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Patellofemoral pain syndrome: A review on the

associated neuromuscular deficits and current
treatment options

Article in British Journal of Sports Medicine · August 2008

DOI: 10.1136/bjsm.2008.046623 · Source: PubMed

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School of Physiotherapy and
Performance Science, University
College Dublin, Dublin, Republic
of Ireland
Correspondence to:
Dr E Delahunt, School of
Physiotherapy and Performance
Science, University College Dublin,
Health Sciences Centre, Belfield,
Dublin 4, Republic of Ireland;
eamonn.delahunt@ucd.ie
Accepted 26 March 2008
Published Online First
14 July 2008
Br J Sports Med 2008;42:789–795. doi:10.1136/bjsm.2008.046623
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Patellofemoral pain syndrome: a review on the
associated neuromuscular deficits and current
treatment options
V Fagan, E Delahunt
ABSTRACT
Background: Patellofemoral pain syndrome (PFPS) is a
common clinical presentation. Various neuromuscular
factors have been reported to contribute to its aetiology.
Study design: Systematic review
Methods: A literature search was carried out from 1998
up to December 2007. Eligible studies were those that:
(1) examined the effects of hip strengthening in subjects
with PFPS; (2) examined the effects of physiotherapy
treatment aimed at restoring muscle balance between the
vastus medialis oblique (VMO) and vastus lateralis (VL) in
subjects with PFPS; (3) examined the effect of taping on
electromyogram (EMG) muscle amplitude in subjects with
PFPS; and (4) compared the effects of open versus closed
kinetic chain exercises in the treatment of subjects with
PFPS.
Results and conclusion: No randomised controlled
trials exist to support the use of hip joint strengthening in
subjects with PFPS. Physiotherapy treatment programmes
appear to be an efficacious method of improving
quadriceps muscle imbalances. Further studies are
required to determine the true efficacy of therapeutic
patellar taping. Both open and closed kinetic chain
exercises are appropriate forms of treatment for subjects
with PFPS.
Patellofemoral pain syndrome (PFPS) is a common
source of anterior knee pain affecting young active
individuals.1 2 It is believed to account for between
25–40% of all knee problems presenting to sports
medicine centres3–5 while McConnell reports that it
affects one in four of the total population.6 In a
study carried out by Fairbank et al,7 30% of
randomly selected students aged between 13–
19 years had experienced anterior knee pain in
the year before the study. Patellofemoral related
problems occur with an incidence of two to one in
females versus males, while men have been shown
to have a greater incidence when athletes alone
were studied.8 9
PFPS is a very common injury encountered
during running.10 In a review of 2002 patients with
running related injuries, Taunton et al11 reported
that the knee joint was the most commonly
injured body site (42.1%) with 46% of these
injuries being due to PFPS. Commonly used
synonymous terms include anterior knee pain,
chondromalacia patella, patellofemoral arthralgia,
patellar pain, patellar pain syndrome and patello-
femoral pain.12 13
Symptoms usually consist of diffuse pain origi-
nating from the anterior aspect of the knee, most
commonly along the medial aspect of the patella;
Review
however, retro-patellar and lateral patellar pain are
not uncommon.9 13 Pain is typically reproduced on
functions that increase patellofemoral compressive
forces such as running, ascending and descending
stairs, inclined walking, squatting and prolonged
sitting.8 9 14 It therefore has a debilitating effect on
sufferers’ daily lives by reducing their ability to
perform sporting and work related activities pain-
free.
Hip joint musculature strength in PFPS
The association between proximal weakness of the
hip joint musculature and subsequent distal
pathology has been documented rather extensively
in the literature. Dating back to the 1980s, research
has demonstrated the need to consider lower
extremity kinetic chain factors when assessing
and treating distal conditions,15–17 with Carson et
al16 suggesting that anterior and peripatellar knee
pain are a result of lower extremity torsional
malalignment. The results of a study by Lee et al18
on human cadaveric knees showed that with a 30u
medial or lateral rotation deformity, increased
patellofemoral contact pressure is produced on
the lateral facet and medial facet of the patella
respectively, further supporting this theory.
While these studies contribute valuable informa-
tion on the possible aetiology of PFPS, more recent
studies have concentrated on the direct relation-
ship between PFPS patients and hip strength.
The first of such studies on symptomatic PFPS
patients carried out by Ireland et al19 found that
female patients with PFPS had 26% weaker hip
abductors and 36% weaker hip external rotators
than a cohort of age matched female control
subjects. In contrast to this, however, Piva et al20
were unable to associate significant hip muscle
weakness with PFPS. When data were analysed,
they found that patients with PFPS in their study
displayed 4% less external rotation strength and
14% less abduction strength when compared to age
and gender matched controls, which was consid-
ered insignificant. The authors suggest that differ-
ences in studies possibly occurred due to variations
in positioning for tests and inclusion criteria of
subjects. They also allude to the fact that given a
larger sample size, the abduction strength measure-
ment may have proved to be significantly weaker
compared to the control group, thus indicating
that their study may have been under powered to
detect differences between the groups.
Within the last year, two studies have been
published, which conclude that hip muscle weak-
ness is related to PFPS. The first study, carried out
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by Cichanowski et al,21 found that the hip abductors and
external rotators of the injured limb were significantly weaker
than the non-injured side in female PFPS patients. The study
also found global hip muscle weakness in the female athletes
with PFPS when compared with age and sports matched
asymptomatic controls. The authors accept that the general
weakness may be attributable to disuse atrophy from reduced
training; however, they are quick to point out that the
difference in hip abduction and external rotation strength
