The present study was conducted with the purpose to evaluate the effects of

manual therapy in reducing pain and improving functions in young adults with acute

Patellofemoral Pain Syndrome (PFPS). In acute cases of patellofemoral pain

syndrome, anterior knee pain is the main feature because of which patients will suffer

hindrance in performing the movements39. So this study was intended to check the

effects of manual therapy which includes transverse friction massage, tilt

patellofemoral stretches and medial glide to the lateral retinaculum in the young

adults with PFPS by pre and post test analysis.

The result of the present study proved that manual therapy techniques which

include transverse friction massage, tilt patellofemoral stretches and medial glide to

the lateral retinaculum were effective in reducing pain and improving function in

subjects with patellofemoral pain syndrome. The results showed positive changes in

the Patellofemoral Pain Severity Scale (PFPSS), Range of Motion (ROM) and step up

test after treating the subjects with manual therapy techniques. The statistical analysis

indicated that the paired ‘t’ test value of pre and post test analysis of PSS is t = 44.226

with the ‘p’ value highly significant at 0.000 level, pre and post test analysis of step

test is t = 43.199 with the ‘p’ value highly significant at 0.000 level and paired ‘t’ test

value of pre and post test analysis of flexion ROM analysis is t = 29.601 with the ‘p’

value highly significant at 0.000 level, paired ‘t’ test value of pre and post test

analysis of extension ROM analysis is t = 22.286 with the ‘p’ value highly significant

at 0.000 level.

The result of the present study also illustrated that the males participated in the

study was equal to the females and the highest percentage of subjects was present

between the age of 26 – 30 years. The results showed that the mean difference in the

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step test and PFPSS between pre and post were highly significant with the value of

step test of pre and post analysis (p=0.000 and mean difference = -4.160) and PFPSS

of pre and post analysis (p=0.000 and mean difference= 4.2500). The values also

interpret that the difference in the ROM between pre and post is also highly

significant. They showed difference in the treatment outcome in flexion ROM of pre

and post analysis (p=0.000 and mean difference= -11.720), in extension ROM of pre

and post analysis (p=0.000 and mean difference= -12.0298).

The result of the present study also represents that there is a positive

correlation between the age and PSS in the post test with Pearson correlation values

were r = 0.300, p = 0.035 which showed significance and also showed negative

correlation between the age and flexion, extension ROM in the post test with Pearson

correlation values were r = -0.182, p = 0.207 which is not significant. It also showed

that there is a negative correlation between the age and step test in the post test with

Pearson correlation values were r = 0.014, p = -0.925 which is not significant. The

results also indicated that there is a negative correlation between the PFPSS and ROM

in the post test with Pearson correlation values were r = -0.268, p = 0.060 which is not

significant. The results also showed that there is a positive correlation between the

PFPSS and step test in the post test with Pearson correlation values were r = 0.022,

p = 0.879 which is not significant. The results also indicated that there is a positive

correlation between the flexion ROM and extension ROM in the post test with

Pearson correlation values were r = 0.999, p = 0.000 which is highly significant. The

results also showed that there is a positive correlation between the ROM and step test

in the post test with Pearson correlation values were r = 0.152, p = 0.291 which is not

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significant. More the age there is more change in the difference of the pre and post

test analysis. Similarly high change in flexion leads to high change in extension.

The results showed that the mean difference in the PFPSS, ROM and

step test between males and females were not significant with the value of PSS of

male and female (p=0.758) and ROM of male and female (p=0.369). The values also

interprets that the difference in the step test between male and female (p=0.097) is

also not significant.

The pain scores are a subjective measure so it cannot be used to know the

clinical significance of the present study. The ROM74,75,76 and step test77,78 is an

objective measure, and it can be used to know the clinical significance of this study.

The results showed a mean difference in the ROM of the subjects. It denoted that the

mean difference in the flexion ROM is 11.72 degrees, the mean difference in

extension ROM is 12.034 degrees. The results also showed a mean difference in the

step test of the subjects. The values interpret that there is an increase of about 4 steps

in the subjects after the intervention. Therefore the present study proved to be

clinically significant.

Most of the subjects who participated in this study had an insidious onset of

patellofemoral pain syndrome with a mean age between 26-30 years. Even though

according to many researchers females were found to be more affected by this

condition than the males, in the present study it was seen that number of males was

equal to that of the females42,47,49. However few researchers said that this condition is

seen in young male adults and athletes more as compared to the females32,36,39.

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 Patellofemoral pain syndrome is a common cause of overuse, trauma, muscle

dysfunction, tight lateral restraints, patellar hypermobility, and poor quadriceps

flexibility. PFPS is a condition presenting with anterior knee pain or pain behind the

patella (retropatellar pain).1 The term “PFPS” is often used interchangeably with

“anterior knee pain” or “runner’s knee.” It is a disabling and sometimes severely

painful condition. PFPS can be defined as anterior knee pain involving the patella and

retinaculum that excludes other intraarticular and peripatellar pathology2 and is

commonly experienced during running, squatting, stair climbing, prolonged sitting

and kneeling9,10. It most commonly occurs in the young age group and affects around

7% of the general population. Researchers have suggested that identification of the

underlying pathophysiology is difficult, though the classic picture in Patellofemoral

pain is easily identifiable16,17,20.

