concluded that

stretching of lateral patellar retinaculum via patellar glides and deep friction massage and

glides to the patella were an effective mode of treatment.67

22
 Sameer Dixit; John P Difiori et al (2007) performed a study on the Management

of Patellofemoral Pain Syndrome. In their study they discussed about the definition,

etiology, risk factors, symptoms, and diagnosis and treatment modes of patellofemoral

pain syndrome. They described that physical therapy is effective in treating PFPS. They

also added that several studies have shown physical therapy to be effective in treating

PFPS. According to them the rehabilitation program should focus on correcting

maltracking of patella. They soft tissue techniques like transverse friction to the lateral

retinaculum and flexibility exercises like stretching can be helpful for these patients.

They also added that some patients who lack strength in quadriceps may need

strengthening as well.68

Gary F Stefanick (2004) conducted a case study on Low-tech rehabilitation of

bilateral patellofemoral knee pain in a runner. His study included evidence based

treatment modalities in combination, which included manual friction, patellar

mobilization, spinal manipulation, proprioceptive and strength training, and semi-rigid

orthotic use, to effect vastus medialis oblique vs. vastus lateralis activation, vastus

medialis strength, and patellar movement. The patient responded very well to a 12 week

course of treatment and resumed recreational running with minimal to no pain at the six

month, one and two year follow-ups. In his study he also concluded that the manual

friction massage was helpful in reducing pain and early progress. Manual friction

massage was utilized to break up scar tissue and disrupt the inflammatory process. For

each knee, five minutes of cross friction massage was performed around the inferior and

medial margins of the patella, medial patellar retinaculum, and the tendons of the

quadriceps and sartorius muscles.69

23
 Rowlands BW, Brantingham JW (1999) conducted a study on the efficacy of

patella mobilization in patients suffering from patellofemoral pain syndrome. This pilot

study served to investigate the efficacy of patella mobilization in the treatment of PFPS.

The authors concluded that their results appear to support the potential efficacy of

patellar mobilization for PFPS patients, and suggest that patellar mobilization may be

useful when combined with patient-specific treatment options such as stretching, manual

therapy techniques and orthoses.70

Palumbo PM (1981) Dynamic patellar brace: a new orthosis in the management of

patellofemoral pain. In this study he stated that the dynamic patellar brace can be used

with other conservative intervention like tapping, stretching to treat the patellofemoral

pain syndrome.40

Cowan, Sallie M.; Bennell, Kim L et al (2002) conducted a study on Physical

therapy alters recruitment of the vasti in patellofemoral pain syndrome. The purpose of

this study was to investigate the effect of physical therapy treatment on the timing of

electromyographic (EMG) activity of the vasti in individuals with patellofemoral pain

syndrome (PFPS). Before treatment, the EMG onset of VL occurred before that of VMO.

After physical therapy intervention, there was a reduction in symptoms, and this

improvement was associated with a significant change in the time of onset of Vastus

Medialis Oblique (VMO) EMG compared with that of Vastus Lateralis (VL) in both

phases of the stair-stepping task. After physical therapy treatment, the onset of VMO

preceded VL in the eccentric phase and occurred at the same time in the concentric phase

of the stair-stepping task. This study demonstrates that physical therapy treatment regime

24
including stretching, transverse friction and manual therapy techniques were helpful in

the treatment of PFPS.5

Paul A van den Dolder and David L Roberts (2006) performed a study on Six

Sessions Manual Therapy increase knee flexion and improve activity in people with

anterior knee pain: A Randomized Controlled Trial. The purpose of their study was to

evaluate the effects of manual therapy techniques on pain, range of motion and activity in

subjects with anterior knee pain. They concluded that manual therapy is effective in

improving knee flexion and stair climbing in subjects with anterior knee pain. They also

stated that manual therapy techniques are also effective in reducing pain.39

Brukner P et al (2001) in his book “Clinical Sports Medicine”, 2 nd edition gave a

complete examination of the knee, including a careful assessment of the patellofemoral

joint. He also wrote that physical therapy interventions play an important role in the

treatment of patellofemoral pain. Techniques such as medial glides tilt patellofemoral

stretches and exercises are very useful in the rehabilitation regime of the PFPS.20