between the affected and unaffected side in the symptomatic
group could not be related to this. Their conclusions about the
crucial role of hip abductors and external rotators in the
development of PFPS are therefore in line with the results
previously obtained by Ireland et al.19 A more recent study by
Robinson et al,22 investigating the association between hip
strength and PFPS, reports similar results to those observed
by Cichanowski et al.21 The authors found that female subjects
with unilateral PFPS displayed hip abductor, extensor and
external rotator strength values that were only between 71–
79% of the strength of the uninvolved side. Their results
also indicate that PFPS patients have reduced hip muscle
strength when compared to the weaker limbs of asymptomatic
subjects.
Quadriceps muscle imbalances in PFPS
Maltracking of the patella on the femur as a result of an
imbalance in the activity of the vastus medialis oblique (VMO)
relative to the vastus lateralis (VL) as a possible cause of PFPS
has received much attention in the literature.23–25 It has been
suggested that delayed onset and decreased activation magni-
tude of the VMO in relation to the VL leads to abnormal lateral
tracking, increased patellofemoral contact pressure and resul-
tant pathology of the articular cartilage.24 26 A reduction in the
force producing capabilities of the VMO muscle27 or altered
motor control of the VMO and VL24 28 have been proposed as
possible causes of this imbalance. Neptune et al29 concluded that
a 5 ms VMO timing delay is associated with a significant
increase in lateral patellofemoral joint loading.
Effects of taping on quadriceps electromyogram (EMG)
activation in PFPS
The use of patellar taping techniques for the treatment of PFPS
became popular following the publication of McConnell’s
original article in 1986.6 It was proposed that when the patella
undergoes medial glide taping, it changes position, resulting in
better alignment between the patella and the troclear notch of
the femur, there is a stretch on the lateral structures, as well as
an increase in VMO activity and a decrease in pain, thereby
facilitating an earlier initiation of strengthening exercises.
Since this original hypothesis, numerous studies have been
carried out in an attempt to explain the mechanisms of action
of patellar taping. Some studies suggest that taping produces a
reduction in neural inhibition of the quadriceps as a result of
proprioceptive feedback to A-b afferents, thereby modulating
pain and resulting in increased quadriceps force.30 Consequently
there would be greater articulation between the patella and the
trochlear groove resulting in increased leverage and maximised
mechanical advantage of the quadriceps muscle.31 32
The proposed effects of patellar taping on the neuromotor
control of the patellofemoral joint are that it either improves
the amplitude or timing of the VMO or decreases the amplitude
or timing of VL, or both.6
790
Open versus closed kinetic chain exercises
Quadriceps strength deficits are a common clinical finding in
patients with PFPS and therefore strengthening exercises either
in the form of open kinetic chain (OKC) or closed kinetic chain
(CKC) often form part of the rehabilitation process.32 Much
debate exists in the literature as to the relative efficacy of open
and closed kinetic chain exercises. OKC exercises are single joint
movements performed in non-weight bearing positions with a
free distal segment. CKC exercises in comparison are multi-joint
movements performed in weight bearing or simulated weight
bearing positions with a fixed distal segment.33 Selection for
either exercise regimen is based upon the assumption that both
strategies have different physiological effects. OKC leg exten-
sion exercises have been the traditional means of strengthening
the quadriceps; however, in recent times, these exercises have
been contraindicated in the treatment of PFPS with some
authors suggesting that they aggravate symptoms.6 As a result,
there has been a significant increase in the use of CKC exercises
in the treatment of PFPS.34
A number of benefits associated with CKC have been
suggested. As CKC exercises simulate and replicate the role of
the lower limb muscles during activities of daily living, they are
believed to be more functional and potentially task/sport
specific.35 Proprioceptive feedback is also believed to differ
between CKC and OKC tasks possibly due to the greater
compressive force from the body’s mass36 and foot–ground
contact37 in CKC. CKC exercises are also believed to result in
lower patellofemoral joint stresses when compared with OKC
exercises. In CKC exercises compressive forces are heightened
with increasing knee flexion—for example, squatting; however,
this force is distributed and compensated for by greater contact
area between the patella and trochlear groove of the femur.
During OKC exercises—for example, knee extension exercises—
joint stress increases from 90u flexion as the knee extends. This
suggests that patients may tolerate and comply better with
CKC exercises resulting in more favourable outcomes.
AIMS OF THIS REVIEW
Traditionally, physiotherapy has focused on treating the
structures surrounding the patellofemoral joint itself. This
review, however, examines the relationship between PFPS and
deficits in neuromuscular function around the knee and hip
joints. Specific aims of the review are to identify:
c randomised controlled trials (RCTs) and intervention
studies that evaluate the effectiveness of strengthening the
hip joint musculature in subjects with PFPS
c RCTs and intervention studies that evaluate the effective-
ness of physiotherapeutic interventions for quadriceps
muscle imbalances in subjects with PFPS
c RCTs and intervention studies that evaluate the effective-
ness of taping on the quadriceps muscle activation in
subjects with PFPS
c RCTs and intervention studies that evaluate the effective-
ness of open and closed kinetic chain exercises in subjects
with PFPS.
METHODS
Search strategy for identification of studies
Relevant studies were identified using a computer based
literature search of the databases Medline (1998–January
2006) and PEDro, using the following keywords: patellofemoral
pain, patellofemoral pain syndrome, patellar taping, hip
strength, vastus medialis oblique, vastus lateralis, open kinetic
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Table 1 Efficacy of hip joint musculature strengthening in subjects with patellofemoral pain syndrome
Mascal et al13 Tyler et al38 Boling et al41

