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172 Volume 13 & Number 3 & May/June 2014 Rehabilitation of Patellofemoral Pain
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Table 1.
Etiologic contributors to PFPS.
Local Joint Impairments Altered Lower Extremity Biomechanics Training Errors/Overuse
Quadriceps weakness Hip abductor weakness Increasing exercise too quickly
Impaired VM function Hip external rotator weakness Inadequate time for recovery
Soft tissue inflexibility Excessive foot pronation Excessive hill work
Quadriceps Pes planus
Gastrocnemius Excessive impact shock with heel strike
Iliotibial band
Hamstring
exercise promotes strengthening throughout the arc of mo- Vastus medialis strength
tion. Moreover open kinetic chain exercises (especially in the Much attention has been given to the role of the vastus
range of 90-Y45-) may be better tolerated in the acute phases medialis (VM), and particularly the VM oblique (VMO),
of PFPS when there is significant weakness or pain with based on observations of reduced VMO volume and strength
weight bearing (31). In the long run, however, closed kinetic in individuals postsurgery, following injury, or with PFPS.
chain exercises with an emphasis on cocontraction of the The VMO fibers insert more distally and horizontally on the
hamstring and quadriceps muscles have proven overall su- patella and are critical to providing dynamic medial patellar
perior to open kinetic chain exercises in improving function stability (30,32,44). Studies have found a significant correla-
(2,84). Thus closed kinetic chain exercises should be incor- tion between VMO abnormalities (insertion level, fiber angle,
porated to the rehabilitation program as early as a patient is and VMO volume) and patellofemoral pain (39,57). However
able to tolerate (15). three randomized controlled trials have compared attempts
Table 2.
Approach to PFPS management.
Causative Element Physical Examination Correlate Management Considerations
Local factors Patellar malposition/maltracking Patella alta Patellar taping
Lateral patellar tilt Patellar bracing
Lateral patellar displacement Correction of vasti activation imbalance
Soft tissue inflexibility Tight iliotibial band Stretching and foam roll
Tight quadriceps
Tight hamstring
Tight gastrocnemius
Lower extremity Hip muscle weakness Static hip abductor weakness, Hip strengthening progressing to
biomechanics Dynamic knee valgum, functional movement patterns
Excessive hip adduction with
SLS, and Contralateral pelvic
drop with single leg squat
Foot malposition Excessive pronation contributing Foot orthosis
to increased femoral rotation
Gait Ipsilateral hip adduction Gait retraining
Contralateral pelvic drop
Excessive impact shock with
heel strike
Training errors Overly rapid NA Relative rest
exercise progression Correct training errors
Overly intense exercise
intensity for level of fitness
Inadequate recovery
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
at VMO strengthening to overall quadriceps strengthening Once vasti activation imbalance is recognized, several tech-
using electromyographic feedback techniques, with unani- niques may be effective to modify VM discrepancies. EMG
mous results that negate any difference in short-term out- biofeedback measures neuromuscular contractions and pro-
comes (26,74,88). Another study examined nine commonly vides auditory or visual feedback signals designed to increase
used strengthening exercises and found that electromyo- awareness and voluntary control of muscle activation. When
graphic activity was no different between the VMO and combined with therapeutic exercise, EMG biofeedback aimed
other muscles comprising the quadriceps complex (49). at increasing VMO activation while maintaining constant VL
Therefore specific exercises to isolate the VMO for activity has been shown to improve VMO/VL activation ra-
strengthening are not indicated. A well-rounded quadri- tios (53). Patellar taping, discussed in greater detail below,
ceps strengthening program should correct any imbalance in may likewise represent a useful adjuvant to augment tem-
strength between the quadriceps muscles. poral activation of the VMO (14,19).
174 Volume 13 & Number 3 & May/June 2014 Rehabilitation of Patellofemoral Pain
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
in management of PFPS. The McConnell method aims to speed and step length. Despite this, others have failed to
control patellar tilt, glide, and/or spin based on physical uncover a therapeutic benefit to bracing (48). This may rep-
examination findings (20). Studies have found increased resent inappropriate patient selection (normal patellar kine-
tolerance to knee joint loading, increased VMO activity, matics) or variability in the type of brace employed. Although
and improved onset of the VMO in relation to the VL further studies are needed to clarify the outcomes and most
muscles utilizing this method (14,19,63,68). Alterations in appropriate subpopulations for brace utilization, a properly
patellofemoral kinematics have been demonstrated also fitted patellar stabilization brace represents a potential ad-
(22). Taping performed under dynamic magnetic resonance juvant to a physical therapy program, particularly in those
imaging reveals inferior shift of the patella, thereby in- patients with documented patellar maltracking, and is a rea-
creasing the patellofemoral contact area within the trochlea sonable alternative to patellar taping.