Post W R (1999) in his book named Clinical evaluation of patients with

patellofemoral disorders provided a thorough review of the PFPS, from the pathogenesis

to the treatment alternatives both surgical and non surgical. In his book he mentioned that

physical therapy has been the recent developing treatment trend for the subjects with

PFPS. He also penned that various physical therapy treatment techniques like manual

therapy, tapping, transverse friction massages would be very effective in treating PFPS.45

25
John P. Fulkerson (2002) performed a study on Diagnosis and Treatment of

Patients with Patellofemoral Pain. The purpose of this study was to know the

effective treatment modality for the subjects with PFPS. They concluded that non-

operative treatment is effective in most subjects. Prone quadriceps muscle stretches,

balanced strengthening, proprioceptive training, hip external rotator strengthening,

patellar taping, friction massages, manual therapy techniques, orthotic devices, and

effective bracing helped most of the subjects with PFPS.31

C. Benjamin Ma; Anthony C. Luke et al (2007) conducted a study on

Patellofemoral Pain syndrome: Treatment. In their study they made two group of

subjects, one receiving surgical treatment and the other non surgical. They

concluded that most active people respond to non-surgical treatments. They also

reported that depending on the amount of malalignment, the subjects would require

a well-supervised rehabilitation program for six weeks to six months which

includes manual therapy techniques, stretching. In most cases, the exercises learnt

in physical therapy would be continued for life long.14

Warren Hammer (2001) performed a study on Treatment for Patellofemoral Pain

Syndrome. This study explains the etiology and treatment of patellofemoral pain

syndrome. He said that soft tissue methods such as fascial release and friction

massage have helped patients with anterior knee pain, with much of the treatment

directed to the medial and lateral retinaculum. In PFPS, pain will occur along the

medial patella facet or patellar tendon. Most often there is more tightness of the

26
 lateral retinaculum. He concluded that static patellar glide, medial-to-lateral and

lateral-to-medial with the knee flexed 30 would be effective in treating PFPS.11

Cyriax J (1984) in his book “Textbook of orthopaedic Medicine: Treatment by

Manipulation, Massage and Injection” tells that the transverse friction massage on

the lateral aspect of the knee is very effective for the subjects with anterior knee

pain or patellofemoral pain.44

Avraham, Feazadeh (F); Aviv, Saposhnik et al (2007) conducted a study on The

efficacy of treatment of different intervention programs for patellofemoral pain

syndrome - A single blinded randomized clinical trial, Pilot study. The study was

conducted with a total of 30 consecutive patients, diagnosed with PFPS. All patients

were randomly allocated into 3 groups. Group I received conventional knee

rehabilitation program which included quadriceps strengthening, medial glide to the

patella, stretching, friction massage and Trans Electric Neuromuscular Stimulation

(TENS). Group II received hip oriented rehabilitation program which included

stretching, hip external rotators strengthening and TENS. Group III received a

combination of the two above programs. Pain and function were documented on

initial of the program and again 3 weeks later, on the completion. At end of trial, all

groups showed significant improvements in function and reduction in pain

(p<0.0001). They concluded that these improvements did not vary significantly

between the 3 groups and different rehabilitation programs showed a similar

beneficial effect.71

27
Outcome Measures:

Pain Severity Scale:

J A Laprade and E G Culham (2002) conducted a study on A self administered

Pain Severity Scale (PSS) for Patellofemoral Pain Syndrome. The objective of their study

was to develop a scale for estimating the severity of PFPS and to determine its reliability

and validity. Reliability of the pain severity scale was determined by comparing the

scores obtained on two test days. Convergent validity of the PSS was determined by

comparing data obtained from PSS with two established knee scales: the WOMAC

osteoarthritis knee Index and Hughston Foundation subjective knee scale. The results

showed excellent test retest reliability and the co-relations between PSS and the

