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Accepted Manuscript

How to manage patellofemoral pain – Understanding the multifactorial nature and


treatment options

Simon Lack, Bradley Neal, Danilo De Oliveira Silva, Christian Barton

PII: S1466-853X(17)30674-0
DOI: 10.1016/j.ptsp.2018.04.010
Reference: YPTSP 879

To appear in: Physical Therapy in Sport

Received Date: 18 December 2017


Revised Date: 11 April 2018
Accepted Date: 11 April 2018

Please cite this article as: Lack, S., Neal, B., De Oliveira Silva, D., Barton, C., How to manage
patellofemoral pain – Understanding the multifactorial nature and treatment options, Physical Therapy in
Sports (2018), doi: 10.1016/j.ptsp.2018.04.010.

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How to manage Patellofemoral Pain – understanding the multifactorial nature and
treatment options

Clinical Masterclass

Dr Simon Lack 1,2, Mr Bradley Neal 1,2, Mr Danilo De Oliveira Silva3,4, Dr Christian
Barton 1,3

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1. Sports and Exercise Medicine, William Harvey Research Institute, School of

Medicine and Dentistry, Queen Mary University London, London, United

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Kingdom

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2. Pure Sports Medicine, London, United Kingdom

3. Sport and Exercise Medicine Research Centre, School of Allied Health, La

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Trobe University, Melbourne, Australia.
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4. Laboratory of Biomechanics and Motor Control, Sao Paulo State University
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(UNESP), Presidente Prudente, Brazil


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CORRESPONDING AUTHOR
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Dr Simon Lack email: s.lack@qmul.ac.uk


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Sports and Exercise Medicine, Mile End Hospital, Bancroft Road, London E1 4DG, United
Kingdom.
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Word Count 6887 (excl Tables and Figures)

Funding statement

No funding
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1 ABSTRACT

2 Patellofemoral pain (PFP) is one of the most prevalent conditions within sports
3 medicine, orthopaedic and general practice settings. Long-term treatment
4 outcomes are poor, with estimates that more than 50% of people with the condition
5 will report symptoms beyond 5 years following diagnosis. Additionally, emerging
6 evidence indicates that PFP may be on a continuum with patellofemoral

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7 osteoarthritis. Consensus of world leading clinicians and academics highlights the
8 potential benefit of delivering tailored interventions, specific to an individual’s

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9 needs, to improve patient outcome. This clinical masterclass aims to develop the
10 reader’s understanding of PFP aetiology, inform clinical assessment and increase

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11 knowledge regarding individually tailored treatment approaches. It offers practical
12 application guidance, and additional resources, that can positively impact clinical
13 practice.
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14 Keywords
15 Patellofemoral Pain, Rehabilitation, Biomechanics, Education
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16 INTRODUCTION

17 Patellofemoral pain (PFP) is one of the most prevalent conditions within sports
18 medicine, orthopaedic and general practice settings (Baquie & Brukner, 1997;
19 Kannus, Aho, Jarvinen, & Niittymaki, 1987; Taunton, et al., 2002). The incidence of
20 PFP varies significantly between specific populations, with figures as low as 3% in
21 established runners and to as high as 43% in naval recruits during basic military

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22 training (Boling, et al., 2009; Smith, et al., 2018; Thijs, Van Tiggelen, Roosen, De
23 Clercq, & Witvrouw, 2007). In adolescents, the incidence of PFP has been reported

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24 to be as high as 10% in high school female athletes during the competitive basketball
25 season (Myer, et al., 2010). The variability in incidence and high prevalence within

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26 specific populations is indicative of a complex multifactorial condition and a lack of
27 consensus on the most appropriate diagnostic criteria (Crossley, Stefanik, et al.,
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2016; Nunes, Stapait, Kirsten, Noronha, & Santos, 2013).
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29 Symptoms of PFP are characterised by pain around or behind the patella, aggravated
30 by activities that increase load on the patellofemoral joint (PFJ) (e.g. squatting,
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31 ascending and descending stairs, prolonged sitting and running) (Collins, Vicenzino,
32 van der Heijden, & van Middelkoop, 2016; Crossley, Stefanik, et al., 2016).
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33 Individuals with PFP may also describe or experience crepitus emanating from the
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34 PFJ, tenderness on palpation of the patella facets and a small effusion (Crossley,
35 Stefanik, et al., 2016). Although widely researched, the exact source of pain in
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36 people with PFP is unclear, with several theoretical models previously described
37 (Dye, 2005; Sanchis-Alfonso, Rosello-Sastre, Monteagudo-Castro, & Esquerdo, 1998).
38 These include altered patellar tracking, resulting in elevated patellofemoral joint
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39 contact pressure (Ho, Hu, Colletti, & Powers, 2014; Powers, 2003), and a loss of
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40 tissue homeostasis in the surrounding innervated tissues including the synovial lining
41 or fat pad (Dye, 2005).

42 Based on current evidence and clinical practice, exercise therapy forms the
43 cornerstone of management for PFP (Crossley, van Middelkoop, et al., 2016; van der
44 Heijden, Lankhorst, van Linschoten, Bierma-Zeinstra, & van Middelkoop, 2015) with
45 efficacy of a multimodal approach having been well reported (Barton, Lack,
46 Hemmings, Tufail, & Morrissey, 2015; Collins, Bisset, Crossley, & Vicenzino, 2012).
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47 Despite the reported benefits of multimodal treatment for PFP, longer-term follow
48 up data (5-20 years) indicates that more than 50% of individuals with PFP continue
49 to experience symptoms and unfavourable outcomes (Lankhorst, et al., 2016;
50 Nimon, Murray, Sandow, & Goodfellow, 1998; Witvrouw, Danneels, Van Tiggelen,
51 Willems, & Cambier, 2004). The development of a targeted intervention has been
52 proposed to represent an approach that could positively impact long-term treatment

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53 outcomes (Crossley, van Middelkoop, et al., 2016; Glaviano & Saliba, 2016; Powers,
54 Bolgla, Callaghan, Collins, & Sheehan, 2012; Witvrouw, et al., 2014).

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55 This masterclass aims to introduce the clinician to currently proposed theories linked
56 to the aetiology of PFP, and the multiple potential factors related to PFP symptom

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57 development and persistence. This information will then be used as foundation
58 knowledge to inform clinical assessment and provide insight into potentially
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effective treatments, along with discussion of areas where greater understanding is
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60 still required. Importantly, the masterclass will provide practical tools and resources
61 that can be directly implemented into clinical practice.
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62 Why does it hurt? Proposed theories linked to the aetiology of


63 patellofemoral pain
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64 Biomechanical model: Traditional paradigms of pain presentation have been derived


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65 from a primary nociceptive pathway directly associated with overload of the PFJ. It
66 has been proposed that alterations in lower limb biomechanics result in maltracking
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67 of the patella within the trochlea groove (Figure 1) (Powers, 2010). Multiple
68 potential mechanisms are thought to result in PFJ maltracking, including movement
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69 of the patella relative to the femur, or the femur underneath the patella driven by
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70 proximal or distal biomechanical variables (Lee, Morris, & Csintalan, 2003; Witvrouw,
71 et al., 2014). Theoretically, this maltracking subsequently increases PFJ stress,
72 initiating nociceptive firing from the densely innervated subchondral bone (Powers,
73 2003). Evidence related to the validity of this proposed biomechanical model is
74 outlined in the ‘common biomechanical deficits reported in PFP’ section below.
75 Whilst it remains plausible that this represents the primary nociceptive pathway for
76 some individuals, the complexity of the central nervous system within which this
77 peripheral nociception is processed, requires the clinician to be considerate of the
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78 individuals psychosocial characteristics in addition to biological theories and
79 concepts (Maclachlan, Collins, Matthews, Hodges, & Vicenzino, 2017).