Type of study 2 case reports Cohort study Pre-/post-test intervention study

Groups 2 patients with PFPS, exhibiting weak hip 1 group—35 PFPS patients, mean (SD) age 35 Group 1—14 PFPS patients
abductors, extensors and external rotators (16) years (29 women, 6 men) demonstrating hip Group 2—14 control subjects
flexion, abduction and adduction weakness
Treatment Physical therapy once or twice weekly for 6 week treatment programme-consisted of OKC 6 week progressive weight bearing rehabilitation
14 weeks plus HEP. Weeks 0–6 involved non-WB and CKC strengthening and flexibility exercises programme, with emphasis on hip joint abductor and
exercises, abdominals and isometric hip exercises. for hip musculature. Hip flexors, abductors, quadriceps strengthening. 3 sessions per week (1
Weeks 6–10 involved WB exercises, isometric adductors and extensors were progressively supervised session and 2 self directed sessions)
and dynamic exercises in single leg stance. Weeks strengthened. Stretching in Ober and Thomas
10–14 involved functional training test positions as well as self performed stretches
Outcome Functional status questionnaire, VAS worst pain, Hip flexion, abduction and adduction strength, Pain as measured on a VAS. FIQ. VMO and VL EMG
measures hip and abdominal strength, observational gait Thomas and Ober tests, VAS for pain on ADLs as onsets. Gluteus medius EMG onset
analysis, step down task, 3 dimensional well as on exercise (treatment success defined
kinematics of lower extremity as a min of 1.5 cm reduction of pain on each
VAS)
Results Significant reduction in pain, improved lower Hip flexion strength improved by 35%, VMO and VL onset timing differences, as well as VAS and
extremity kinematics, ability to return to original improvements in hip abduction and adduction FIQ scores improved in group 1 subjects. Post-test scores
level of function strength, increased flexibility, significant for group1 were equivalent to those in group 2
decrease in VAS scores
ADL, activities of daily living; CKC, closed kinetic chain; EMG, electromyogram; FIQ, Functional Index Questionnaire; HEP, home exercise programme; OKC, open kinetic chain; PFPS,
patellofemoral pain syndrome; VAS, Visual Analogue Scale; VL, vastus lateralis; VMO, vastus medialis oblique; WB, weight bearing.

chain exercise, closed kinetic chain exercise. Limits were
imposed in the search strategy to restrict the search to articles
published in the English language. Reference lists of identified
studies were also checked for additional sources of information.
Inclusion criteria
All studies generated from the initial search were screened by
both authors, and studies deemed appropriate were grouped
into one of four sections. Inclusion criteria were then applied to
all studies in each of these four groups:
1. Hip joint musculature strength in PFPS
– studies involving patients with a diagnosis of PFPS were
considered
– studies which examined the effects of hip strengthening in
subjects with PFPS
2. Quadriceps muscle imbalance in PFPS
– studies involving patients with a diagnosis of PFPS were
considered
– studies which examined the effects of physiotherapy
treatment aimed at restoring muscle balance between
the VMO and VL in subjects with PFPS
3. The effects of taping on quadriceps muscle activation in PFPS
– studies involving patients with a diagnosis of PFPS were
considered
– studies which examined the effect of taping on EMG
muscle onset timing in subjects with PFPS
– studies which examined the effect of taping on EMG
muscle amplitude in subjects with PFPS
4. Open versus closed kinetic chain exercises in PFPS
– studies involving patients with a diagnosis of PFPS were
considered
– studies which compared the effects of open versus closed
kinetic chain exercises in the treatment of subjects with
PFPS.
Assessment of methodological quality and levels of evidence
All identified RCTs were rated for methodological quality using
the PEDro scale.
Summary statements on the efficacy of four interventions—
(a) hip joint musculature strengthening, (b) physiotherapy
treatment aimed at addressing quadriceps muscle imbalances,
(c) taping for quadriceps muscle activation, (d) open versus
closed kinetic chain exercises—were based on a system

Table 2 Studies investigating the efficacy of physiotherapeutic intervention aimed at addressing quadriceps muscle imbalances in subjects with PFPS
Cowan et al21 Cowan et al30

Type of study Randomised controlled trial Randomised controlled trial

Groups 65 PFPS subjects, mean (SD) age 29.2 (7.8) years
Group 1—(30) placebo
Group 2—(35) physical therapy treatment
Treatment Group 1—placebo vertical taping to patella, inoperative US, light
application of non-operative gel
Group 2—6 week progressive VMO retraining. Weeks 1–2 isometric VMO
in sitting, inner range squats with isometric gluteal contraction. Weeks 3–
6 step-down exercises and VMO retraining in standing. Also application of
medial patellar glide taping, stretching and hip strengthening
Outcome EMG recordings of VMO and VL during stair stepping task, VAS worst and
measures average pain in last week, AKP self administered questionnaire
Results In intervention group, post-treatment, reduction in symptoms, VMO onset
preceded VL in eccentric phase and occurred simultaneously in concentric
phase of stair stepping task. Placebo group—no change, VL before VMO
PEDro score 6/10
AKP, anterior knee pain; EMG, electromyogram; PFPS, patellofemoral pain syndrome; VAS, Visual Analogue Scale; VL, vastus lateralis; VMO, vastus medialis oblique; US,
ultrasound.
40 PFPS subjects, mean (SD) age 27.2 (7.8) years.
Group 1—(18) placebo treatment
Group 2—(22) physical therapy intervention
Group 1—placebo vertical taping to patella, sham therapeutic US, light application of
non-therapeutic gel
Group 2—6 week progressive VMO retraining. Weeks 1–2 isometric VMO in sitting,
inner range squats with isometric gluteal contraction. Weeks 3–6 step-down
exercises and VMO retraining in standing. Also application of medial patellar glide
taping, stretching and hip strengthening
EMG recordings of VMO and VL, tibialis anterior and soleus during ‘‘rock and rise’’
task, VAS worst pain in last week, AKP questionnaire
In intervention group, post-treatment VMO and VL activation onset occurred
simultaneously compared to VL occurring before VMO pre-treatment. No change in
placebo group
5/10

