Kay M. Crossley

Physical Therapy for Patellofemoral Pain A Randomized, Double-Blinded, Placebo-Controlled Trial

Background Although physical therapy forms the mainstay of nonoperative management for patellofemoral pain, its efficacy has not been established. Hypothesis Significantly more pain relief will be achieved from a 6-week regimen of physical therapy than from placebo treatment. Study Design Multicenter, randomized, double-blinded, placebo-controlled trial. Methods Seventy-one subjects, 40 years of age or younger with patellofemoral pain of 1 month or longer, were randomly allocated to a physical therapy or placebo group. A standardized treatment program consisted of six treatment sessions, once weekly. Physical therapy included quadriceps muscle retraining, patellofemoral joint mobilization, and patellar taping, and daily home exercises. The placebo treatment consisted of sham ultrasound, light application of a nontherapeutic gel, and placebo taping. Results Sixty-seven participants completed the trial. The physical therapy group (N = 33) demonstrated significantly greater reduction in the scores for average pain, worst pain, and disability than did the placebo group (N = 34). Conclusions A six-treatment, 6-week physical therapy regimen is efficacious for alleviation of patellofemoral pain.

Stress fractures: A review of 180 cases

OBJECTIVE To review the cases of stress fracture seen over a 2-year period at a sports medicine clinic. DESIGN One hundred and eighty cases diagnosed as stress fractures on the basis of clinical picture and radiological evidence were reviewed. The following features of each stress fracture were noted: age, sex, site, sport/activity. SETTING A sports medicine centre in Melbourne, Australia. PATIENTS The average age was 21.8 years. Seventy eight of these stress fractures were seen in women, 102 in men. RESULTS The most common sites of stress fractures were the metatarsal bones (n = 42), tibia (n = 36), fibula (n = 30), tarsal navicular (n = 26) and pars interarticularis (n = 17). The most common sport was track (n = 54). Other common sports activities were jogging/distance running (n = 35), dance (n = 32) and Australian football (n = 14). The distribution of sites of stress fractures varied from sport to sport. Among the track athletes (n = 54), navicular (n = 19), tibia (n = 14) and metatarsal (n = 9) were the most common stress fracture sites. The distance runners (n = 35) predominantly sustained tibia (n = 15), and fibula (n = 8) stress fractures, while metatarsal stress fractures (n = 18) were the most common among dancers. The distribution of sports varied with the site of the stress fracture. In the metatarsal stress fractures (n = 42), dance was the most common activity. Distance running (n = 15) and track (n = 14) were the most common sports in the group to have sustained tibia stress fractures (n = 36). Track athletes (n = 14) were particularly prevalent in the navicular stress fracture group (n = 26). CONCLUSION The distribution of sites of stress fractures in this study shows some differences from previously published studies.

A systematic review of physical interventions for patellofemoral pain syndrome

ObjectivePhysical interventions (nonpharmacological and nonsurgical) are the mainstay of treatment for patellofemoral pain syndrome (PFPS). Physiotherapy is the most common of all physical interventions and includes specific vastus medialis obliquus or general quadriceps strengthening and/or realignment procedures (tape, brace, stretching). These treatments appear to be based on sound theoretical rationale and have attained widespread acceptance, but evidence for the efficacy of these interventions is not well established. This review will present the available evidence for physical interventions for PFPS. Data SourcesComputerized bibliographic databases (MEDLINE, Current Contents, CINAHL) were searched, including the keywords “patellofemoral,” “patella,” and “anterior knee pain,” combined with “treatment,” “rehabilitation,” and limited to clinical trials through October 2000. Study SelectionThe critical eligibility criteria used for inclusion were that the study be a controlled trial, that outcome assessments were adequately described, and that the treatment was a nonpharmacological, nonsurgical physical intervention. ResultsOf the 89 potentially relevant titles, 16 studies were reviewed and none of these fulfilled all of the requirements for a randomized, controlled trial. Physiotherapy interventions were evaluated in eight trials, and the remaining eight trials examined different physical interventions. Significant reductions in PFPS symptoms were found with a corrective foot orthosis and a progressive resistance brace, but there is no evidence to support the use of patellofemoral orthoses, acupuncture, low-level laser, chiropractic patellar mobilization, or patellar taping. Overall the physiotherapy interventions had significant beneficial effects but these interventions were not compared with a placebo control. There is inconclusive evidence to support the superiority of one physiotherapy intervention compared with others. ConclusionsThe evidence to support the use of physical interventions in the management of PFPS is limited. There appears to be a consistent improvement in short-term pain and function due to physiotherapy treatment, but comparison with a placebo group is required to determine efficacy, and further trials are warranted for the other interventions.

Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial

Objective To compare the clinical efficacy of foot orthoses in the management of patellofemoral pain syndrome with flat inserts or physiotherapy, and to investigate the effectiveness of foot orthoses plus physiotherapy. Design Prospective, single blind, randomised clinical trial. Setting Single centre trial within a community setting in Brisbane, Australia. Participants 179 participants (100 women) aged 18 to 40 years, with a clinical diagnosis of patellofemoral pain syndrome of greater than six weeks’ duration, who had no previous treatment with foot orthoses or physiotherapy in the preceding 12 months. Interventions Six weeks of physiotherapist intervention with off the shelf foot orthoses, flat inserts, multimodal physiotherapy (patellofemoral joint mobilisation, patellar taping, quadriceps muscle retraining, and education), or foot orthoses plus physiotherapy. Main outcome measures Global improvement, severity of usual and worst pain over the preceding week, anterior knee pain scale, and functional index questionnaire measured at 6, 12, and 52 weeks. Results Foot orthoses produced improvement beyond that of flat inserts in the short term, notably at six weeks (relative risk reduction 0.66, 99% confidence interval 0.05 to 1.17; NNT 4 (99% confidence interval 2 to 51). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy plus orthoses. All groups showed clinically meaningful improvements in primary outcomes over 52 weeks. Conclusion While foot orthoses are superior to flat inserts according to participants’ overall perception, they are similar to physiotherapy and do not improve outcomes when added to physiotherapy in the short term management of patellofemoral pain. Given the long term improvement observed in all treatment groups, general practitioners may seek to hasten recovery by prescribing prefabricated orthoses. Trial registration Australian Clinical Trials Registry ACTRN012605000463673 and ClinicalTrials.gov NCT00118521.

Abnormal knee joint position sense in individuals with patellofemoral pain syndrome

The purpose of this cross‐sectional study was to compare knee joint position sense (JPS) in 20 individuals with and 20 without patellofemoral pain syndrome (PFPS). Five active tests with ipsilateral limb matching responses were performed at 20° and 60° flexion under non‐weightbearing conditions, and at 40° flexion under uni‐ and bi‐lateral weightbearing conditions. The response errors were calculated as the difference between each target and response position (accuracy) and the standard deviation of these differences (reliability).

Performance on the Single-Leg Squat Task Indicates Hip Abductor Muscle Function

Background: Contemporary clinical expertise and emerging research in anterior knee pain indicate that treatment of hip muscle function will result in greater effects, if such treatments can be provided to those with hip muscle dysfunction. Thus, it is imperative to develop and evaluate a clinical assessment tool that is capable of identifying people with poor hip muscle function. Hypothesis: The clinical assessment of single-leg squat performance will have acceptable inter- and intrarater reliability. Furthermore, people with good performance on the single-leg squat will have better hip muscle function (earlier onset of gluteus medius activity and greater lateral trunk, hip abduction, and external rotation strength) than people with poor performance. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A consensus panel of 5 experienced clinicians developed criteria to rate the performance of a single-leg squat task as “good,” “fair,” or “poor.” The panel rated the performance of 34 asymptomatic participants (mean ± SD: age, 24 ± 5 y; height, 1.69 ± 0.10 m; weight, 65.0 ± 10.7 kg), and these ratings served as the standard. The ratings of 3 different clinicians were compared with those of the consensus panel ratings (interrater reliability) and to their own rating on 2 occasions (intrarater reliability). For the participants rated as good performers (n = 9) and poor performers (n = 12), hip muscle strength (hip abduction, external rotation, and trunk side bridge) and onset timing of anterior (AGM) and posterior gluteus medius (PGM) electromyographic activity were compared. Results: Concurrency with the consensus panel was excellent to substantial for the 3 raters (agreement 87%-73%; κ = 0.800-0.600). Similarly, intrarater agreement was excellent to substantial (agreement 87%-73%; κ = 0.800-0.613). Participants rated as good performers had significantly earlier onset timing of AGM (mean difference, –152; 95% confidence interval [CI], –258 to –48 ms) and PGM (mean difference, –115; 95% CI, –227 to –3 ms) electromyographic activity than those who were rated as poor performers. The good performers also exhibited greater hip abduction torque (mean difference, 0.47; 95% CI, 0.10-0.83 N·m·Bw−1) and trunk side flexion force (mean difference, 1.08; 95% CI, 0.25-1.91 N·Bw−1). There was no difference in hip external rotation torque (P > .05) between the 2 groups. Conclusion: Targeted treatments, although considered ideal, rely on the capacity to identify subgroups of people with chronic anterior knee pain who might respond optimally to a given treatment component. Clinical assessment of performance on the single-leg squat task is a reliable tool that may be used to identify people with hip muscle dysfunction.

Ground reaction forces, bone characteristics, and tibial stress fracture in male runners.

