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Review
. 2015 Jan 20;1(1):CD010387.
doi: 10.1002/14651858.CD010387.pub2.

Exercise for treating patellofemoral pain syndrome

Rianne A van der Heijden  1 , Nienke E Lankhorst, Robbart van Linschoten, Sita M A Bierma-Zeinstra, Marienke van Middelkoop
Affiliations
Review

Exercise for treating patellofemoral pain syndrome

Rianne A van der Heijden et al. Cochrane Database Syst Rev. .

Abstract

Background: Patellofemoral pain syndrome (PFPS) is a common knee problem, which particularly affects adolescents and young adults. PFPS, which is characterised by retropatellar (behind the kneecap) or peripatellar (around the kneecap) pain, is often referred to as anterior knee pain. The pain mostly occurs when load is put on the knee extensor mechanism when climbing stairs, squatting, running, cycling or sitting with flexed knees. Exercise therapy is often prescribed for this condition.

Objectives: To assess the effects (benefits and harms) of exercise therapy aimed at reducing knee pain and improving knee function for people with patellofemoral pain syndrome.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2014), the Cochrane Central Register of Controlled Trials (2014, Issue 4), MEDLINE (1946 to May 2014), EMBASE (1980 to 2014 Week 20), PEDro (to June 2014), CINAHL (1982 to May 2014) and AMED (1985 to May 2014), trial registers (to June 2014) and conference abstracts.

Selection criteria: Randomised and quasi-randomised trials evaluating the effect of exercise therapy on pain, function and recovery in adolescents and adults with patellofemoral pain syndrome. We included comparisons of exercise therapy versus control (e.g. no treatment) or versus another non-surgical therapy; or of different exercises or exercise programmes.

Data collection and analysis: Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. Where appropriate, we pooled data using either fixed-effect or random-effects methods. We selected the following seven outcomes for summarising the available evidence: pain during activity (short-term: ≤ 3 months); usual pain (short-term); pain during activity (long-term: > 3 months); usual pain (long-term); functional ability (short-term); functional ability (long-term); and recovery (long-term).

Main results: In total, 31 heterogeneous trials including 1690 participants with patellofemoral pain are included in this review. There was considerable between-study variation in patient characteristics (e.g. activity level) and diagnostic criteria for study inclusion (e.g. minimum duration of symptoms) and exercise therapy. Eight trials, six of which were quasi-randomised, were at high risk of selection bias. We assessed most trials as being at high risk of performance bias and detection bias, which resulted from lack of blinding.The included studies, some of which contributed to more than one comparison, provided evidence for the following comparisons: exercise therapy versus control (10 trials); exercise therapy versus other conservative interventions (e.g. taping; eight trials evaluating different interventions); and different exercises or exercise programmes. The latter group comprised: supervised versus home exercises (two trials); closed kinetic chain (KC) versus open KC exercises (four trials); variants of closed KC exercises (two trials making different comparisons); other comparisons of other types of KC or miscellaneous exercises (five trials evaluating different interventions); hip and knee versus knee exercises (seven trials); hip versus knee exercises (two studies); and high- versus low-intensity exercises (one study). There were no trials testing exercise medium (land versus water) or duration of exercises. Where available, the evidence for each of seven main outcomes for all comparisons was of very low quality, generally due to serious flaws in design and small numbers of participants. This means that we are very unsure about the estimates. The evidence for the two largest comparisons is summarised here. Exercise versus control. Pooled data from five studies (375 participants) for pain during activity (short-term) favoured exercise therapy: mean difference (MD) -1.46, 95% confidence interval (CI) -2.39 to -0.54. The CI included the minimal clinically important difference (MCID) of 1.3 (scale 0 to 10), indicating the possibility of a clinically important reduction in pain. The same finding applied for usual pain (short-term; two studies, 41 participants), pain during activity (long-term; two studies, 180 participants) and usual pain (long-term; one study, 94 participants). Pooled data from seven studies (483 participants) for functional ability (short-term) also favoured exercise therapy; standardised mean difference (SMD) 1.10, 95% CI 0.58 to 1.63. Re-expressed in terms of the Anterior Knee Pain Score (AKPS; 0 to 100), this result (estimated MD 12.21 higher, 95% CI 6.44 to 18.09 higher) included the MCID of 10.0, indicating the possibility of a clinically important improvement in function. The same finding applied for functional ability (long-term; three studies, 274 participants). Pooled data (two studies, 166 participants) indicated that, based on the 'recovery' of 250 per 1000 in the control group, 88 more (95% CI 2 fewer to 210 more) participants per 1000 recovered in the long term (12 months) as a result of exercise therapy. Hip plus knee versus knee exercises. Pooled data from three studies (104 participants) for pain during activity (short-term) favoured hip and knee exercise: MD -2.20, 95% CI -3.80 to -0.60; the CI included a clinically important effect. The same applied for usual pain (short-term; two studies, 46 participants). One study (49 participants) found a clinically important reduction in pain during activity (long-term) for hip and knee exercise. Although tending to favour hip and knee exercises, the evidence for functional ability (short-term; four studies, 174 participants; and long-term; two studies, 78 participants) and recovery (one study, 29 participants) did not show that either approach was superior.