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Table 3 Studies investigating the efficacy of taping for quadriceps muscle activation in subjects with patellofemoral pain syndrome
Cowan et al39
Type of study Randomised within subject, controlled clinical trial
Groups Group 1—10 PFPS patients
Group 2—12 asymptomatic controls
Type of taping Subjects completed task under each of 3 conditions:
(1) no tape; (2) placebo tape; (3) therapeutic tape—
included medial tilt and glide, anterior tilt, rotation and fat
pad unloading. Placebo tape—vertical patellar taping
Outcome EMG onset of VMO and VL
measures
Results In PFPS group—therapeutic tape altered temporal
characteristics of VMO and VL activation, placebo tape
had no effect
In asymptomatic group—no change in EMG onset of
VMO and VL with either therapeutic or placebo tape
Pedro score 3/10
EMG, electromyogram; PFPS, patellofemoral pain syndrome; VAS, Visual Analogue Scale; VL, vastus lateralis; VMO, vastus medialis oblique.
described by van Tulder et al38 and previously used by Maher39 in
a systematic review of workplace interventions to prevent low
back pain. This system considers the quality, amount and
consistency of evidence from RCTs:
c Strong evidence: .1 high quality RCT with consistent
outcomes
c Moderate evidence: 1 high quality and 1 low quality RCT
with consistent outcomes
c Limited evidence: 1 high quality or 1 low quality RCT with
consistent outcomes
c No evidence: 1 low quality RCT, no RCTs or inconsistent
outcomes.
Statistical pooling was not possible, because the trials often
did not present sufficient data and, more importantly, there was
not a common set of outcomes across trials. A trial was
considered to be of high quality if it scored at least 5/10 on the
PEDro quality scale.
RESULTS
Efficacy of hip joint musculature strengthening in subjects with
PFPS
No RCTs were identified which investigated the effect of hip
joint strengthening in the treatment of PFPS. Two case reports,
a cohort study and an intervention study were identified.15 40 41
These studies are summarised in table 1. Thus, based on the
system developed by van Tulder et al,38 there is no evidence to
suggest that hip joint strengthening can improve symptoms in
subjects with PFPS.
Efficacy of physiotherapeutic intervention aimed at addressing
quadriceps muscle imbalances in subjects with PFPS
Two RCTs were identified which investigated the effect of
physiotherapeutic interventions aimed at addressing quadriceps
muscle imbalances in subjects with PFPS.23 32 These scored 5/10
and 6/10 on the PEDro scale, respectively. These RCTs are
summarised in table 2. Based on the system developed by van
Tulder et al38 there is strong evidence to suggest that
physiotherapeutic intervention is efficacious in addressing
quadriceps muscle imbalances in subjects with PFPS.
Efficacy of taping for quadriceps muscle activation in subjects
with PFPS
Three RCTs were identified which examined the effect of taping of
quadriceps muscle activation in subjects with PFPS.42–44 These
792
Cowan et al40 Keet et al41
Randomised crossover trial A placebo controlled clinical trial with randomised
interventions
Group 1—10 PFPS patients Group 1—15 PFPS subjects
Group 2—12 asymptomatic patients Group 2—20 healthy subjects
Task carried out under 3 conditions: Each subject carried out tasks during 3 knee taping
(1) therapeutic tape—medial tilt and glide, conditions: (1) no tape; (2) placebo tape—directly
anterior tilt, rotation and fat pad unloading; over patella with no glide (neutral); (3) medial glide
(2) placebo tape; (3) no tape condition tape
EMG amplitude of VMO and VL during VAS, isokinetic and isometric force output, EMG
concentric phase of stair stepping task analysis
No change in amplitude of vasti with either In PFPS group medial taping did not result in a
tape condition in either subject group reduction in pain or an increase in Quads force
Significant decrease in pain in PFPS group Decrease in EMG VMO activity in both groups during
with therapeutic taping step test suggests greater efficiency of VMO
5/10 4/10
scored 3/10, 5/10 and 4/10 on the PEDro scale, respectively. These
RCTs are summarised in table 3. Furthermore, four intervention
studies were identified.45–48 The results of these RCTs are as
follows. The first RCT42 indicated that the use of therapeutic
taping alters the onset timing of the VMO and VL during a stair
stepping task. Before the application of therapeutic taping the
EMG onset of the VMO occurred after the VL in the PFPS group
during both the concentric and eccentric phases of a stair stepping
task, in contrast to a prior and simultaneous onset in the control
group. Following the application of therapeutic taping, onset of
the VMO occurred before that of the VL and simultaneous to that
of the VL during the concentric and eccentric phases of the stair
stepping task, respectively, in subjects with PFPS, with no change
in onset timing in the control group. The second identified RCT43
indicated that therapeutic taping does not produce a change in
VMO or VL amplitude, with the authors concluding that the main
effect of therapeutic taping is not the result of changes in EMG
amplitude but may rather be the result of EMG onset timing.
The results of the third identified RCT44 indicated that the
application of therapeutic taping produced a decrease in both
VMO EMG amplitude and the VMO to VL ratio.
There were no consistent results to be found across the
intervention studies. Thus, there is inconclusive evidence to
suggest that therapeutic patellar taping has any beneficial effect
on quadriceps muscle activation in subjects with PFPS.
Efficacy of open versus closed kinetic chain exercises in
subjects with PFPS
Three RCTS were identified which investigated the use of OKC
and CKC exercises in subjects with PFPS (table 4).33 34 49 These
scored 6/10, 7/10 and 6/10 on the PEDro scale, respectively. The
study by Witvrouw et al34 was a 5 year follow-up of the study
originally conducted by the same author.33 Results of these
RCTs indicted that there is strong evidence to suggest that both
OKC and CKC exercises are beneficial in reducing symptoms
associated with PFPS.
DISCUSSION
Hip joint musculature strength in PFPS
Currently no RCTs exist to suggest that hip joint musculature
strengthening is an efficacious form of treatment for subjects
with PFPS. A number of studies suggest that the hip joint
musculature may play a role in the development of PFPS,19–22
and from a biomechanical point of view there certainly seems to
be some logic in this argument. However, caution must be
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Table 4 Studies investigating the efficacy of open kinetic chain and closed kinetic chain exercises in subjects with patellofemoral pain syndrome
Witvrouw et al31 Witvrouw et al32 Herrington et al46