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80

81 Figure 1 - Demonstrating altered biomechanics leading to the maltracking of the patella within the
82 trochlea groove – from proximal to distal the arrows indicate, contralateral pelvic drop, internal
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83 femoral rotation, knee valgus, internal tibial rotation and foot pronation (Reprinted with permission
84 (Barton & Rathleff, 2016))
85 Tissue homeostasis: In 1999, Scott Dye and colleagues proposed a tissue
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86 homeostasis model for the development of PFP, describing how relative


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87 supraphysiological over- or under-load on innervated musculoskeletal tissues in the


88 region of the PFJ, may result in symptoms (Dye, Stäubli, Biedert, & Vaupel, 1999)
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89 (Figure 2). It has subsequently been described how a resultant single loading event
90 of sufficient magnitude or a number of repeated loading events of lower magnitude
91 may result in the loss of tissue homeostasis, at least temporarily, and subsequent
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92 increase in nociceptive firing (Dye, 2005).


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Zone of structural
failure

Zone of
Envelope of func8on
supraphysiologic
overload

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Load

Zone of
homeostasis

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Zone of subphysiologic
underload

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Frequency
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94 Figure 2 – Diagrammatic representation of the zone of tissue homeostasis reproduced (with
95 permission) from Dye 1999 (Dye, et al., 1999)
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97 Proposed structural source of symptoms: Prior to and following the suggestion of a


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98 homeostasis model, a number of potential tissue derived characteristics may be


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99 present in those with PFP symptoms (Fulkerson, 1983; Ho, et al., 2014; Sanchis-
100 Alfonso, et al., 1998; Schoots, Tak, Veenstra, Krebbers, & Bax, 2013; van der Heijden,
101 et al., 2016). These included alterations in the neovascularity and thickness of the
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102 lateral retinaculum, increased water content of the subchondral bone and articular
103 cartilage stress (Farrokhi, Keyak, & Powers, 2011; Ho, et al., 2014; Schoots, et al.,
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104 2013). The absence of association between changes in cartilage composition and
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105 PFP symptoms continues to challenge the assumption that patient’s pain can be
106 explained by structural changes in isolation (van der Heijden, et al., 2016).

107 Non-mechanical contributors to pain: Despite nociceptive activity representing the


108 dominant mechanism of acute pain, the large number of individuals with recurrent
109 or persistent PFP symptoms means that exploration of possible non-mechanical
110 contributors to symptom persistence is warranted (Arendt-Nielsen, Skou, Nielsen, &
111 Petersen, 2015). The biomedical model in isolation possesses inherent limitations
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112 within the complex paradigm of human pain perception (Gifford & Butler, 1997) and
113 a treating clinician may need to prioritise assessment of the unique filters through
114 which an individual’s nociceptive signals pass.

115 In some, the non-mechanical amplification of nociceptive signalling that can occur
116 within both the peripheral and central nervous systems (pain sensitisation), may be

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117 the predominant driver of pain perception and persistence. In both adolescents
118 (Rathleff, Roos, Olesen, Rasmussen, & Arendt-Nielsen, 2013) and female adults

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119 (Pazzinatto, et al., 2016; Rathleff, Petersen, Arendt-Nielsen, Thorborg, & Graven-
120 Nielsen, 2015) with persistent PFP symptoms, local and widespread hyperalgesia has

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121 been reported, thought to represent altered pain processing. The activities that load
122 the PFJ (e.g. stair negotiation, squatting, walking, running) may generate repetitive
123 nociceptive stimuli, leading to the development and maintenance of pain
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sensitisation. A recent study provides support for this assumption, as greater running
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125 volume was associated with localized and remote pressure hyperalgesia and poorer
126 self-reported knee function in female runners with PFP (Pazzinatto, et al., 2017).
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127 Elevated levels of anxiety, depression, catastrophising and fear of movement have
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128 also been reported in individuals with PFP, which have the capacity to negatively
129 influence physical function and activity related behaviours (Maclachlan, et al., 2017).
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130 These observations, in combination with reductions in pain and disability being
131 associated with improvements in psychosocial health (Doménech, Sanchis-Alfonso,
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132 & Espejo, 2014), highlight the importance of recognising alterations in a patient’s
133 pain processing during clinical examination and integrating these findings into their
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134 eventual management plan (Maclachlan, et al., 2017).


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Key Points

- Altered biomechanics, tissue homeostasis, structure and non-mechanical


factors may all contribute to PFP symptoms and persistence

-Individual variation relating to the relative importance of these factors is likely


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135 Common biomechanical deficits reported in PFP

136 Proximal, distal and local to the PFJ, biomechanical deficits are evident in people
137 with PFP. In some instances these deficits may exist prior to the development of
138 symptoms, potentially representative of the primary driver of symptoms through
139 resultant altered loading and loss of tissue homeostasis about the PFJ (Dye, 2005).
140 To optimize treatment, individual patient deficits need to be identified and an

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141 appropriately tailored intervention programme developed and delivered.

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142 The most frequently investigated muscle local to the PFJ is the quadriceps, with
143 prospective level one evidence indicating PFP development is more common in

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144 individuals with reduced knee extension strength (Lankhorst, Bierma-Zeinstra, & van
145 Middelkoop, 2012), level two evidence indicating VMO is delayed in those who
146 develop PFP (Van Tiggelen, Cowan, Coorevits, Duvigneaud, & Witvrouw, 2009) and
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level one retrospective evidence reporting reduced quadriceps cross sectional area
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148 in those with symptoms (Giles, Webster, McClelland, & Cook, 2013). The
149 prospective data is, however, limited to military populations (Boling, et al., 2009;
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150 Duvigneaud, Bernard, Stevens, Witvrouw, & Van Tiggelen, 2008; Van Tiggelen, et al.,
151 2009) and it is currently unclear if quadriceps weakness or VMO activation delays
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152 increase the risk of PFP development in non-military populations. Consistent cross-
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153 sectional findings indicate decreased knee extension strength exists in various
154 populations with PFP symptoms (Lankhorst, Bierma-Zeinstra, & van Middelkoop,
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155 2013), including recreational runners and physically active individuals. It is important
156 to note that the same quadriceps muscle strength deficits reported in adults with
157 PFP have not been reported to exist in adolescents with PFP, potentially indicating
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158 exercise therapy targeting strength in this population may be less beneficial or
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159 relevant (Rathleff, Baird, et al., 2013).