WOMAC and Hughston scales were strong. They concluded that PSS is reliable and has

demonstrated convergent validity making it a useful tool for monitoring rehabilitative or

surgical outcomes in subjects with PFPS.72

Paul A van den Dolder and David L Roberts (2006) performed a study on Six

Sessions Manual Therapy increase knee flexion and improve activity in people with

anterior knee pain: A Randomized Controlled Trial. In their study they used the pain

severity scale for patellofemoral pain syndrome as the outcome measure. They also stated

that the pain severity scale has shown excellent test retest reliability and a high degree of

concurrent validity when compared with WOMAC and Hughston scales.39

C Brushoj; P Holmich et al (2007) conducted a study on Acute patellofemoral

pain: aggravating activities, clinical examination, MRI and ultrasound findings. They

28
conducted an observational study on 30 army recruits with anterior knee pain (mean

duration of pain 4 weeks) who were examined using the PFPS pain severity scale (PSS).

On PSS typical knee loading activities were the most painful. They concluded that the

patellofemoral pain severity scale was a useful tool which helped them in knowing that

the pain occurred in which particular activity.73

Range of motion:

Watkins MA, Riddle DL et al (1991) performed a study to know the reliability of

goniometric measurements and visual estimates of knee range of motion obtained in a

clinical setting. The purpose of this study was to examine the intratester and intertester

reliability for goniometric measurements of knee flexion and extension passive range of

motion (PROM). In addition, parallel-forms reliability for passive ROM measurements of

the knee obtained by use of a goniometer and by visual estimation was examined. Their

results suggest that the clinicians should use a goniometer to take repeated passive ROM

measurements of a patient's knee to minimize the error associated with these

measurements.74

Sara R Piva, Kelley Fitzgerald et al (2006) conducted a study to evaluate the

reliability of measures of impairments associated with patellofemoral pain syndrome. The

purpose was to determine the inter-tester reliability and measurement error of measures

of impairments associated with PFPS in patients with PFPS. They checked the measures

of Q-angle, tibial torsion, hip external rotation strength, lateral retinacular tightness; and

poor for femoral anteversion. Q-Angle, tibial torsion was measured with a universal

29
goniometer. They also added that the Measurements taken by the universal goniometer

resulted in fair reliability.75

Fredericson, Michael; Yoon, Kisung (2006) conducted a study on Physical

Examination and Patellofemoral Pain Syndrome. In their study they evaluated the

physical signs of patellofemoral pain syndrome. They also concluded that goniometric

measures were very necessary so as to find out the ROM of the knee joint and also to

measure the ‘Q’ angle as an abnormal ‘Q’ angle is most often correlated with

patellofemoral pain syndrome.76

Step Test:

J. Nijs, C. Van Geel et al (2001) performed a study on Diagnostic value of five

clinical tests in patellofemoral pain syndrome. Their study was aimed at examining the

validity of five clinical patellofemoral tests used in the diagnosis of patellofemoral pain

syndrome (PFPS). They performed the vastus medialis coordination test, patellar

apprehension test, Waldron's test, Clarke's test, and the eccentric step test. They

concluded that a positive outcome on either the vastus medialis coordination test, the

patellar apprehension test, or the eccentric step test increased the probability of PFPS to a

small, but sometimes important, degree.77

Harrison E, Quinney H et al (1995) conducted a study on Analysis of outcome

measures used in the study of patellofemoral pain syndrome. The goal of this study was

to investigate the psychometric properties of five evaluation methods: a functional index

questionnaire (FIQ), visual analogue scales (VAS) for pain, a patellofemoral function

30
scale (PFS), a step test and a subjective report of functional limitations. Modest test-retest

reliability for the FIQ, VAS and step test were found. The VAS, FIQ and step test were

found to be good discriminators for measuring clinical change.78

Harrison EL, Sheppard MS et al (1999) conducted a study on Physical Therapy

Treatment Programs in Patellofemoral Pain Syndrome: A Randomized Controlled Trial.

The purpose of this study was to evaluate the efficacy of 3 physical therapy treatment

approaches for PFPS. The following outcome measures were used in this study: the

Functional Index Questionnaire, a visual analog scale (VAS) for pain, a measure of

clinical change (i.e., condition worse, no improvement, some improvement, substantial

improvement), a patellofemoral scale, and a step test. This proves that the step test can be

used to measure the clinical changes in PFPS 37.

31
32