Type of study Randomised controlled trial
Groups 60 PFPS patients randomly allocated into either 60 PFPS patients randomly allocated into either
OKC (n = 30) or CKC (n = 30) exercise group
Treatment (1) Maximal static quadriceps muscle
contractions
(2) SLR in supine
(3) Inner range quads exercises
(4) Leg adduction exercises in the lateral
decubitus position
3 sets of 10 repetitions, isometric contraction 3 sets of 10 repetitions, isometric contraction held
held for 6 s with a 3 s rest in between
(1) Seated leg presses
(2) One third knee bends on one and both legs
(3) Stationary bicycling
(4) Rowing machine
(5) Step-up/step-down exercises
(6) Programme of jumping exercises
3 sets of 10 repetitions
Outcome 18 VAS scores—at rest and on various activities 18 VAS scores—at rest and on various
measures Kujala scoring scale 0–100
Functional outcome measures
Muscle strength
Muscle length
Measurements taken before and after treatment, Measurements taken before and after treatment
and after 3 months
Results Both groups experienced a significant decrease
in pain and an increase in functional
performance. CKC group received significantly
better functional results in some of the VAS
scores which were not found in the OKC group.
In CKC group, a significant increase in jumping
distance was noted; however no significant
increase noted in OKC group
PEDro score 6/10
CKC, closed kinetic chain; OKC, open kinetic chain; PFPS, patellofemoral pain syndrome; ROM, range of movement; SLR, straight leg raise; VAS, visual analogue scale.
Randomised controlled trial
OKC (n = 30) or CKC (n = 30) exercise group
(1) Maximal static quadriceps muscle
contractions
(2) SLR in supine
(3) Inner range quads exercises
(4) Leg adduction exercises in the lateral decubitus
position
for 6 s with a 3 s rest in between
(1) Seated leg presses
(2) One third knee bends on one and both legs
(3) Stationary bicycling
(4) Rowing machine
(5) Step-up/step-down exercises
(6) Programme of jumping exercises
3 sets of 10 repetitions, 3 s rest between
repetitions
activities
Functional outcome measures
Muscle strength
Muscle length
and again after 5 years
At 5 year follow-up, both groups demonstrated
maintenance of good subjective and functional
outcomes achieved after the treatment
No significant difference was noted between
groups on most parameters examined
On 3 of the 18 VAS recordings, the OKC group
showed significantly fewer complaints compared
to CKC group
7/10
Randomised controlled trial
45 male PFPS patients randomly allocated into 1 of 3
groups:
Group 1—non-weight bearing single joint exercises
(n = 15)
Group 2—weight bearing multiple joint exercise (n = 15)
Group 3—control, no treatment group (n = 15)
Knee extension exercise in sitting position (resistance and
number of sets and repetitions calculated daily based on an
adjustable progressive resistive exercise technique for each
participant)
Seated leg press (resistance and number of sets and
repetitions calculated daily based on an adjustable
progressive resistive exercise technique for each
participant)
Modified Kujala Questionnaire—pain level (ranging from 0–
100) during stair climbing, squatting, running, jumping, and
prolonged sitting. The presence of limp, swelling,
subluxation, muscle atrophy examined as well as knee
ROM deficits and the need for support when walking
VAS on step-up/step-down
Knee extension strength
Measured at start and after 6 weeks rehabilitation
Subjects in both groups showed a statistically significant
decrease in pain and an increase in strength and functional
performance when compared with the control group. No
significant differences were seen between the 2 exercise
groups.
6/10

