Jean-Francois Esculier

2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures

Patellofemoral pain (PFP) typically presents as diffuse anterior knee pain, usually with activities such as squatting, running, stair ascent and descent. It is common in active individuals across the lifespan,1–4 and is a frequent cause for presentation at physiotherapy, general practice, orthopaedic and sports medicine clinics in particular.5 ,6 Its impact is profound, often reducing the ability of those with PFP to perform sporting, physical activity and work-related activities pain-free. Increasing evidence suggests that it is a recalcitrant condition, persisting for many years.7–9 In an attempt to share recent innovations, build on the first three successful biennial retreats and define the ‘state of the art’ for this common, impactful condition; the 4th International Patellofemoral Pain Research Retreat was convened. The 4th International Patellofemoral Research Retreat was held in Manchester, UK, over 3 days (September 2–4th, 2015). After undergoing peer-review for scientific merit and relevance to the retreat, 67 abstracts were accepted for the retreat (50 podium presentations, and 17 short presentations). The podium and short presentations were grouped into five categories; (1) PFP, (2) factors that influence PFP (3) the trunk and lower extremity (4) interventions and (5) systematic analyses. Three keynote speakers were chosen for their scientific contribution in the area of PFP. Professor Andrew Amis spoke on the biomechanics of the patellofemoral joint. Professor David Felson spoke on patellofemoral arthritis,10 and Dr Michael Ratleffs keynote theme was PFP in the adolescent patient.11 As part of the retreat, we held structured, whole-group discussions in order to develop consensus relating to the work presented at the meeting as well as evidence gathered from the literature. ### Consensus development process In our past three International Patellofemoral Research Retreats, we developed a consensus statement addressing different presentation categories.12–14 In Manchester in 2015, we revised the format. For the exercise and …

Lower limb control and strength in runners with and without patellofemoral pain syndrome.

Recreational runners with patellofemoral pain syndrome (PFPS) have been shown to present altered movement kinematics, muscle activations, and ground reaction forces (GRF) during running as well as decreased lower limb strength. However, these variables have never been concurrently evaluated in a specific cohort. Therefore, the aim of this study was to compare lower limb control variables during running in recreational runners with and without PFPS. Lower limb control during treadmill running under typical training conditions (usual shoes, foot strike pattern, and speed) was compared between runners with (n=21) and without (n=20) PFPS using lower limb kinematics, electromyographic (EMG) recordings from representative muscles (gluteus medius/maximus, quadriceps and soleus), and vertical GRF. Isometric muscle strength was also evaluated. When comparing all runners from both groups, no between-group differences were found in variables commonly associated with PFPS such as peak hip adduction, hip internal rotation, contralateral pelvic drop, EMG of gluteal and quadriceps muscles, vertical loading rate, or lower limb strength. However, runners with PFPS showed significantly higher hip adduction at toe-off, lower excursion in hip adduction during late-stance, and longer duration of soleus activation. Sub-analyses were performed for females and for rearfoot strikers (RFS), and revealed that these subgroups accounted for most of between-group differences in hip adduction kinematics. Specifically for RFS with PFPS, lower activation of gluteus medius as well as lower GRF were observed. Our results suggest that deficits reported in runners with PFPS may vary depending on gender and on foot strike pattern.

Psychometric evidence of self-reported questionnaires for patellofemoral pain syndrome: a systematic review.

Abstract Purpose: To conduct a systematic review of psychometric properties of self-reported questionnaires used to assess the level of symptoms and disability in individuals with patellofemoral pain syndrome (PFPS). Methods: A structured search was conducted in four databases (Medline, Embase, CINAHL, SportDiscus). A total of 24 studies about five different self-reported questionnaires were analyzed. A pair of independent raters extracted data on validity, reliability and responsiveness to change, and performed critical appraisal (0–100%). Results: Activities of Daily Living Scale (ADLS), Anterior Knee Pain Scale (AKPS), International Knee Documentation Committee (IKDC) and Lysholm Scale (LS) present excellent test–retest reliability (weighted average intraclass correlation coefficients [ICC] > 0.80), whereas Functional Index Questionnaire (FIQ) is moderately reliable (ICC = 0.61). Minimal detectable change is 8.3% for ADLS, 9.0% for AKPS, 19% for FIQ, 8.5% for IKDC and 30% for LS. ADLS, AKPS, IKDC and LS are highly responsive (effect size/standardized response mean >0.95) in individuals with PFPS, while FIQ is lowly responsive (effect size = 0.49). Conclusion: Based on available evidence, ADLS presents the best psychometric properties and should be preferred when evaluating patients with PFPS. AKPS and IKDC are also adequate, while FIQ and LS are not recommended for individuals with PFPS. Implications for Rehabilitation While several questionnaires have been developed to assess symptoms and functional limitations caused by knee pain, their psychometric properties can vary depending on the condition presented by the patient. The Activities of Daily Living Scale of the Knee Outcome Survey should be preferred by clinicians when evaluating a patient with PFPS. The Anterior Knee Pain Scale and International Knee Documentation Committee Subjective knee evaluation are also adequate for use with this population. The Functional Index Questionnaire and Lysholm Scale are not recommended for PFPS.

Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain?A randomised clinical trial

Design Single-blind randomised clinical trial. Objective To compare the effects of three 8-week rehabilitation programmes on symptoms and functional limitations of runners with patellofemoral pain (PFP). Methods Sixty-nine runners with PFP were randomly assigned to one of three intervention groups: (1) education on symptoms management and training modifications (education); (2) exercise programme in addition to education (exercises); (3) gait retraining in addition to education (gait retraining). Symptoms and functional limitations were assessed at baseline (T0), and after 4, 8 and 20 weeks (T4, T8 and T20) using the Knee Outcome Survey of the Activities of Daily Living Scale (KOS-ADLS) and visual analogue scales (VASs) for usual pain, worst pain and pain during running. Lower limb kinematics and kinetics during running, and isometric strength were also evaluated at T0 and T8. The effects of rehabilitation programmes were assessed using two-way analysis of variance. Results No significant group × time interactions (p<0.447) were found for KOS-ADLS and VASs. All three groups showed similar improvements at T4, T8 and T20 compared with T0 (p<0.05). Only the exercises group increased knee extension strength following rehabilitation (group × time: p<0.001) and only the gait retraining group (group × time: p<0.001) increased step rate (+7.0%) and decreased average vertical loading rate (−25.4%). Conclusion Even though gait retraining and exercises improved their targeted mechanisms, their addition to education did not provide additional benefits on symptoms and functional limitations. Appropriate education on symptoms and management of training loads should be included as a primary component of treatment in runners with PFP. Trial registration number ClinicalTrials.gov (NCT02352909).

Translation, cross-cultural adaptation and validation of the French version of the Knee Outcome Survey–Activities of Daily Living Scale

Purpose: The Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS) is a joint-specific questionnaire measuring functional limitation experienced by individuals with knee disorders. The original English version of the KOS-ADLS has been shown to be highly reliable and responsive to change. The purpose of this study was to perform a translation and cross-cultural adaptation of the original version of the KOS-ADLS questionnaire into French and to validate this French version of the questionnaire. Method: In accordance with standard procedure, the original version of the KOS-ADLS was translated and cross-culturally adapted into French. Once the final French version of the KOS-ADLS was developed, it was subjected to further psychometric evaluation with 76 individuals with knee disorders. Each participant completed the KOS-ADLS on three occasions: at baseline, two days later to evaluate test–retest reliability, and four weeks later to evaluate responsiveness. Symptoms and function-oriented construct questions were also completed to evaluate construct-convergent and known-group validity. Results: The cross-cultural adaptation procedure revealed no major problems with content or language. The French version of the KOS-ADLS showed excellent test–retest reliability with low measurement error (intraclass correlation coefficient = 0.92, minimal detectable change = 8.3), as well as high responsiveness (standardized response mean = 1.41; clinically important difference = 13.6). Further, it discriminates between different levels of self-rated or clinician-rated knee function. Conclusions: The French version of the KOS-ADLS is a reliable, valid and responsive questionnaire for the assessment of functional limitation in individuals with musculoskeletal knee disorders.

Psychometric evidence for clinical outcome measures assessing shoulder disorders

Abstract Background: A wide range of outcome measures is available for the assessment of individuals with shoulder disorders. Since outcome measures are used to orientate treatment decision-making, clinicians must make sure that the ones they intend to use present adequate properties for their clinical purpose. Objectives: To review the psychometric evidence relating to five categories of shoulder outcome measures: range of motion, scapular position and motion, strength, functional performance, and self-report questionnaires. Validity, reliability, and responsiveness were reviewed for each category. Major findings: For most of the shoulder outcomes reviewed, evidence relating to relative reliability (intraclass correlation coefficients) and construct validity was favorable. Globally, intrarater and test–retest reliability indices were excellent, while interrater indices were good to excellent. Favorable evidence on responsiveness (effect size, standardized response mean, clinically important difference) and absolute reliability (minimal detectable change) was also found for self-report questionnaires. However, for range of motion, scapular position and motion, strength and functional performance tests, evidence on responsiveness and absolute reliability was limited or non-existent. Conclusions: Self-reported scales, such as the DASH, ASES, WORC, or WOSI, should be first line tests as they are highly responsive. Furthermore, they are the only shoulder outcomes for which most useful clinical benchmarks are established, such as minimal detectable change or clinically important difference. As for more conventional measures such as range of motion and strength, while still clinically relevant, they require further investigations to define their responsiveness, minimal detectable change, or clinically important difference.