PURPOSE Tibial stress fracture is a common overuse running injury resulting from repetitive mechanical loading. This research project aimed to determine whether runners with a history of tibial stress fracture (TSF) differ in tibial bone geometry, tibial bone mass, and ground reaction force (GRF) parameters during running from those who have never sustained a stress fracture (NSF). METHODS Forty-six male running athletes (23 TSF; 23 NSF) ranging in age from 18 to 42 yr were recruited for this cross-sectional study. A force platform was used to measure selected GRF parameters (peak and time to peak for vertical impact force, vertical active force, and horizontal braking force) during running at 4.0 m x s(-1). Tibial bone geometry (cross-sectional dimensions and area) was calculated from a computerized tomography (CT) scan at the junction of the middle and distal thirds. Dual energy x-ray absorptiometry (DXA) provided measurements of tibial bone area, bone mineral content (BMC), and bone mineral density (BMD). RESULTS The TSF group had significantly smaller tibial cross-sectional area (P = 0.02) and DXA tibial bone area (P = 0.02), after adjusting for height and weight, than the NSF group. There were no significant differences between groups for GRF, tibial BMC, or tibial BMD. CONCLUSION These findings support the contention that bone geometry plays a role in stress fracture development and that male athletes with smaller bones in relation to body size are at greater risk for this bony injury.

Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment

Varus knee alignment is a risk factor for medial knee osteoarthritis and is associated with high knee adduction moments. Therefore, reducing the knee adduction moment in varus-aligned individuals with otherwise healthy knees may reduce their risk for developing osteoarthritis. A gait modification that improves dynamic knee alignment may reduce the adduction moment, and systematic training may lead to more natural-feeling and less effortful execution of this pattern. To test these hypotheses, eight healthy, varus-aligned individuals underwent a gait modification protocol. Real-time feedback of dynamic knee alignment was provided over eight training sessions, using a fading paradigm. Natural and modified gait were assessed post-training and after 1 month, and compared to pre-training natural gait. The knee adduction moment, as well as hip adduction, hip internal rotation and knee adduction angles were evaluated. At each training session, subjects rated how effortful and natural-feeling the modified pattern was to execute. Post-training, the modified pattern demonstrated an 8 degrees increase in hip internal rotation and 3 degrees increase in hip adduction. Knee adduction decreased 2 degrees , and the knee adduction moment decreased 19%. Natural gait did not differ between the three visits, nor did the modified gait pattern between the post-training and 1 month visits. The modified pattern felt more natural and required less effort after training. Based on these results, gait retraining to improve dynamic knee alignment resulted in significant reductions in the knee adduction moment, primarily through hip internal rotation. Further, systematic training led to more natural-feeling and less effortful execution of the gait pattern.

Patellar taping and bracing for the treatment of chronic knee pain: A systematic review and meta‐analysis

OBJECTIVE To evaluate the evidence for patellar taping and bracing in the management of chronic knee pain. METHODS Randomized or quasi-randomized studies assessing patellar taping or bracing effects on chronic knee pain were sourced from 7 electronic databases (to November 2006), and assessed using the Physiotherapy Evidence Database scale. Weighted mean differences were determined, and pooled estimates of taping and bracing effects were obtained using random-effects models. RESULTS Of 16 eligible trials, 13 investigated patellar taping or bracing effects in individuals with anterior knee pain, and 3 investigated taping effects in individuals with knee osteoarthritis (OA). The methodologic quality of the taping studies was significantly higher than the bracing studies (mean+/-SD 4.8+/-2.1 versus 2.8+/-0.8; P<0.05). On a 100-mm scale, tape applied to exert a medially-directed force on the patella decreased chronic knee pain compared with no tape by 16.1 mm (95% confidence interval [95% CI] -22.2, -10.0; P<0.001) and sham tape by 10.9 mm (95% CI -18.4, -3.4; P<0.001). For anterior knee pain and OA, medially-directed tape decreased pain compared with no tape by 14.7 mm (95% CI -22.8, -6.9; P<0.001) and 20.1 mm (95% CI -26.0, -14.3; P<0.001), respectively. There was disputable evidence from low-quality studies for patellar bracing benefits. CONCLUSION There was evidence that tape applied to exert a medially-directed force on the patella produces a clinically meaningful change in chronic knee pain. There was limited evidence to demonstrate the efficacy of patellar bracing. These outcomes were limited by the presence of high heterogeneity between study outcomes and significant publication bias.

Delayed onset of transversus abdominus in long-standing groin pain.

UNLABELLED Long-standing groin pain is a persistent problem that is commonly difficult to rehabilitate. Theoretical rationale indicates a relationship between the motor control of the pelvis and long-standing groin pain; however, this link has not been investigated. PURPOSE The current experiment aimed to evaluate motor control of the abdominal muscles in a group of Australian football players with and without long-standing groin pain. METHODS Ten participants with long-standing groin pain and 12 asymptomatic controls were recruited for the study. Participants were elite or subelite Australian football players. Fine-wire and surface electromyography electrodes were used to record the activity of the selected abdominal and leg muscles during a visual choice reaction-time task (active straight leg raising). RESULTS When the asymptomatic controls completed the active straight leg raise (ASLR) task, the transversus abdominus contracted in a feed-forward manner. However, when individuals with long-standing groin pain completed the ASLR task, the onset of transversus abdominus was delayed (P < 0.05) compared with the control group. There were no differences between groups for the onset of activity of internal oblique, external oblique, and rectus abdominus (all P > 0.05). CONCLUSIONS The finding that the onset of transversus abdominus is delayed in individuals with long-standing groin pain is important, as it demonstrates an association between long-standing groin pain and transversus abdominus activation.