160 Kinematically, individuals with PFP are reported to ascend stairs with reduced peak
161 knee flexion when compared to healthy controls (Crossley, Cowan, Bennell, &
162 McConnell, 2004; de Oliveira Silva, Briani, Pazzinatto, Ferrari, Aragão, & de Azevedo,
163 2015), which may be reflective of kinesiophobia, or an attempt, conscious or
164 unconscious, to decrease symptoms through a reduction of PFJ and quadriceps
165 loading requirements (Salsich, Brechter, & Powers, 2001).
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166 The relationship between hip strength and symptom development is unclear, with
167 previous prospective studies reporting either increased hip abduction strength
168 (Herbst, et al., 2015; Ramskov, Barton, Nielsen, & Rasmussen, 2015) or no
169 association between hip abduction strength and increased risk of future PFP
170 development (Herbst, et al., 2015; Ramskov, et al., 2015; Rathleff, Rathleff, Crossley,
171 & Barton, 2014). Cross-sectional studies have reported more consistent evidence for

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172 decreased hip abduction, extension and external rotation strength (Rathleff, et al.,
173 2014), along with a delayed and shorter duration of gluteal muscle activity during

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174 functional tasks (Barton, Kennedy, et al., 2014), in people with PFP. In addition,
175 emerging evidence indicates rate of force development in females with PFP may also

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176 be slower when compared to asymptomatic females (Nunes, Barton, & Serrão,
177 2017), suggesting that muscle function variables in addition to strength should be of

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178 interest to those delivering PFP rehabilitation. Consistent with quadriceps findings,
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179 hip muscle weakness is reported to exist in older (15-19 y/o) but not younger (12-16
180 y/o) adolescents with PFP (Rathleff, Baird, et al., 2013). This indicates proximal
181 muscle deficits may develop as a result of PFP symptoms rather than be a causative
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182 factor. Nevertheless, considering potential effects of the hip on knee mechanics,
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183 these deficits represent a key treatment target.


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184 Proximal kinematic factors have been reported to be associated with a greater risk of
185 developing PFP. Specifically, increased peak hip internal rotation during a double leg
186 drop landing was reported in a predominantly male military cohort during jump
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187 landing who developed PFP compared to those who did not (Boling, et al., 2009).
188 Additionally, increased peak hip adduction during running was reported in a group of
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189 females who developed PFP compared to those who did not (Noehren, Hamill, &
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190 Davis, 2013). This profile of greater hip adduction and internal rotation also appears
191 to exist consistently during running once symptoms have developed (Neal, Barton,
192 Gallie, O’Halloran, & Morrissey, 2015). Interestingly, the same link is not seen during
193 walking, where less peak internal rotation has been reported in people with PFP
194 (Barton, Bonanno, Levinger, & Menz, 2010; Powers, 2003). It is predominantly the
195 female sex where associations between hip biomechanics and PFP are seen, whereas
196 an increase in peak knee adduction has been reported in male runners with PFP
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197 compared to female runners with PFP (Willy, Manal, Witvrouw, & Davis, 2012).
198 Overall, the lower limb biomechanical differences between the sexes during high
199 impact tasks have not been fully investigated and further work is required in this
200 field.

201 Distal to the PFJ, coupling between


202 rearfoot eversion and tibial rotation has

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203 been proposed to influence PFJ
204 mechanics (Figure 3) (Tiberio, 1987),

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205 possibly driving symptom development or
206 persistence. Specifically, a theoretical

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207 paradigm of prolonged or increased
208 rearfoot eversion, increasing tibial
209 internal rotation and resulting in a
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210 compensatory increase in femoral Figure 3 - A diagrammatic presentation of
the coupling between rearfoot motion and
211 internal rotation to achieve knee shank motion (Right foot) adapted from
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212 extension has been proposed (Tiberio, (Tiberio, 1987)

213 1987). The consequence of this coupled movement is proposed to be elevated


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214 loading between the lateral femoral condyle and lateral facet of the patella (Lee, et
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215 al., 2003; Tiberio, 1987). Subsequent investigation of this proposed coupled
216 movement in individuals with PFP has been conflicting (Barton, Levinger, Crossley,
217 Webster, & Menz, 2012; Powers, Chen, Reischl, & Perry, 2002). Individuals with PFP
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218 symptoms are reported to demonstrate a more pronated foot posture both statically
219 (Lankhorst, et al., 2013) and quasi statically (normalised navicular drop) (Barton,
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220 Bonanno, et al., 2010) when compared to those without pain. However, the
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221 potential impact of these findings on dynamic function is unclear (Barton, Levinger,
222 Crossley, Webster, & Menz, 2011; McPoil & Cornwall, 1996). Prospectively,
223 increased navicular drop has been reported as a risk factor for future symptom
224 development in a military population (Boling, et al., 2009; Neal, et al., 2014), but the
225 small difference between those who did and did not develop pain (< 1mm) means
226 the finding may be of questionable clinical relevance. Overall, the relevance of static
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227 alignment remains unclear warranting only limited attention during the assessment
228 of the patient with PFP.

229 Dynamically, there does not appear to be any differences in peak rear- or forefoot
230 motion between people with and without PFP during running (Noehren, Pohl,
231 Sanchez, Cunningham, & Lattermann, 2012; Powers, et al., 2002) or walking (Barton,
232 Levinger, Webster, & Menz, 2011). However, during stair ascent and running, higher

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233 rearfoot eversion and a greater percentage of the available pronation range utilised
234 in those with PFP respectively, has been reported (de Oliveira Silva, Barton,

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235 Pazzinatto, Briani, & de Azevedo, 2016; de Oliveira Silva, Briani, Pazzinatto, Ferrari,
236 Aragão, de Albuquerque, et al., 2015; Rodrigues, TenBroek, & Hamill, 2013). Plantar

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237 pressure evaluation in previous literature seems to provide a stronger link between
238 foot function and PFP. Specifically, increased laterally directed pressure distribution
239
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at initial foot contact, shorter time to maximal pressure on the 4th metatarsal during
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240 running (Thijs, De Clercq, Roosen, & Witvrouw, 2008) and slower maximal velocity of
241 the change in lateromedial direction of the centre of pressure during forefoot
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242 contact during walking, have been reported to be associated with high risk of PFP
243 development (Thijs, et al., 2007). The mechanistic link between these biomechanical
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244 variables and symptom development has not been established, but may be
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245 indicative of decreased foot pronation during the loading phase of gait, resulting in
246 reduced load absorption and thus an increased transfer of forces proximally to the
247 patellofemoral joint (Dowling, et al., 2014; Neal, et al., 2015).
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248 The presentation of biomechanical deficits in people with PFP is both common and
249 varied (Ferrari, et al., 2017; Fox, Ferber, Saunders, Osis, & Bonacci, 2017). Following
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250 the assessment of proximal, local and distal kinematics during stair ascent, 52% of
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251 females presented at least two kinematic alterations and three kinematic alterations
252 were found in 48% of the females with PFP (Figure 4) (Ferrari, et al., 2017). A higher
253 number of kinematic alterations were strongly associated (r = 0.78) with higher
254 levels of pain and lower functional status (Ferrari, et al., 2017) and those with

Key Points

- Proximal, distal and local biomechanical deficits have all been identified in
individuals with PFP
- In the presence of PFP, kinematic deficits may not exist in isolation, and are
commonly evident in all three regions
- Kinematic coupling throughout the kinetic chain can result in elevated PFJ
loads, and may contribute to symptoms
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255 chronic PFP have been reported to differ throughout the kinetic chain compared
256 with an acute PFP population and controls (Fox, et al., 2017). Therefore, clinicians
257 should carefully assess the movement patterns throughout the kinetic chain during
258 different tasks, as identified biomechanical deficits may indicate a more severe
259 condition and can help guide an individual specific treatment plan.