In the acute phase, symptoms such as anterior knee pain or pain under the

knee cap occurs while running, jumping, prolonged sitting or kneeling. Many authors

have proposed theories to explain the etiology of patellofemoral pain and have said

that the etiology is multifactorial39,40,55. Patients were included in this present study if -

(1) they have complains of anterior knee pain which excludes knee pain caused by

trauma, any infection, any surgery; (2) they reported subjective complaints of

decreased functional mobility of the knee; (3) their age should be between 18 – 35

years.

Symptoms of patellofemoral pain syndrome develop insidiously and may last

for six months, and then gradually disappear. Sometimes, there may be long lasting

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pain and restricted motion. Mc Connell described the natural history of patellofemoral

pain and found a mean duration of this condition for six months (range = 4 - 6)41. As

the symptoms of the subjects in this study were present for at least two months, there

is an indication that the changes seen after two months in the subjects due to the

treatment could be attributed to manual therapy techniques rather than to the natural

history of patellofemoral pain syndrome.

In many studies the most important outcome measures were ROM measured

by means of a goniometer and step test74,75,76,77,78. Both describe impairments in daily

activities in a simple way and are not measures of function or disability. In evaluating

the effect of treatment, having the same observer for measuring ROM is

recommended. In this study Patellofemoral Pain Severity Scale (PFPSS) was also

used as an outcome measure39,722,73. The PFPSS is measure covering 10 items designed

to evaluate functional status limitation in subjects with PFPS. Many studies suggest

that PFPSS is reliable and valid and is as responsive as the compared outcome

measure, and therefore is ready for use in clinical trials.

Manual therapy techniques are assumed to induce various beneficial effects.

The neurophysiologic effect is based on the stimulation of peripheral

mechanoreceptors and the inhibition of nociceptors. The biomechanical effect

manifests itself when forces are directed toward resistance but within the limits of a

subject’s tolerance. The mechanical changes may include breaking up of adhesions,

realigning collagen, or increasing fiber glide when specific movements stress the

specific parts of the capsular tissue. Furthermore, manual therapy techniques are

supposed to increase or maintain joint mobility by inducing rheologic changes in

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synovial fluid, enhanced exchange between synovial fluid and cartilage matrix, and

increased synovial fluid turnover67,70.

In acute patellofemoral pain there is considerable pain and hypmobility in the

knee joint. Therefore the present study aimed for the management in the acute stage

which included the control of pain and increases the joint mobility. The joint was

given rest to minimize pain. No therapeutic exercises were given. Six sessions (each

session lasted for 15 – 20 minutes, one session per day) of manual therapy consisting

of transverse frictions to the lateral retinaculum as described by Cyriax (1984)44

conducted both in the fully extended and fully flexed position, tilt patellofemoral

stretches as described by Brukner20 et al (2001), and the application of a sustained

medial glide during repeated flexion and extension of the knee was given so as to

maintain soft tissue and joint integrity and mobility.

The indications of the manual therapy techniques in this study were to reduce

pain and improve the functions in young adults with PFPS. Various studies described

that the anterior knee pain can be treated with transverse friction massage to the

lateral retinaculum; tilt patellofemoral stretches and sustained medial glide during

repeated flexion and extension of the knee are used to cause synovial fluid motion,

which is the vehicle for bringing nutrients to the avascular portions of the articular

cartilage (and intra-articular fibrocartilage when present)3,4,5. Manual therapy

techniques help to maintain nutrient exchange and thus prevent the painful and

degenerating effects of stasis when there is pain and restriction of ROM in the knee

joint.

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 Randomized studies describing the effectiveness of manual therapy as a single

intervention in subjects with acute patellofemoral pain syndrome are scarce52,53. The

comparison of the results of the present study with those of other randomized studies

concerning the application of manual therapy techniques in PFPS is hampered by an

insufficient description of the manual therapy techniques in the majority of the

available trials and, except for ROM, the use of different outcome measures like

PFPSS and step test to evaluate treatment effects.

Many studies have been done to compare the effectiveness of 2 treatment

strategies including operative and non-operative ones like physical therapy in subjects

with PFPS and it appeared that the subjects showed clinically significant

improvement40,42,43. In the present study it was found that the subjects had an

improvement in function and reduction in pain after receiving physical therapy

treatment. Therefore, for subjects who are anxious about experiencing pain, physical

therapy treatment could be the preferred treatment mode.

Some studies have been performed to compare the effects of the

electrotherapy modalities and patellar mobilization70,71. A study conducted by

Rowlands included thirty subjects who were randomly divided into two groups for

comparison: group A received patella mobilization; group B received detuned

ultrasound as placebo and found that patellar mobilization were useful in reducing

pain and improving functions in subjects with PFPS.

Mc Connell conducted a study on PFPS in which he reported that no physical

therapy is effective unless manual therapy techniques were included in it 41. He added

manual therapy techniques like stretching of lateral patellar retinaculum via patellar

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glides and deep friction massage and found best results. The techniques used in the

present study were transverse friction massage, tilt patellofemoral stretches and

medial glide to the lateral retinaculum. There was recovery of the subjects with acute

PFPS treated with these manual therapy techniques.

The limitations of the present study were that there was no control group,

which means that, at least in part, these results could be explained by a placebo effect.

In addition, the effect of manual therapy was measured only two days after the

cessation of the intervention and so the long term effect remains unknown. The

inclusion of placebo group and long term follow up would be useful in future studies.

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