taken when interpreting the results of such studies. A common
limitation to all these studies lies with the inability of the
authors to distinguish between cause and effect.19 Without
prospective studies on the topic, it is not known whether hip
weakness is a precursor of PFPS or whether it develops as a
result of changes in motor control15 19 or disuse atrophy.19
There is a current need for further intensive research to be
carried out to evaluate the effectiveness of hip joint musculature
strengthening in reducing symptoms associated with PFPS.
Quadriceps muscle imbalances in PFPS
The use of physiotherapeutic intervention seems to be an
efficacious form of treatment for the muscle imbalances
thought to be present in subjects with PFPS, with two high
quality RCTs reporting positive outcomes.23 32 Both of these
studies had very similar types of interventions and indeed come
from the same research group, which is an important
consideration when interpreting the results of these studies.
Thus, further studies are required to examine the most efficient
form of intervention that can achieve the maximum effect.
Also, neither study examined the effect of the intervention on
pain in the recruited subjects as well as lacking a long term
follow-up of subjects.
Effects of taping in PFPS
Currently there is conflicting evidence regarding the efficacy of
therapeutic taping in changing quadriceps muscle activity.
Limitations of identified studies must be considered when
evaluating the results. Variations in sample size exist which
reduces the ability of the authors to detect statistical
significance, with many of the studies being under pow-
ered.44 46 48 A lack of adequate long term follow-up was a
common limitation of most studies reviewed. Further studies
should address not only one single application of tape but
multiple applications over a longer time period.
Conflicting evidence on the effect of taping on muscle
activity suggests that its use in a clinical setting should be
based on an individual patient-to-patient basis with full
attention given to the patient’s specific deficits. Having said
this, much evidence, not reviewed in this study, exists on the
pain relieving effects of patellar taping for PFPS.
Open versus closed kinetic chain exercises
PEDro scale scores for the three reviewed studies ranged from 6–
7/10 suggesting high quality. The study by Herrington et al49
failed to assess the long term effects of OKC versus CKC
exercises in PFPS patients, leaving Witrouw et al33 the only study

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Review
group to have examined this; thus further studies are required to
evaluate the long term effect of both types of intervention. It
was found that at the 5 year follow-up period, 92% of the OKC
group patients were involved in sport compared with only 60%
of the CKC group patients.34 This factor may have contributed
to the slightly better functionality of the OKC group compared
with the CKC group observed during the 3 month and 5 year
follow-up period. Despite the fact that only 20% of the patients
were completely pain-free at the 5 year follow-up in one study,
significant improvements in pain, strength and function were
documented in all studies in both OKC and CKC exercise
groups. The lack of statistically significant differences between
the OKC and CKC groups in these studies highlights the
beneficial effects of both regimens and therefore emphasises a
combined approach in the treatment of PFPS. The results of
these studies therefore reject the frequently encountered
hypothesis that OKC exercises augment symptoms in PFPS
patients.
The issue of long term follow-up of patients with PFPS
Previous research has suggested that the development of PFPS in
childhood or adolescence may not be as self limiting as
previously thought.50 51 A study by Stathopulu et al50 has
indicated that 91% of respondents in their follow-up still had
knee pain. Furthermore this affected daily life in 45% of cases.
The results of this study are supported by the results of a study
by Nimon et al,51 who indicated that about one in four of the
patients originally diagnosed as having PFPS continued to have
significant symptoms up to 20 years after presentation. Thus, it
is vital that future studies evaluate outcome measures over an
extended period of time.
What is already known on this topic
c Subjects with PFPS have been shown to exhibit deficits in hip
joint musculature strength.
c Imbalances in VMO and VL are often addressed in clinical
practice.
c Therapeutic taping of the patellofemoral joint is proposed to
improve the amplitude or timing of VMO EMG or decrease the
amplitude of VL EMG, or both.
c CKC exercises are often preferred to OKC exercises in clinical
practice.
What this study adds
c There are currently no RCTs to support the efficacy of hip joint
musculature strengthening in subjects with PFPS. However, a
number of intervention studies do support its use in clinical
practice.
c Physiotherapy intervention programmes appear to be an
efficacious form of intervention for addressing quadriceps
muscle imbalances.
c Further studies are required to determine the true efficacy of
therapeutic patellar taping as it applies to VMO and VL
activation patterns.
c Both OKC and CKC exercises appear to be appropriate forms of
treatment for subjects with PFPS.
794
Conclusions
Although no RCTs exist to support the use of hip joint
musculature strengthening as an efficacious form of treatment
for subjects with PFPS, the results of a number of case studies do
support the use of hip joint musculature strengthening for the
treatment of patients found to have hip strength deficits in
association with PFPS.
Based on the results of reviewed studies, quadriceps retraining
is, however, associated with good clinical outcomes in patients
found to have VMO impairments and can therefore be
recommended to therapists. Limited evidence exists supporting
the use of patellar taping techniques in changing the amplitude
or onset timing of the VMO relative to the VL. Refuting the
common misconception that PFPS patients should not be
treated with OKC exercises, the results of this study support
the use of both OKC and CKC forms of exercise. Both have been
shown to reduce pain, increase strength and ultimately improve
function in subjects with PFPS. A combined approach is
recommended.
In order for an accurate diagnosis, appropriate treatment
plans and optimal clinical results, it is important to understand
the neuromuscular mechanisms and causes of patients’ patello-
femoral pain. Looking beyond the patellofemoral joint, at the
rest of the lower extremity kinetic chain, may reveal the source
of the patients’ problems. According to the current literature on
this topic, the use of a combination of interventions based on
the specific causes of the patients’ symptoms is recommended.
Competing interests: None.
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New education sections for BJSM

We are delighted to introduce two new education sections for the journal: the Pictorial Essay and the
I-Test being coordinated by Senior Associate Editor Dr Babette Pluim, with support from radiologists
Bruce Forster and Mario Maas.
Pictorial Essays are highly-illustrated articles (x rays, CT, MRI, etc) with limited text and related
multiple choice questions; I-Tests (or Imaging Tests) are very brief ‘‘what’s your diagnosis’’ articles.
The articles and answers will appear in the same issue of the journal (but obviously not on the same
page!) and we aim to work with BMJ Learning (learning.bmj.com) to create an interactive online
resource for practitioners in sports medicine.
We encourage you to submit your articles for these sections following the instructions for authors
http://bjsm.bmj.com/ifora/article_type.dtl and we welcome your feedback on this initiative
(bjsm@bmjgroup.com).