260

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Local 0

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6 4
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Proximal 0 3 Distal 0
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261
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262 Figure 4 - Demonstrating the distribution of kinematic deficits, local, distal and proximal to the PFJ in
263 individuals with PFP, reprinted (with permission) from Ferrari et al. 2017 (Ferrari, et al., 2017)
264
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265 ASSESSMENT
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266 We recently developed a ‘Best Practice Guide’ for managing PFP by combining
267 systematic review findings with qualitative interviews of international experts in
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268 order to guide clinical decision-making and inform evidence based treatment
269 delivery (Barton, et al., 2015). This synthesis of evidence highlights that in order to
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270 effectively manage the multifactorial nature of PFP, consideration of multiple


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271 different intervention approaches is required (Table 1) (Barton, et al., 2015). To


272 effectively direct and deliver a tailored treatment plan a multi-dimensional
273 assessment, to identify the drivers of the individual’s symptoms, must be adopted
274 (Figure 5). Careful questioning should be adopted throughout the subjective
275 examination, with the appropriate use of reflective questioning to increase the
276 patients understanding of the problem from the outset (Lee & Barnett, 1994).
277 Examples include, ‘How do you think that significant increase, compared with your
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278 normal exercise volumes, affected your knee pain?’ and ‘Considering similar changes
279 in knee cap cartilage are observed in people with and without pain, how much do
280 you think your scan results explain the symptoms you have?’.

281 Structure and Pathology

282 Assessment of the individuals underlying structure and degree of joint pathology

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283 may be important to objectify in some presentations of PFP. However, consistent
284 with emerging evidence in other common musculoskeletal conditions such as low

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285 back pain (Baker, 2014; Jensen, et al., 1994), the correlation between structure and
286 symptoms has been shown to be tenuous in those with PFP (Stefanik, et al., 2014).

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287 Imaging findings should have limited impact on treatment decisions in most cases,
288 and clinicians who are working with patients seeking interventions aiming to address
289 structure or structural pathology should ensure adequate time is spent discussing
290
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the available evidence (Barton & Crossley, 2016) as they either lack evidence to
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291 support their use (e.g. platelet-rich plasma injections) or are unsupported in RCTs
292 (e.g. arthroscopy surgery) (Kettunen, et al., 2007, 2012). Practitioners treating PFP
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293 should be encouraged to carefully consider the purpose of requesting imaging and
294 should ensure the patient is well educated on the relevance of structural changes
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295 identified following imaging investigations.


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Structure

Psychology

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Load, volume,
Biomechanics
intensity

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296

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297 Figure 5 - Diagrammatic representation of the multiple domains that require consideration during the
298 assessment of an individual with PFP
299 Biomechanics

300
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Pragmatic clinical measures such as a single leg squat have been proposed to detect
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301 movement deficits (Whatman, Hing, & Hume, 2011, 2012) and altered
302 neuromuscular function (Crossley, Zhang, Schache, Bryant, & Cowan, 2011).
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303 However, the clinical impact of targeting changes in mechanics observed during a
304 single leg squat needs to be scrutinised, as improvement in the tasks performance is
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305 unlikely to lead to movement pattern changes during other more dynamic tasks such
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306 as running (Willy & Davis, 2011). To maximise the relevance of findings to the
307 individual patient’s presentation, assessment of functional movement patterns
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308 should be evaluated during specific tasks the patient reports as painful (e.g. running,
309 jumping/hopping, squatting and sit to stand). Movement can be observed in
310 comparison to the asymptomatic or less symptomatic limb, and integrated within
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311 the wider context of the individual’s presentation. Adoption of this assessment
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312 approach allows for the appropriate weighting of interventions that aim to address
313 these deficits. Incorporating movement modification strategies using hands on
314 approaches, taping or appropriate cueing, and gauging the immediate effect on
315 reported symptoms offers useful insight into the strength of association between
316 the identified movement deficit and the patients pain.
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317 Volume, Frequency and Intensity

318 Quantification of the volume, frequency and intensity of load that an individual is
319 imposing on their PFJ should form an integral part of the subjective assessment.
320 Questioning should be directly related to the patient’s training, activity and playing
321 habits to gain insight into the role of these variables on symptom development
322 and/or persistence. Additionally, questions related to extrinsic factors affecting load

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323 may also offer useful insight, including the influence of coaches, parents, teachers
324 and training environment to allow for adequate rest and recovery. These factors may

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325 be particularly important in some adolescent patients, given the high prevalence of
326 PFP in this population (6.95% of 2200 adolescents (Rathleff, Rathleff, Olesen,

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327 Rasmussen, & Roos, 2016)) and commonly reported absence of strength deficits
328 (Rathleff, Baird, et al., 2013), as they can often be fully immersed in sporting
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activities and influenced by those who care for them. Importantly, education relating
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330 to load management has been shown to have a positive effect on symptoms
331 (Esculier, et al., 2017; Rathleff, Roos, Olesen, & Rasmussen, 2015) and optimal load
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332 management and progression shown to reduce the risk of other injuries in varying
333 sporting populations (Gabbett, et al., 2016; Murray, Gabbett, & Townshend, 2016;
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334 Windt, Gabbett, Ferris, & Khan, 2017). Therefore, accurate quantification and
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335 consideration of its relevance to the patient’s symptom development during their
336 assessment and development of a treatment plan, is essential.
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337 Psychology

338 An individuals psychology has been reported to represent an important factor in the
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339 persistence of symptoms in a sub-group of individuals with PFP (Maclachlan, et al.,


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340 2017; Maclachlan, Matthews, Hodges, Collins, & Vicenzino, 2018). For some,
341 behaviours associated with change in psychology may represent a driver for
342 symptom development (e.g. increased training volumes to manage stress or low
343 mood), but this hypothesis is yet to be tested within a prospective study design.
344 Incorporating measures of psychological health into the initial assessment in those

Key Points

- A multidimensional assessment, using reflective questioning, should be


adopted to ensure the development of an appropriately targeted and
individualised management plan
- Measures of psychological health may offer the clinician insight into levels
of anxiety, fear or depression associated with pain
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345 with PFP (e.g. using the Orebro Musculoskeletal Pain Questionnaire, Hospital Anxiety
346 and Depression Scale, Tampa Scale for Kinesiophobia and/or Fear Avoidance Beliefs
347 Questionnaire) can offer useful insight into levels of anxiety, fear or depression
348 associated with their pain presentation (French, France, Vigneau, French, & Evans,
349 2007; Johnston, Pollard, & Hennessey, 2000; Linton & Boersma, 2003; Swinkels-
350 Meewisse, Swinkels, Verbeek, Vlaeyen, & Oostendorp, 2003). Interventions

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351 specifically directed at these markers of psychological health in those with PFP have
352 not been explored (Maclachlan, et al., 2017). However, within other persistent

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353 musculoskeletal (MSK) complaints such as low back pain, the positive role of
354 cognitive behavioural interventions have been reported (Cherkin, et al., 2017;

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355 O'Sullivan, 2005), indicating similar approaches may be worthy of consideration in
356 PFP. Appropriate onward referral to a suitably qualified health professional (e.g.