Predictors of clinical success in runners with patellofemoral pain: Secondary analyses of a randomized clinical trial

OBJECTIVES To identify predictors of outcome to a rehabilitation program focused on education and management of training loads in runners with patellofemoral pain (PFP). DESIGN Secondary analyses of a randomized clinical trial. METHODS Fifty-eight runners with PFP (62% female, aged 31.2±6.6years, running 20.3±5.6km/week) were included in analyses. Following baseline collection of demographics, anthropometry, symptomatology, isometric strength, running mechanics and radiological data, runners were randomized to one of the three 8-week intervention program: (1) Education on symptoms management and training modifications; (2) Education+Exercise program; (3) Education+Gait retraining. Clinical success was defined as an increase ≥13.6% on the Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS) at 3 months following program completion. Potential predictors were entered into logistic regression analyses. RESULTS Forty-five runners (78%) were categorized as Success. Together, KOS-ADLS score (<70%), knee extension isometric strength (<70% bodyweight), presence of patellar tendinopathy (Grade >0) and level of usual pain (>2/10) at baseline predicted treatment outcome with 87.9% accuracy. The model provided sensitivity of 0.93 (95% C.I. 0.82-0.98), specificity of 0.69 (95% C.I. 0.42-0.87), positive likelihood ratio of 3.0 (95% C.I. 1.3-6.9), and negative likelihood ratio of 0.1 (95% C.I. 0-0.3). The best individual predictors were KOS-ADLS score and knee extension strength. CONCLUSIONS The combination of KOS-ADLS, knee extensors strength, patellar tendon integrity and usual pain best predicted clinical outcome of runners with PFP following an intervention that had a common education component. Further testing is needed before a clinical prediction rule can be recommended to clinicians.

Footwear characteristics are related to running mechanics in runners with patellofemoral pain

Running footwear is known to influence step rate, foot inclination at foot strike, average vertical loading rate (VLR) and peak patellofemoral joint (PFJ) force. However, the association between the level of minimalism of running shoes and running mechanics, especially with regards to these relevant variables for runners with patellofemoral pain (PFP), has yet to be investigated. The objective of this study was to explore the relationship between the level of minimalism of running shoes and habitual running kinematics and kinetics in runners with PFP. Running shoes of 69 runners with PFP (46 females, 23 males, 30.7±6.4years) were evaluated using the Minimalist Index (MI). Kinematic and kinetic data were collected during running on an instrumented treadmill. Principal component and correlation analyses were performed between the MI and its subscales and step rate, foot inclination at foot strike, average VLR, peak PFJ force and peak Achilles tendon force. Higher MI scores were moderately correlated with lower foot inclination (r=-0.410, P<0.001) and lower peak PFJ force (r=-0.412, P<0.001). Moderate correlations also showed that lower shoe mass is indicative of greater step rate (ρ=0.531, P<0.001) and lower peak PFJ force (ρ=-0.481, P<0.001). Greater shoe flexibility was moderately associated with lower foot inclination (ρ=-0.447, P<0.001). Results suggest that greater levels of minimalism are associated with lower inclination angle and lower peak PFJ force in runners with PFP. Thus, this population may potentially benefit from changes in running mechanics associated with the use of shoes with a higher level of minimalism.

Effects of minimalist and traditional running shoes on injury rates: a pilot randomised controlled trial

Despite recent advances in running shoe conception, injuries represent a major concern in the running community. The objective of this study was to gather the pilot data for a larger randomised controlled trial regarding the effects of traditional and minimalist shoes on the incidence of running-related injuries (RRI), as well as the rate of adherence to a running programme. Twenty-six recreational runners were recruited. They were randomly assigned to minimalist (MS) or traditional (TS) shoes and participated in a 16-week training programme. The information on previously reported risk factors for RRI was gathered. Participants reported pain and compliance using an online tool. Main outcome measures included the rates of recruitment, adherence to the programme and programme completion, RRI and the missed training days secondary to the running-related pain. The recruited runners represented 72.2% of potential participants, among which 20 (76.9%) completed the programme. Two subjects dropped out before randomisation, plus three in MS and one in TS during the programme. Rate of adherence was 82.4% in MS and 86.2% in TS. Three runners per group sustained an RRI (25%, 95% C.I. = 9.8%–46.7%). Results support the feasibility of a larger scale study. A total of 116 runners would be needed to detect a clinically significant difference of 20% in injury incidence between MS and TS.

Hip kinematics during functional tasks in females with patellofemoral pain: Modification following rehabilitation and correlation with clinical improvement

OBJECTIVES To compare hip kinematics during two functional tasks in females with and without patellofemoral pain (PFP), and to determine if hip kinematics and, symptoms and functional limitations were improved after a rehabilitation program. DESIGN Cross sectional and longitudinal. PARTICIPANTS Sixteen females with and 15 without PFP. SETTING Laboratory and physical therapy clinic. MAIN OUTCOME MEASURES Hip adduction (HADD) and medial rotation (HMR) peak angles, time integrals and inter-movement variability during step-down and vertical drop jump, symptoms and functional limitations evaluated using the Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS). RESULTS At baseline, no significant differences were found in step-down and vertical drop jump between PFP and controls. Following rehabilitation, significant improvements were reported in KOS-ADLS (p < 0.001). There was a significant decrease in HADD and HMR variability (p < 0.05), a trend for decreased peak HMR (p = 0.06) during step-down, and a significant decrease in HADD variability (p < 0.05) during vertical drop jump. These kinematic changes did not correlate with changes in KOS-ADLS (all p > 0.05). CONCLUSION Females with and without PFP demonstrated no hip kinematic differences during functional tasks. A rehabilitation program improved symptoms and functional status, and modified hip kinematics in females with PFP; however these changes were not correlated.