(22). Taping also may lateralize the patella partially in in-
dividuals with baseline medial displacement and medialize the
patella in individuals with baseline lateral displacement, again Altered Lower Extremity Biomechanics
improving patellofemoral contact area (22). This increase in While addressing local joint impairments remains an in-
contact area is theorized to contribute to pain reduction in tegral component of PFPS rehabilitation, there is expanding
PFPS by producing a wider distribution of forces across the evidence to support the influence of lower extremity kine-
patella and possibly relieving contact in sensitive areas (62). matics in the development of PFPS. Aberrations that result
McConnell taping shows promise in providing enhanced in excessive internal rotation of the femur in particular
pain relief and function particularly when combined with appear to increase patellofemoral stress. Studies utilizing
exercise (45,79). Whittingham et al. (79) investigated pain dynamic magnetic resonance imaging suggest excessive in-
and functional outcomes among three treatment groups: ternal femoral rotation, rather than patellar rotation, as
McConnell taping combined with exercise, placebo taping giving rise to lateral patellar tracking and increased patello-
combined with exercise, and exercise alone. While pain im- femoral joint stress (59,70). These kinematic changes more
proved across all groups by 4 wk, both pain and function likely are to be seen during more demanding tasks such as
scores were significantly better in the group managed with a single-limb squat, running, single-limb jumping, and single-
combination of McConnell taping and exercise. In an effort limb drop landing (24,71,80,81).
to further delineate the impact of taping, Mason et al. (45)
evaluated the effect of quadriceps strengthening, quadriceps
stretching, and McConnell taping in isolation and in com- Hip strength
bination. Improvements in pain and strength were demon- Deficits in hip muscle performance, particularly the ex-
strated for all intervention groups in isolation, but more ternal rotators and abductors including gluteus maximus and
significant and pervasive improvements were observed when medius, could result in internal rotation of the femur during
the three modalities were combined. A recent meta-analysis dynamic lower limb functions and consequent increased pa-
further concluded that there is moderate evidence to support tellofemoral compressive forces. Multiple studies have estab-
incorporation of tailored taping into a rehabilitation pro- lished a correlation between hip external rotator and abductor
gram for PFPS, particularly for early pain reduction (7). weakness in women with PFPS (8,38). Altered neuromuscular
activity of gluteus medius and maximus also has been associ-
Patellar bracing ated with PFPS (51).
Bracing has been explored similarly for its role in patel- Recent experience corroborates the incorporation of hip
lar stabilization and management of PFPS. As with taping, strengthening in the management of PFPS, especially for the
bracing has been shown to modify patellofemoral kinematics female population. In 2008, Nakagawa et al. (51) published
(27,62). Medially directed patellofemoral stabilization braces, the first randomized controlled trial investigating the utility
and to a lesser degree, simple knee support sleeves, contribute of a hip strengthening protocol. This study demonstrated that
to reduced lateral translation of the patella (27). Medially di- the addition of hip abduction and external rotation strength-
rected braces also may reduce patellar tilt (27). These alter- ening exercises to a traditional rehabilitation program of pa-
ations are more apparent in a subset of individuals who have tellar mobilization and quadriceps strengthening results in less
baseline abnormal kinematics when compared to controls (27). pain and improved gluteus medius neuromuscular activation
However it is recognized that the impact of braces on patellar (51). Since that time, four additional randomized controlled
lateralization and tilt is limited, and alignment is not restored trials investigating female patients with PFPS have supported
to normal with bracing alone (27,62). Patellofemoral contact hip strengthening further in reducing patellofemoral pain and
area, on the other hand, does appear to increase substantially optimizing function (25,34,35,41). Importantly when com-
with the application of a medially directed brace and may pared to knee stretching and strengthening alone, the addition
be a driving factor in associated pain reduction (62). of targeted hip exercise appears to provide significantly more
The clinical effect of knee braces on patellofemoral pain lasting benefits at 1 year and minimize risk of pain relapse
has been investigated with varying results. There are few (35). Thus targeted hip muscle strengthening is encouraged for
prospective randomized clinical trials evaluating the impact PFPS rehabilitation, particularly in women who demonstrate
of bracing. Immediate pain reduction following application static or dynamic evidence of hip weakness and medial femoral
of a brace has been reported (62). Longer-term benefits in a collapse on physical examination. Exercises should address the
small population also have been demonstrated (1). Arazpour gluteus medius and maximus specifically. Gluteus medius may
et al. (1) found a nearly 60% reduction in pain with the be targeted with side-lying abduction and single-limb squats.
use of bracing and additionally ascertained gains in walking Gluteus maximus is best recruited using front planks with hip
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
extension and gluteal squeezes. Side planks effectively target orthosis when performing a single-leg squat are more likely
both gluteus maximus and medius (10). to benefit from one (4).