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357 psychologist) should be considered if indicated based on the patient’s psychological
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358 assessment. Further research in this area in people with PFP is required before we
359 can provide clear recommendations of the most appropriate interventional
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360 approach.
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361
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362 Figure 6 - Demonstrating the integrated approach of interventions with proven efficacy (figure
363 created with the assistance of Dr Michael Rathleff)
364

365 TREATMENT

366 The development and implementation of an individually tailored treatment plan,


367 that incorporates interventions of proven efficacy (Figure 6), follows the detailed

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368 assessment of the individual. Whilst interventions that aim to address specific
369 deficits are advocated, the current recommended physical interventions for the

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370 management of PFP include approaches that combine more than one treatment
371 approach (Crossley, van Middelkoop, et al., 2016). A greater understanding of the

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372 potential mechanisms of treatment effects is required to improve the accuracy with
373 which tailored treatment approaches are delivered (Crossley, van Middelkoop, et al.,

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374 2016). Clinicians are encouraged to incorporate one or all of the treatment
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375 approaches presented below if indicated following clinical assessment.

376 Exercise Therapy


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377 Based on current evidence and clinical practice, exercise therapy forms the
378 cornerstone of management for PFP (Crossley, van Middelkoop, et al., 2016; Lack,
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379 Barton, Sohan, Crossley, & Morrissey, 2015; van der Heijden, et al., 2015) and
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380 traditionally, exercise has focussed on the knee musculature. However, findings from
381 a recent systematic review indicate that proximally targeted exercise, when added to
382 knee targeted exercise, may improve symptoms and function in the short (< 3
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383 months), medium (3-12 months) and longer term (> 12 months) (Lack, et al., 2015).
384 Additionally, in the early stages of rehabilitation (first 6 months), proximally targeted
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385 exercise may improve pain and function to a greater extent than knee targeted
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386 exercise. These more recent advances in our understanding of exercise therapy for
387 PFP highlight that the early (<6 months) focus of exercise prescription should be
388 proximal rehabilitation to improve hip strength and mechanics, particularly in
389 patients where knee targeted exercises may exacerbate symptoms.
390 Whilst the mechanism for exercise intervention has not been definitively
391 established, several authors have investigated the potential mechanisms of effect
392 following exercise therapy. Locally, changes in timing of the vasti muscles (Cowan,
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393 Bennell, Crossley, Hodges, & McConnell, 2002; Witvrouw, et al., 2003), and
394 increased isometric quadriceps strength (Hazneci, Yildiz, Sekir, Aydin, & Kalyon,
395 2005; Witvrouw, et al., 2004) have been reported. Proximally, hip strength gains
396 (Khayambashi, Mohammadkhani, Ghaznavi, Lyle, & Powers, 2012) and reduced knee
397 valgus variability (Ferber, Kendall, & Farr, 2011) during running has been reported in
398 rehabilitation groups compared to no intervention control groups.

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399 Based on limited evidence, our review of the proximal rehabilitation literature
400 identified no significant improvements in strength at the hip following proximal or

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401 proximal combined with knee targeted exercise when compared to a knee targeted
402 exercise alone (Lack, et al., 2015). This is despite significantly greater symptom

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403 reduction reported for programs targeting the proximal musculature (Lack, et al.,
404 2015). The reason of no difference between these groups could be explained by the

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405 progression of quadriceps rehabilitation to closed kinetic chain (CKC) exercises.
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406 During CKC exercises, the proximal muscles will also be receiving a loading stimulus
407 that may be sufficient to match the beneficial changes of an isolated proximal
408 rehabilitation programme.
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409 Although the beneficial effect of exercise therapy is strong, it is not possible to
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410 replicate previously published exercise protocols for PFP (Holden, Rathleff, Jensen, &
411 Barton, 2017). Additionally, the majority of previous studies appear to focus on
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412 neuromuscular or strength-endurance prescription, despite stating a focus on


413 strength in their titles (Lack, et al., 2015). Considering possible deficits in strength
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414 (Rathleff, et al., 2014) and muscle power (Nunes, et al., 2017), we encourage
415 clinicians to assess each patient for specific muscle function deficits, and prescribe a
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416 specific progressive resistance training program accordingly. Where necessary,


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417 design of an appropriate programme should aim to use accepted exercise


418 prescription principles (Figure 7) (American College of Sports, 2009).
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419
420 Figure 7 - Exercise prescription principles
421 In addition, further considerations should be made to ensure the exercise
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422 prescription delivers an appropriate time under tension, load magnitude and
423 numbers of sets and repetitions, to optimise the specificity of the prescription to
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424 achieve the desired physiological response (Toigo & Boutellier, 2006) (see
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425 http://patellofemoral.trekeducation.org/).
426 Short-term rehabilitation programs rarely provide additional benefit when evaluated
427 in the longer term (e.g. 12 months after enrolment), and in some cases initial
428 benefits compared to control interventions diminish over time (Lack, et al., 2015;
429 van der Heijden, et al., 2015). Considering potential long standing pain and
430 kinesiophopia (Domenech, Sanchis-Alfonso, López, & Espejo, 2013), and associated
431 strength deficits and muscle atrophy (Giles, et al., 2013; Lankhorst, et al., 2013) in
432 PFP, this is not surprising. Put simply, fully addressing significant muscle function
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433 deficits will take time – far longer than the 3 to 8 weeks of rehabilitation
434 intervention that has commonly been described within the current evidence base.

435 Large neural adaptations occur in the early stages of any resistance training
436 (American College of Sports, 2009; Sale, 1988), and hence these are likely to explain
437 a lot of improvement from previously evaluated exercise rehabilitation programs in
438 PFP management (Lack, et al., 2015; van der Heijden, et al., 2015). However, true

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439 muscle hypertrophy, which may be required to address muscle atrophy in individuals
440 with PFP, is much slower, taking around 6 weeks before signs of hypertrophy are

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441 evident. Improvements are unlikely to plateau for at least 6 months in healthy
442 adults (American College of Sports, 2009), and in the presence of muscle atrophy as

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443 a result of PFP, we believe this time period may be much longer. Whilst in all therapy
444 environments treatment delivery over longer time periods is not feasible, follow up
445
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for at least 12 months following commencement of rehabilitation is desirable.
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446 Current research comparing differing exercise dosage in PFP rehabilitation is limited,
447 and requires attention. However, in a previous randomised trial comparing exercise
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448 dose and outcomes in PFP, higher dose (3x/wk, 3x30reps, 9 exercises, 60mins) was
449 reported to be more effective than lower dose (3x/wk, 2x10reps, 5 exercises,
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450 20mins) exercise prescription (Østerås, Østerås, Torstensen, & Vasseljen, 2013).
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451 Additionally, the only study reporting improvements in pain at 1 year follow up used
452 exercise intensities of > 70% of 1 repetition maximum (1RM) (Fukuda, et al., 2012).
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453 This exercise prescription is consistent with recommendations that novice to


454 intermediate individuals train with loads corresponding to 60–70% of 1 RM for 8–12
455 repetitions to maximise strength increases (American College of Sports, 2009).
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456 In most cases, home exercise including the use of resistance bands and body weight
457 exercise is appropriate in the early stages of rehabilitation and the majority of
458 clinical trials supporting the efficacy of exercise rehabilitation in PFP have used this
459 approach (Lack, et al., 2015; van der Heijden, et al., 2015). When commencing any
460 resistance training program, low to moderate intensity exercise prescription is
461 recommended to facilitate muscle function (strength, power and endurance)
462 improvements (American College of Sports, 2009). However, progressing from home
463 based to gym based rehabilitation may be an important step in optimising the
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464 management of PFP, particularly in patients who wish to return to activities where
465 knee and other lower limb joint forces increase significantly (e.g. stair negotiation
466 and running). Gym based resistance training, a minimum of 2 times per week, will
467 allow the prescription of progressive overload, and hence optimal muscle function
468 improvements (American College of Sports, 2009).