Br J Sports Med 2008;42:789–795. doi:10.1136/bjsm.2008.046623 795

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PostScript
CORRECTION
There was an error in the pagination of the
articles published in the October and
November 2008 issues of the journal. Please
see a corrected list of citations below. The
journal apologises for this error.
Khan KM. Preventing ACL injuries, turning
research into practice and avoiding media
ambush. Br J Sports Med 2008;42:483–4.
should be Khan KM. Preventing ACL
injuries, turning research into practice and
avoiding media ambush. Br J Sports Med
2008;42:783–4.
Gregory PL, Seah R, Pollock N. What to tell
the media—or not: consensus guidelines for
sports physicians. Br J Sports Med
2008;42:485–8. should be Gregory PL,
Seah R, Pollock N. What to tell the
media—or not: consensus guidelines for
sports physicians. Br J Sports Med
2008;42:785–8.
Fagan V, Delahunt E. Patellofemoral pain
syndrome: a review on the associated
neuromuscular deficits and current treat-
ment options. Br J Sports Med 2008;42:489–
95. should be Fagan V, Delahunt E.
Patellofemoral pain syndrome: a review on
the associated neuromuscular deficits and
current treatment options. Br J Sports Med
2008;42:789–95.
Beltrami FG, Hew-Butler T, Noakes TD.
Drinking policies and exercise-associated
hyponatraemia: is anyone still promoting
overdrinking? Br J Sports Med 2008;42:496–
501. should be Beltrami FG, Hew-Butler T,
Noakes TD. Drinking policies and exercise-
associated hyponatraemia: is anyone still
promoting overdrinking? Br J Sports Med
2008;42:796–801.
Diehl JJ, Pirozzolo JJ, Best TM. The practice
of primary care sports medicine in the USA.
Br J Sports Med 2008;42:506–9. should be
Diehl JJ, Pirozzolo JJ, Best TM. The practice
of primary care sports medicine in the USA.
Br J Sports Med 2008;42:806–8.
Hides J, Stanton W, Freke M, et al. MRI
study of the size, symmetry and function of
the trunk muscles among elite cricketers
with and without low back pain. Br J Sports
Med 2008;42:509–13. should be Hides J,
Stanton W, Freke M, et al. MRI study of the
size, symmetry and function of the trunk
muscles among elite cricketers with and
without low back pain. Br J Sports Med
2008;42:809–13.
Kukidome T, Shirai K, Kubo J, et al. MRI
evaluation of body composition changes in
wrestlers undergoing rapid weight loss. Br J
Sports Med 2008;42:514–18. should be
Kukidome T, Shirai K, Kubo J, et al. MRI
evaluation of body composition changes in
wrestlers undergoing rapid weight loss. Br J
Sports Med 2008;42:814–18.
310
Zhang Y, Lin Z, Hu Y, et al. Effect of
Ganoderma lucidum capsules on T lympho-
cyte subsets in football on ‘‘living high—
training low’’. Br J Sports Med 2009;42:
519–22. should be Zhang Y, Lin Z, Hu Y, et
al. Effect of Ganoderma lucidum capsules on
T lymphocyte subsets in football on ‘‘living
high—training low’’. Br J Sports Med
2009;42:819–22.
Edwards AM, Wells C, Butterly R.
Concurrent inspiratory muscle and cardio-
vascular training differentially improves
both perceptions of effort and 5000m run-
ning performance compared with cardiovas-
cular training alone. Br J Sports Med
2009;42:523–7. should be Edwards AM,
Wells C, Butterly R. Concurrent inspiratory
muscle and cardiovascular training differen-
tially improves both perceptions of effort
and 5000m running performance compared
with cardiovascular training alone. Br J
Sports Med 2009;42:823–7.
Baron B, Noakes TD, Dekerle J, et al. Why
does exercise terminate at the maximal
lactate steady state intensity? Br J Sports
Med 2008;42:528–33. should be Baron B,
Noakes TD, Dekerle J, et al. Why does
exercise terminate at the maximal lactate
steady state intensity? Br J Sports Med
2008;42:828–33.
Ogai R, Yamane M, Matsumoto T, et al.
Effects of petrissage massage on fatigue and
exercise performance following intensive
cycle pedalling. Br J Sports Med
2008;42:534–8. should be Ogai R, Yamane
M, Matsumoto T, et al. Effects of petrissage
massage on fatigue and exercise performance
following intensive cycle pedalling. Br J
Sports Med 2008;42:834–8.
Sandrock M, Schulze C, Schmitz D, et al.
Physical activity throughout life reduces the
atherosclerotic wall process in the carotid
artery. Br J Sports Med 2008;42:539–44.
should be Sandrock M, Schulze C,
Schmitz D, et al. Physical activity through-
out life reduces the atherosclerotic wall
process in the carotid artery. Br J Sports
Med 2008;42:839–44.
Ferrari M, Bonella F, Benini L, et al. Acid
reflux into the oesophagus does not influ-
ence exercise-induced airway narrowing in
bronchial asthma. Br J Sports Med
2008;42:545–9. should be Ferrari M,
Bonella F, Benini L, et al. Acid reflux into
the oesophagus does not influence exercise-
induced airway narrowing in bronchial
asthma. Br J Sports Med 2008;42:845–9.
Randolph CC. Commentary on Acid reflux