There are no specific criteria to identify those individuals
Foot position who warrant a trial of an orthosis in the management of
Observational studies have demonstrated an association PFPS. Nevertheless it is reasonable to trial a foot orthosis
between excessive foot pronation and PFPS (3,67). The pre- simultaneously, or after an appropriate course of physical
cise manner by which excessive pronation may result in in- therapy, in individuals with excessive pronation on dynamic
creased patellofemoral stress has not been elucidated; however examination. If an over-the-counter orthosis is not sufficient,
Tiberio (76) theorized one possible mechanism through com- a custom orthosis with a stiffer medial heel wedge may be
pensatory internal rotation of the femur. In normal gait, the indicated (33,61).
subtalar joint is supinated at heel strike. During early contact, The majority of research on the foot has focused on the
the foot pronates and the tibia internally rotates. Once the rearfoot. However due to reported findings of increased
foot reaches midstance and the foot is in full contact with the foot mobility in individuals with PFPS, future research may
ground, the subtalar joint again supinates and the tibia fol- be better served by focusing more on the midfoot. Pro-
lows, externally rotating, in order to move the knee into ex- spective evaluation of the foot’s association with PFPS is
tension. However in situations of excessive pronation, the needed also (60).
subtalar joint remains in a pronated position at midstance,
preventing the tibia from externally rotating. Tiberio pro- Gait
posed that to compensate and promote knee extension, the Gait patterns that demonstrate excessive hip adduction
femur internally rotates on the tibia (the so-called compen- (9,52), femoral internal rotation (9,71), and excessive pro-
satory internal rotation of the femur). This then results in nation during dynamic activities (67) have been implicated
lateral tracking of the patella, thereby increasing patellofem- in the development of PFPS. Souza and Powers (71) also re-
oral strain. Although not proven, this model has become ported that isotonic hip extension endurance was a signifi-
accepted widely and provides a plausible rationale for the cant predictor of peak hip rotation during running, suggesting
apparent relation between overpronation and PFPS. How- that impaired hip muscle performance may underlie the ab-
ever Reischl et al. (66) have reported that the magnitude of normal hip kinematics thought to contribute to PFPS. It is
foot pronation does not predict the magnitude of tibia or interesting that targeted hip strengthening regimens, while
femur rotation. As such, patients need be evaluated on an improving strength, may not affect these associated gait im-
individual basis to determine whether abnormal foot me- pairments necessarily (29,83). Failure to correct these dy-
chanics are contributing to a kinematic pattern that could namic patterns may result in suboptimal clinical outcomes.
explain the presence of patellofemoral symptoms. Several researchers have addressed this problem through case
Historically results utilizing foot orthoses to correct ex- series incorporating various feedback mechanisms, including
cessive pronation in the management of PFPS have been visual feedback from an instrumented treadmill (21), real-
mixed; however there is a growing body of literature to sup- time hip adduction measurements (54), adoption of a fore-
port the use of foot orthoses. The predominance of recent foot strike pattern (13), and direct mirror feedback (82), and
studies implement semirigid orthoses. Instead of rigid mate- all report both biomechanical and clinical success. Thus
rials, semifirm materials that absorb shock and provide me- while these methods of gait retraining show great promise,
dial longitudinal arch support without hindering the natural prospective and controlled studies are needed to evaluate
pronation mechanism of the foot are recommended (61). these techniques further in the prevention and treatment
Positive effects in both pain reduction and functional of PFPS.
performance have been reported immediately following use Increased peak ground reaction forces also have been im-
(6) and over a period of time up to 3 months (5,40). In a plicated also in the development of PFPS in runners (75).
recent randomized clinical trial comparing the efficacy of Efforts to reduce forces through gait modification have been
foot orthoses to flat inserts or physical therapy, prefabri- undertaken. Heiderscheit et al. (36) performed biomechan-
cated orthoses did appear superior to flat inserts according ical evaluations in healthy runners through modification of
to participants’ perception in the short-term management of step rate and demonstrated that a higher step rate is asso-
PFPS (16). Outcomes were no different between the orthosis ciated with a decreased foot inclination angle, step length,
group and physical therapy. Furthermore the combined use center of mass vertical excursion, and horizontal distance
of a foot orthosis with physical therapy did not portend any from center of mass and heel at initial contact. A subsequent
additional gains in pain or function at follow-up. It is worth follow-up study associated a 14% force reduction at the
noting that participants of this study were not screened for patellofemoral joint with a 10% increase in step rate (43). It
lower extremity mechanics including foot posture. The stands to reason that methods aimed at reducing ground
failure to detect an advantage, particularly in the combined reaction and transmitted patellofemoral forces, such as re-
group, may reflect inclusion of individuals for whom an ducing step length, are a reasonable approach to managing
orthosis would be less likely beneficial. Several predictors PFPS; however additional trials are necessary to confirm
for response to foot orthoses have been identified includ- this notion.