469 Although exercise prescription should be tailored at the beginning of rehabilitation

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470 to prioritise addressing key deficits (e.g. muscle activation or soft tissue flexibility),
471 evolution of the program must be guided to ensure all potential deficits are

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472 addressed over time. There are no recipes, and progression requires careful on-going
473 assessment by the treating clinician. Consideration should be given to specific

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474 deficits, including type of muscle activation (concentric, eccentric, isometric),
475 movement velocity and power, endurance, range of motion, and muscle group
476
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(quadriceps, gluteal, etc.). Additionally, the patient’s functional goals must also be
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477 considered. To achieve these treatment goals, patients will need to continue with an
478 exercise programme into the longer term (>6months). Clinicians may need to
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479 develop a gym-based resistance programme that the patient has the skills and
480 knowledge to progress independently beyond the course of supervised
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481 physiotherapy treatment.


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Key Points
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- Exercise therapy should incorporate both proximal and local components


- Consider starting with proximally targeted exercise, before later
incorporating locally targeted exercise, especially if the patient has irritable
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symptoms
- To deliver an effective exercise intervention:
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o Specific rehabilitative stimuli must be of sufficient intensity to elicit


change
o The programme must be progressive
o Both the clinician and patient must allow sufficient time for
adaptation to occur

482
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483 Movement/Run Retraining

484 There is evidence to suggest that an exercise intervention targeting muscle function
485 (e.g. strength) may not change movement patterns (kinematics) during a specific
486 high load task like running (Sheerin, Hume, & Whatman, 2012; Willy, et al., 2011;
487 Wouters, et al., 2012). For a sub-group of individuals with movement pattern
488 deficits that have contributed to their symptom development, (Noehren, et al.,

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489 2013) this may explain the poor long-term outcomes seen post exercise-only
490 programs (Collins, et al., 2013; Witvrouw, et al., 2004).

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491 Movement pattern retraining for individuals with PFP is receiving growing attention

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492 in research and clinical practice, and has been recommended by international
493 experts (Barton, et al., 2015). In female runners with excessive peak hip adduction
494 (>20˚) and PFP, emerging evidence indicates visual and verbal cues are effective at
495
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reducing hip adduction angles and patient reported symptoms (Noehren, Scholz, &
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496 Davis, 2011; Willy, Scholz, & Davis, 2012). Strategies to reduce hip adduction may be
497 particularly important considering that excessive peak hip adduction during running
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498 is reported to be a risk factor for PFP development (Noehren, et al., 2013), and
499 exercise in individuals with PFP does not seem to address this deficit (Earl & Hoch,
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500 2011; Ferber, et al., 2011). Similar cueing to reduce hip adduction and internal
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501 rotation during other activities that increase loading on the PFJ such as squatting and
502 stair negotiation may also be an important part of rehabilitation in patients with PFP.
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503 The need for movement pattern retraining should be assessed on an individual basis,
504 and can be aided by video and mirror feedback in the clinic (Barton, et al., 2015).
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505 More recent research has evaluated other movement pattern retraining strategies
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506 for runners with PFP, reporting mixed results. Roper et al. (Roper, et al., 2016)
507 reported a significant short-term reduction in pain after external cueing to transition
508 to a forefoot strike pattern, compared to load management control. In addition,
509 Bonacci et al. (Bonacci, Hall, Saunders, & Vicenzino, 2017) reported a significant
510 short-term reduction in pain after external cueing to increase step rate to match a
511 metronome beat, combined with the use of a minimalist shoe, in comparison to
512 prefabricated foot orthoses. In contrast, Esculier et al. (Esculier, et al., 2017)
513 evaluated the additional benefit of increasing step rate with the option of
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514 transitioning to a non-rearfoot strike pattern if the treating clinician deemed
515 necessary, but reported no additional benefit of this running retraining protocol
516 compared to load management education.

517 This variance in outcome could be explained by the lower feedback dosage delivered
518 by Esculier at al. (five ten minute sessions over 8 weeks) (Esculier, et al., 2017),
519 compared to both Roper et al. (8 sessions over 2 weeks) (Roper, et al., 2016) and

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520 Bonacci et al. (10 sessions over 6 weeks) (Bonacci, et al., 2017). It should also be
521 noted that feedback targeting a specific movement deficit (high peak hip adduction

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522 and a rearfoot strike pattern respectively) was adopted in three comparable studies
523 (Bonacci, et al., 2017; Roper, et al., 2016; Willy, Scholz, et al., 2012), whereas Esculier

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524 et al. (Esculier, et al., 2017) utilized a step rate cue that may not have been required
525 by all participants within their cohort. Finally, there was no faded-feedback protocol
526
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employed within the retraining design of Esculier et al. (Esculier, et al., 2017), found
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527 to be effective by multiple previous studies (Noehren, et al., 2011; Roper, et al.,
528 2016; Willy, Scholz, et al., 2012). Whilst the emerging evidence from differing study
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529 designs (no RCT’s) presents conflicting findings, the most recent systematic review of
530 the literature indicates running retraining strategies are beneficial for short-term
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531 improvements in running specific PFP (Neal, et al., 2015). Delivering movement
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532 pattern retraining targeting a specific deficit and using a faded-feedback protocol,
533 where feedback is optimised (acquisition phase) and then gradually reduced
534 (transfer phase), is recommended to optimise the potential for skill acquisition
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535 (Noehren, et al., 2011; Willy, Scholz, et al., 2012) (See


536 http://patellofemoral.trekeducation.org/).
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537
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Key Points

- Visual and verbal cues can be used to reduce peak hip adduction angles
during running, and this may help reduce pain
- Movement retraining should be delivered on an individual basis, and can be
valuable during pain provocative tasks e.g. stairs
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538 Passive adjuncts

539 Two passive interventions possess evidence of benefit in the short term (i.e. 4-6
540 weeks), and warrant consideration in the management of PFP.

541 Taping: Taping interventions for PFP published in the literature vary in terms of
542 application and follow up time. Level one evidence identified moderate evidence

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543 that tailored (large effect) and untailored (small effect) patellar taping immediately
544 reduces pain, and tailored patellar taping promotes an earlier onset of the vastus

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545 medialis oblique (VMO) relative to vastus lateralis (VL) (Barton, Balachandar, Lack, &
546 Morrissey, 2014). The important distinction related to tailoring is that lateral patellar

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547 tilt, glide and rotation are targeted until a minimum 50% pain reduction during a
548 functional task (e.g. step down) is achieved (McConnell, 1996). Untailored taping
549 tends to involve just one strip of tape that targets lateral glide of the patella. Further
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guidance on the two methods is provided at
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551 http://patellofemoral.trekeducation.org/ .