Authors' conclusions: This review has found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery. However, there is insufficient evidence to determine the best form of exercise therapy and it is unknown whether this result would apply to all people with PFPS. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone.Further randomised trials are warranted but in order to optimise research effort and engender the large multicentre randomised trials that are required to inform practice, these should be preceded by research that aims to identify priority questions and attain agreement and, where practical, standardisation regarding diagnostic criteria and measurement of outcome.

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Conflict of interest statement

Study selection, data collection and risk of bias assessment of Van Linschoten 2009 were conducted by review authors who were not study investigators of this trial.

Rianne A van der Heijden: none declared. Nienke E Lankhorst: none declared. Robbart van Linschoten: none declared. Sita MA Bierma‐Zeinstra: none declared. Marienke van Middelkoop: none declared.

Figures

1
1
Study flow diagram
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Forest plot of comparison: 1 1: Exercise therapy versus control, outcome: 1.1 Sum: pain during activity continuous short‐term
5
5
Forest plot of comparison: 1 1: Exercise therapy versus control, outcome: 1.5 Sum: functional ability continuous short‐term
1.1
1.1. Analysis
Comparison 1 Exercise therapy versus control, Outcome 1 Pain during activity (short‐term).
1.2
1.2. Analysis
Comparison 1 Exercise therapy versus control, Outcome 2 Usual pain (short‐term).
1.3
1.3. Analysis
Comparison 1 Exercise therapy versus control, Outcome 3 Worst pain (short‐term).
1.4
1.4. Analysis
Comparison 1 Exercise therapy versus control, Outcome 4 Pain during activity (long‐term).
1.5
1.5. Analysis
Comparison 1 Exercise therapy versus control, Outcome 5 Usual pain (long‐term).
1.6
1.6. Analysis
Comparison 1 Exercise therapy versus control, Outcome 6 Functional ability (short‐term).
1.7
1.7. Analysis
Comparison 1 Exercise therapy versus control, Outcome 7 Functional ability (short‐term); all participants had malalignment.
1.8
1.8. Analysis
Comparison 1 Exercise therapy versus control, Outcome 8 Functional ability (long‐term).
1.9
1.9. Analysis
Comparison 1 Exercise therapy versus control, Outcome 9 Functional performance (short‐term) single‐limb hop test.
1.10
1.10. Analysis
Comparison 1 Exercise therapy versus control, Outcome 10 Functional performance (short‐term) bilateral squat test.
1.11
1.11. Analysis
Comparison 1 Exercise therapy versus control, Outcome 11 Recovery (short‐term).
1.12
1.12. Analysis
Comparison 1 Exercise therapy versus control, Outcome 12 Recovery (long‐term).
2.1
2.1. Analysis
Comparison 2 Exercise therapy versus unimodal conservative interventions, Outcome 1 Pain during activity (short‐term).
2.2
2.2. Analysis
Comparison 2 Exercise therapy versus unimodal conservative interventions, Outcome 2 Pain during activity (long‐term).
2.3
2.3. Analysis
Comparison 2 Exercise therapy versus unimodal conservative interventions, Outcome 3 Functional ability (short‐term).
2.4
2.4. Analysis
Comparison 2 Exercise therapy versus unimodal conservative interventions, Outcome 4 Functional ability (long‐term).
2.5
2.5. Analysis
Comparison 2 Exercise therapy versus unimodal conservative interventions, Outcome 5 Recovery (long‐term).
3.1
3.1. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 1 Pain (short‐term).
3.2
3.2. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 2 Pain (long‐term).
3.3
3.3. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 3 Functional ability (short‐term).
3.4
3.4. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 4 Functional ability (long‐term).
3.5
3.5. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 5 Recovery (short‐term).
3.6
3.6. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 6 Functional performance (short‐term).
3.7
3.7. Analysis
Comparison 3 Exercise therapy versus multimodal conservative interventions, Outcome 7 Functional performance (long‐term).
4.1
4.1. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 1 Usual pain (short‐term).
4.2
4.2. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 2 Worst pain (short‐term).
4.3
4.3. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 3 Pain (long‐term).
4.4
4.4. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 4 Functional ability (short‐term).
4.5
4.5. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 5 Functional ability (short and long‐term).
4.6
4.6. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 6 Functional performance (short‐term).
4.7
4.7. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 7 Functional performance (long‐term).
4.8
4.8. Analysis
Comparison 4 Delivery of exercise: supervised versus home exercise programme, Outcome 8 Recovery (short‐term).
5.1
5.1. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 1 Pain during activity (short‐term).
5.2
5.2. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 2 Usual pain (short‐term).
5.3
5.3. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 3 Worst pain (short‐term).