ing lower baseline pain levels, increased midfoot mobility
(change in midfoot width between non-weight bearing and Training Errors
weight bearing), reduced ankle dorsiflexion, and use of less The likely role of tissue homeostasis in the development
supportive shoes (4,77). In addition it has been suggested of patellofemoral pain has been described by Dye (28). He
that those who report immediate pain reduction with an maintains that altered tissue homeostasis may occur under
176 Volume 13 & Number 3 & May/June 2014 Rehabilitation of Patellofemoral Pain
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
any circumstance that supersedes the so-called envelope of 10. Boren K, et al. Electromyographic analysis of gluteus medius and gluteus
maximus during rehabilitation exercises. Int. J. Sports Phys. Ther. 2011;
function or load acceptance capacity of the joint. This in- 6:206Y23.
cludes not only gross structural abnormalities but also re- 11. Brindle TJ, Mattacola C, McCrory J. Electromyographic changes in the
petitive, lower magnitude loads (supraphysiological overload) gluteus medius during stair ascent and descent in subjects with anterior knee
to the patellofemoral joint. While not sufficient to produce pain. Knee Surgery, Sports Traumatology, Knee Surg. Sports Traumatol.
Arthrosc. 2003; 11:244Y51.
immediately evident structural damage, these repetitive stresses
12. Chester R, et al. The relative timing of VMO and VL in the aetiology of
over time result in loss of osseous and periosseous soft tissue anterior knee pain: a systematic review and meta-analysis. BMC Musculo-
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cant findings on physical examination (i.e., normal patellar pain in runners: a case series. J. Orthop. Sports Phys. Ther. 2011; 41:914Y9.
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presence of patellofemoral pain. J. Electromyogr. Kinesiol. 2004; 14:495Y504.
gest training errors and overuse resulting in supraphysio-
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population. In such cases, the training program should be 16. Collins N, et al. Foot orthoses and physiotherapy in the treatment of
evaluated for obvious errors, including increasing exercise patellofemoral pain syndrome: randomised clinical trial. Br. J. Sports Med.
intensity too quickly, inadequate time for recovery, and ex- 2009; 43:169Y71.
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Conclusion
19. Cowan SM, Bennell KL, Hodges PW. Therapeutic patellar taping changes the
It is becoming increasingly apparent that PFPS is a mul- timing of vasti muscle activation in people with patellofemoral pain syn-
tifactorial condition that mandates a comprehensive yet in- drome. Clin. J. Sport Med. 2002; 12:339Y47.
dividualized approach to treatment. A rehabilitation program 20. Crossley K, et al. Patellar taping: is clinical success supported by scientific
should incorporate quadriceps strengthening and be tailored evidence? Man. Ther. 2000; 5:142Y50.
further according to identified deficiencies in patellofemoral 21. Crowell HP, Milner CE, Hamill J, Davis IS. Reducing impact loading during
running with the use of real-time visual feedback. J. Orthop. Sports Phys.
kinematics, lower extremity biomechanics, and training. Based Ther. 2010; 40:206Y13.
on an individual’s constitution, additional strategies that 22. Derasari A, et al. McConnell taping shifts the patella inferiorly in patients
may prove valuable include enhanced muscle flexibility, pa- with patellofemoral pain: a dynamic magnetic resonance imaging study.
tellar bracing or taping, hip strengthening, foot orthoses, and Phys. Ther. 2010; 90:411Y9.
gait modification. Training errors and overuse must be ad- 23. Devereaux M, Luchmann S. Patellofemoral arthralgia in athletes attending a
sports injury clinic. Br. J. Sports Med. 1984; 18:18Y21.
dressed also.
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hip and knee kinematics in runners with patellofemoral pain during a
prolonged run. J. Orthop. Sports Phys. Ther. 2008; 38:448Y56.
The authors declare no conflicts of interest and do not 25. Dolak KL, et al. Hip strengthening prior to functional exercises reduces pain
have any financial disclosures. sooner than quadriceps strengthening in females with patellofemoral pain
syndrome: a randomized clinical trial. J. Orthop. Sports Phys. Ther. 2011;
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