552 Beyond the immediate term, limited evidence also indicates tailored patellar taping
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553 combined with exercise improves pain in the short term and promotes increased
554 internal knee extension moments when compared to exercise alone (Barton,
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555 Balachandar, et al., 2014). This highlights that tailored patellar taping may be
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556 beneficial to improving exercise therapy outcomes in the early stages of


557 rehabilitation, as well as providing symptomatic pain relief. Therefore, we
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558 recommend that the tailored approach be used where possible, and the patient
559 taught the optimal approach for them.
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560 Foot orthoses: Broadly, there are two forms of foot orthoses to consider for people
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561 with PFP; prefabricated and custom moulded devices. Both can be modified to tailor
562 prescription specific to the individual, for example adding medial/lateral wedging
563 and/or heel lifts. At present, research tends to focus on inexpensive prefabricated
564 foot orthoses, often modified to optimise patient comfort (Collins, et al., 2008; Mills,
565 Blanch, & Vicenzino, 2012). Based on current evidence, this prescription approach is
566 effective at reducing pain and improving outcomes in the short term (6 weeks) when
567 compared to a wait and see or sham device (Barton, Munteanu, Menz, & Crossley,
568 2010; Collins, et al., 2008; Hossain, Alexander, Burls, & Jobanputra, 2011; Mills,
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569 Blanch, Dev, Martin, & Vicenzino, 2012). Importantly, the number needed to treat
570 ranges between two and four (Collins, et al., 2008; Mills, Blanch, Dev, et al., 2012).
571 With an absence of evidence to suggest more expensive custom moulded foot
572 orthoses will improve outcomes compared to prefabricated devices in PFP (Collins,
573 et al., 2012), we recommend using prefabricated devices, unless there is another
574 clinical reason (e.g. foot deformity) to indicate the need for a custom moulded

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575 device.

576 Considering not all people with PFP will benefit from foot orthoses prescription,

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577 research has sought to identify those most likely to benefit (Barton, Menz, &
578 Crossley, 2011a, 2011b; Mills, Blanch, Dev, et al., 2012; Sutlive, et al., 2004;

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579 Vicenzino, Collins, Cleland, & McPoil, 2010). Based on a biomechanical theoretical
580 paradigm outlined above (Figure 3), foot orthoses have traditionally been thought to
581
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benefit those with excessive foot pronation the most. However, evidence related to
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582 the foot pronation biomechanical paradigm is inconsistent. Specifically, static foot
583 posture has been reported not to relate to greater chance of success with foot
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584 orthoses (Barton, Menz, & Crossley, 2011a; Vicenzino, et al., 2010). Studies
585 evaluating the ability of foot mobility to predict outcomes have reported
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586 inconsistent findings also, including no association (Barton, Menz, & Crossley,
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587 2011a), as well as greater mobility (Mills, Blanch, Dev, et al., 2012; Mills, Blanch, &
588 Vicenzino, 2012; Vicenzino, et al., 2010) and less mobility (Sutlive, et al., 2004)
589 related to success. Considering this, we do not recommend foot orthoses be
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590 prescribed on the basis of foot posture or foot mobility in isolation.

591 Dynamic foot function evaluation may provide greater insight into identifying those
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592 most likely to benefit from foot orthoses, with Barton et al. (Barton, Menz, Levinger,
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593 Webster, & Crossley, 2011) reporting greater peak rearfoot eversion during walking
594 predicted foot orthoses success in people with PFP. Additionally, coupling between
595 greater peak rearfoot eversion, increased tibial internal rotation, and greater hip
596 adduction during walking has been reported in people with PFP (Barton, et al.,
597 2012). A limitation to applying this research to clinical practice, however, is that it is
598 based on three-dimensional motion analysis, a tool rarely available to the clinician
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599 and a measure of foot motion that is not accurately quantified using two-
600 dimensional video analysis (Meyer, Falbriard, Aminian, & Millet, 2018).

601 Given that the mechanisms of effect for distal intervention has not been clearly
602 identified, further research is needed in this area. Beyond foot posture and function,
603 other clinically applicable assessments, including treatment direction testing, may be
604 considered by the clinician when determining likely success of foot orthoses

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605 prescription for PFP (Vicenzino, 2004). Additionally, higher functional index scores
606 (Lack, Barton, Vicenzino, & Morrissey, 2014), immediate improvements in functional

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607 performance (e.g. reduced pain during single legged squat) and patient’s footwear
608 assessed to be less supportive have been reported to be associated with greater

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609 likelihood of success (Barton, Menz, & Crossley, 2011a).

610 Other options: There is currently no evidence to suggest that any other passive
611
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adjunct treatments offer value in improving patient outcomes beyond 6 weeks when
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612 compared to a control or placebo condition. Based on a lack of supporting evidence
613 from a currently limited body of research, the most recent consensus statement
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614 from the International Patellofemoral Research Retreat on physical interventions


615 recommended that patellofemoral, knee and lumbar mobilisations may not improve
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616 outcomes (Crossley, van Middelkoop, et al., 2016). Additionally, electrophyscial


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617 agents such as ultrasound are also unlikely to improve outcomes (Brosseau, et al.,
618 2013). Two weeks of patellar mobilisation compared to no intervention, did not
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619 improve outcomes (Collins, et al., 2012), while stretching in isolation, outside of
620 multimodal physiotherapy intervention, has not been investigated. Consequently,
621 best practice guidelines suggest the use of patellar mobilisation only in the presence
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622 of hypomobility, and that methods to promote flexibility be used on tight structures
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623 alone, especially those laterally (Barton, et al., 2015). Although blanket statements
624 recommending not to use electrophysical agents and joint mobilisations (Crossley,
625 van Middelkoop, et al., 2016) may not apply to all patients with PFP, it is unlikely
626 that many patients would need or should be provided with these passive adjuncts,
627 which frequently rely on the treating therapist to facilitate. In particular, they should

Key Points

- Tailored patella taping and foot orthoses should be considered to modify


pain and promote function
- Other passive adjuncts are not supported by evidence and should not be
prioritised in treatment decisions
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628 not be prioritised over appropriate education and guidance with exercise therapy.

629

630 Education

631 Education is considered a vital component in the treatment of PFP by experts,


632 despite an absence of research directly evaluating its efficacy (Barton, et al., 2015).

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633 Education targets should include managing patient expectations, load management,
634 weight management when appropriate, ensuring self-management, teaching the

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635 importance of adherence to exercise-therapy, and implementing strategies to
636 address fear of movement. Recent data indicates 57% of people with PFP enrolled in

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637 a clinical trial report unfavourable outcomes 5-8 years later (Lankhorst, et al., 2016),
638 indicating complete resolution of symptoms may not always be possible.

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639 Importantly, emerging evidence has linked chronicity in PFP with a poorer prognosis
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640 (Collins, et al., 2013; Collins, Crossley, & Darnell, 2010). Therefore, managing patient
641 expectations in relation to likely outcome, particularly in the short to medium term,
642 is of huge importance. If there is potential for improvement in a patient’s condition,
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643 they must understand the time and effort required to complete appropriate
644 rehabilitation and behaviour change (e.g. load management). This will be impacted
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645 on by the chronicity, current symptoms and irritability, and the associated deficits of
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646 the individual patient.