5.4
5.4. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 4 Pain (long‐term).
5.5
5.5. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 5 Functional ability (short‐term).
5.6
5.6. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 6 Functional ability (long‐term).
5.7
5.7. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 7 Functional performance (short‐term).
5.8
5.8. Analysis
Comparison 5 Types of exercises: closed kinetic chain exercises versus open kinetic chain exercises, Outcome 8 Functional performance (long‐term).
6.1
6.1. Analysis
Comparison 6 Types of exercises: variants of closed kinetic chain exercises, Outcome 1 Pain during activity (short‐term).
6.2
6.2. Analysis
Comparison 6 Types of exercises: variants of closed kinetic chain exercises, Outcome 2 Functional ability (short‐term).
7.1
7.1. Analysis
Comparison 7 Types of exercises: open, mixed or unspecified kinetic chain exercises subgrouped by type of muscle action, Outcome 1 Pain during activity (short‐term).
7.2
7.2. Analysis
Comparison 7 Types of exercises: open, mixed or unspecified kinetic chain exercises subgrouped by type of muscle action, Outcome 2 Usual pain continuous (short‐term).
7.3
7.3. Analysis
Comparison 7 Types of exercises: open, mixed or unspecified kinetic chain exercises subgrouped by type of muscle action, Outcome 3 Pain during activity (long‐term).
7.4
7.4. Analysis
Comparison 7 Types of exercises: open, mixed or unspecified kinetic chain exercises subgrouped by type of muscle action, Outcome 4 Functional ability (short‐term).
7.5
7.5. Analysis
Comparison 7 Types of exercises: open, mixed or unspecified kinetic chain exercises subgrouped by type of muscle action, Outcome 5 Recovery (short‐term).
7.6
7.6. Analysis
Comparison 7 Types of exercises: open, mixed or unspecified kinetic chain exercises subgrouped by type of muscle action, Outcome 6 Adverse events.
8.1
8.1. Analysis
Comparison 8 Types of exercises: proprioceptive neuromuscular facilitation + aerobic exercise versus classic stretching + quadriceps exercises, Outcome 1 Usual pain (long‐term).
8.2
8.2. Analysis
Comparison 8 Types of exercises: proprioceptive neuromuscular facilitation + aerobic exercise versus classic stretching + quadriceps exercises, Outcome 2 Functional ability (long‐term).
9.1
9.1. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 1 Pain during activity (short‐term).
9.2
9.2. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 2 Usual pain (short‐term).
9.3
9.3. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 3 Worst pain (short‐term).
9.4
9.4. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 4 Pain (long‐term).
9.5
9.5. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 5 Functional ability (short‐term).
9.6
9.6. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 6 Functional ability (long‐term).
9.7
9.7. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 7 Functional performance (short‐term).
9.8
9.8. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 8 Functional performance (long‐term).
9.9
9.9. Analysis
Comparison 9 Target of exercises: hip + knee versus knee exercises, Outcome 9 Recovery (short‐ and long‐term).
10.1
10.1. Analysis
Comparison 10 Target of exercises: hip versus knee exercises, Outcome 1 Pain (short‐ and long‐term).
10.2
10.2. Analysis
Comparison 10 Target of exercises: hip versus knee exercises, Outcome 2 Functional ability (short‐term).
10.3
10.3. Analysis
Comparison 10 Target of exercises: hip versus knee exercises, Outcome 3 Functional ability (long‐term).
10.4
10.4. Analysis
Comparison 10 Target of exercises: hip versus knee exercises, Outcome 4 Functional performance (short‐term).
10.5
10.5. Analysis
Comparison 10 Target of exercises: hip versus knee exercises, Outcome 5 Adverse events.
11.1
11.1. Analysis
Comparison 11 Intensity of exercise: high‐ versus low‐intensity exercise programme, Outcome 1 Usual pain (short‐ and long‐term).
11.2
11.2. Analysis
Comparison 11 Intensity of exercise: high‐ versus low‐intensity exercise programme, Outcome 2 Functional ability (short‐ and long‐term).
11.3
11.3. Analysis
Comparison 11 Intensity of exercise: high‐ versus low‐intensity exercise programme, Outcome 3 Functional performance (short‐ and long‐term).
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References

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Wijnen 1996 {published data only}
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References to studies awaiting assessment

Erel 2011 {published data only}
    1. Erel S, Ozkan H. A comparison of the effects of closed and open kinetic chain exercises on functional status in patellofemoral pain syndrome [Turkish]. Fizyoterapi Rehabilitasyon 2011;22(3):217‐23.

References to ongoing studies

RBR‐2cxrpp {published data only}
    1. Serrao FV. Effects of lumbo‐pelvic stabilization training on women with patellofemoral pain syndrome. http://www.ensaiosclinicos.gov.br/rg/RBR‐2cxrpp/ (accessed 30 June 2014).

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References to other published versions of this review

van der Heijden 2013
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