647 Load management education to modify PFJ loading may include appropriate activity
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648 modification, movement pattern modification and training and exercise therapy to
649 increase the capacity to handle exposure to load. Technologies, including smart
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650 phone applications and activity measuring ‘wearables’, provide an easily utilised
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651 objective method to analyse baseline levels of activity and determine the magnitude
652 of change following specific interventions. A detailed description and evaluation of
653 all available devices is beyond the scope of this Masterclass, and the interested
654 reader is referred to Willy’s 2017 Masterclass (Willy, 2017). The objectivity afforded
655 from data obtained from wearable technologies may assist to maximise adherence
656 and facilitate the patient’s reflection on the load magnitude of provocative activities.
657 The clinician may also use this data to assist in guiding the patients return to activity
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658 guided by progression rates that are appropriate to the individual and their
659 symptoms (calculators are provided at http://patellofemoral.trekeducation.org/).

660 Weight management through diet and exercise has been reported to be an effective
661 intervention for knee osteoarthritis (Messier, et al., 2013). Although similar
662 evaluation does not exist in PFP, Hart et al’s (Hart, Barton, Khan, Riel, & Crossley,
663 2017) recent systematic review highlighted greater body mass index (BMI) in people

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664 with PFP, indicating similar weight management strategies may be beneficial in some
665 patients. Regardless of symptomatic benefits, improved weight management in

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666 people with PFP may assist management of other health related issues such as
667 cardiovascular disease, diabetes, and other physical and psychological impairments.

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668 Although the majority of previous research has focused on physical features of PFP,
669 the importance of non-physical features is becoming more understood in recent
670
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research (Maclachlan, et al., 2017). Clinicians are encouraged to consider non-
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671 physical features potentially influencing PFP during assessment, employing
672 appropriate education strategies to inform the patient of the role that these
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673 characteristics can have on symptom severity and persistence (additional resources
674 at http://patellofemoral.trekeducation.org/).
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Key Points

- Patient education should form an integral part of your management


approach
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- Education targets should include managing patient expectations, load


management, ensuring self-management, importance of exercise
adherence and strategies to address fears and anxiety.
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675
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676 CONCLUSION

677 This clinical masterclass presents a synthesis of the current evidence relating to PFP
678 symptom development, persistence, assessment and management. It highlights that
679 structural, biomechanical, volume and psychological factors that can contribute to
680 an individual’s symptoms in differing amounts. Clinically reasoned paradigms have
681 been described to integrate these features into a deficit focused, individually
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682 tailored, rehabilitation plan. The clinician is encouraged to consistently remain
683 patient centred, incorporating shared decision-making strategies to construct the
684 most effective treatment strategy for the patient in front of them. It is imperative
685 that we consider patient’s beliefs and expectations, whilst providing evidence
686 informed interventions including exercise therapy, movement retraining, load
687 management, treatment adjuncts and education to optimise patient adherence to

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688 the programme.

689 REFERENCES

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690 American College of Sports, M. (2009). American College of Sports Medicine position
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692 Sports Exerc, 41, 687-708.
693 Arendt-Nielsen, L., Skou, S. T., Nielsen, T. A., & Petersen, K. K. (2015). Altered central
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696 Baker, A. D. (2014). Abnormal magnetic-resonance scans of the lumbar spine in
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697 asymptomatic subjects. A prospective investigation. In Classic Papers in
698 Orthopaedics (pp. 245-247): Springer.
699 Baquie, P., & Brukner, P. (1997). Injuries presenting to an Australian sports medicine
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700 centre: a 12-month study. Clinical journal of sport medicine : official journal
701 of the Canadian Academy of Sport Medicine, 7, 28-31.
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704 clinical outcomes and biomechanical mechanisms. Br J Sports Med, 48, 417-
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706 Barton, C., & Crossley, K. (2016). Sharing decision-making between patient and
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708 BMJ Publishing Group Ltd and British Association of Sport and Exercise
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713 Barton, C. J., Kennedy, A., Twycross-Lewis, R., Woledge, R., Malliaras, P., &
714 Morrissey, D. (2014). Gluteal muscle activation during the isometric phase of
715 squatting exercises with and without a Swiss ball. Physical therapy in sport :
716 official journal of the Association of Chartered Physiotherapists in Sports
717 Medicine, 15, 39-46.
718 Barton, C. J., Lack, S., Hemmings, S., Tufail, S., & Morrissey, D. (2015). The 'Best
719 Practice Guide to Conservative Management of Patellofemoral Pain':
720 incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med,
721 49, 923-934.
722 Barton, C. J., Levinger, P., Crossley, K. M., Webster, K. E., & Menz, H. B. (2011).
723 Relationships between the Foot Posture Index and foot kinematics during
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724 gait in individuals with and without patellofemoral pain syndrome. Journal of
725 Foot and Ankle Research, 4, 10.
726 Barton, C. J., Levinger, P., Crossley, K. M., Webster, K. E., & Menz, H. B. (2012). The
727 relationship between rearfoot, tibial and hip kinematics in individuals with
728 patellofemoral pain syndrome. Clin Biomech (Bristol, Avon), 27, 702-705.
729 Barton, C. J., Levinger, P., Webster, K. E., & Menz, H. B. (2011). Walking kinematics in
730 individuals with patellofemoral pain syndrome: a case-control study. Gait
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733 orthoses efficacy in individuals with patellofemoral pain. Med Sci Sports
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736 orthoses on functional performance in individuals with patellofemoral pain
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EDUCATION ACTIVE REHABILITATION PASSIVE INTERVENTIONS

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Principles Pain reduction

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1. Ensure patients understand potential 1. Give preference to CKC exercises to replicate function 1. Provide tailored patellar taping to
contributing factors to their condition and 2. Consider OKC exercises in early stages of rehabilitation reduce pain in the immediate term
treatment options

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to target specific strength deficits and movements 2. Consider PFJ braces where taping is
2. Advise about appropriate activity 3. Provide adequate supervision in the early stages to inappropriate (e.g. skin irritation)
modification ensure correct exercise techniques, but progress to 3. Consider foot orthoses

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3. Manage patients expectations regarding independence as soon as possible

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rehabilitation 4. When independent, limit the number of exercises to 3 Optimising biomechanics
4. Encourage and emphasise the or 4 to aid compliance
1. Consider foot orthoses based on
importance of participation in active

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5. Use biofeedback such as mirrors and videos to improve assessment findings (i.e. presence of
rehabilitation exercise quality excessive dynamic pronation)

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Specifics 2. Consider massage and acupuncture/dry
1. Incorporate quadriceps and gluteal strengthening needling to improve the flexibility of tight

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2. Target distal and core muscles where deficits exist muscle and fasciae structures,
3. Consider stretching, particularly of the calf and particularly laterally
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hamstrings, based on assessment findings 3. Consider PFJ mobilisation but only in the
4. Incorporate movement pattern retraining, particularly presence of hypo-mobility
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of the hip 4. Consider mobilisation of the ankle and


first ray in the presence of sagittal plane
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joint restriction
Table 1 - Summary of findings from Level 1 evidence and expert opinion extracted with permission from 'The 'Best practice guide to conservative management of
patellofemoral pain': incorporating level 1 evidence with expert clinical reasoning(Barton, et al., 2015)

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