into the oesophagus does not influence
exercise-induced airway narrowing in bron-
chial asthma. Br J Sports Med 2008;42:549–
50. should be Randolph CC. Commentary
on Acid reflux into the oesophagus does not
influence exercise-induced airway narrowing
in bronchial asthma. Br J Sports Med
2008;42:849–50.
Bradshaw CJ, Bundy M, Falvey E. The
diagnosis of longstanding groin pain: a
prospective clinical cohort study. Br J Sports
Med 2008;42:551–4. should be Bradshaw
CJ, Bundy M, Falvey E. The diagnosis of
longstanding groin pain: a prospective
clinical cohort study. Br J Sports Med
2008;42:851–4.
Zoumalan CI, Blumenkranz MS, McCulley
TJ, et al. Severe surfing-related ocular inju-
ries: the Stanford Northern Californian
experience. Br J Sports Med 2008;42:555–7.
should be Zoumalan CI, Blumenkranz MS,
McCulley TJ, et al. Severe surfing-related
ocular injuries: the Stanford Northern
Californian experience. Br J Sports Med
2008;42:855–7.
Banffi G, Krajewska M, Melegati G, et al.
Effects of whole-body cryotherapy on hae-
matological values in athletes. Br J Sports
Med 2008;42:558. should be Banffi G,
Krajewska M, Melegati G, et al. Effects of
whole-body cryotherapy on haematological
values in athletes. Br J Sports Med
2008;42:858.
Schwellnus M. SportsMedUpdate. Br J
Sports Med 2008;42:559–60. should be
Schwellnus M. SportsMedUpdate. Br J
Sports Med 2008;42:859–60.
Khan KM. Debating transversus abdominis,
the ‘‘exercise pill’’ and whether flying limits
athletes’ performance on arrival. Br J Sports
Med 2008;42:561. should be Khan KM.
Debating transversus abdominis, the ‘‘exer-
cise pill’’ and whether flying limits athletes’
performance on arrival. Br J Sports Med
2008;42:861.
Warden SJ, Fuchs RK. Are ‘‘exercise pills’’
the answer to the growing problem of
physical inactivity? Br J Sports Med
2008;42:562–3. should be Warden SJ,
Fuchs RK. Are ‘‘exercise pills’’ the answer
to the growing problem of physical inactiv-
ity? Br J Sports Med 2008;42:862–3.
Cook J. Jumping on bandwagons: taking the
right clinical message from research. Br J
Sports Med 2008;42:563. should be Cook J.
Jumping on bandwagons: taking the right
clinical message from research. Br J Sports
Med 2008;42:863.
Kuipers H, Van’t Hullenaar GAC, Pluim
BM, et al. Four weeks’ corticosteroid inhala-
tion does not augment maximal power
output in endurance athletes. Br J Sports
Med 2008;42:568–71. should be Kuipers H,
Van’t Hullenaar GAC, Pluim BM, et al. Four
weeks’ corticosteroid inhalation does not
augment maximal power output in endur-
ance athletes. Br J Sports Med 2008;42:
868–71.
du Toit C, Stieler M, Saunders R, et al.
Diagnostic accuracy of power Doppler ultra-
sound in patients with chronic tennis elbow.
Br J Sports Med 2008;42:572–6. should be du
Toit C, Stieler M, Saunders R, et al.
Br J Sports Med April 2009 Vol 43 No 4
 Downloaded from bjsm.bmj.com on May 23, 2013 - Published by group.bmj.com
Diagnostic accuracy of power Doppler ultra-
sound in patients with chronic tennis elbow.
Br J Sports Med 2008;42:872–6.
Geertsema C, Williams AB, Dzendrowskyj
P, et al. Effect of commercial airline travel on
oxygen saturation in athletes. Br J Sports
Med 2008;42:577–81. should be Geertsema
C, Williams AB, Dzendrowskyj P, et al.
Effect of commercial airline travel on oxygen
saturation in athletes. Br J Sports Med
2008;42:877–81.
Gratze G, Mayer H, Luft FC, et al.
Determinants of fast marathon perfor-
mance: low basal sympathetic drive,
enhanced postcompetition vasodilation and
preserved cardiac performance after compe-
tition. Br J Sports Med 2008;42:582–8. should
be Gratze G, Mayer H, Luft FC, et al.
Determinants of fast marathon perfor-
mance: low basal sympathetic drive,
enhanced postcompetition vasodilation and
preserved cardiac performance after compe-
tition. Br J Sports Med 2008;42:882–8.
Bessa A, Nissenbaum M, Monteiro A, et al.
High-intensity ultraendurance promotes
early release of muscle injury markers. Br J
Sports Med 2009;42:589–93. should be Bessa
A, Nissenbaum M, Monteiro A, et al. High-
intensity ultraendurance promotes early
release of muscle injury markers. Br J Sports
Med 2009;42:889–93.
Borrione P, Rizzo M, Spaccamiglio A, et al.
Sport-related hyperhomocysteinaemia: a
Br J Sports Med April 2009 Vol 43 No 4
putative marker of muscular demand to be
noted for cardiovascular risk. Br J Sports Med
2008;42:594–600. should be Borrione P,
Rizzo M, Spaccamiglio A, et al. Sport-related
hyperhomocysteinaemia: a putative marker
of muscular demand to be noted for
cardiovascular risk. Br J Sports Med
2008;42:894–900.
Stamatakis E, Chaudhury M. Temporal
trends in adults’ sports participation pat-
terns in England between 1997 and 2006: the
Health Survey for England. Br J Sports Med
2008;42:601–8. should be Stamatakis E,
Chaudhury M. Temporal trends in adults’
sports participation patterns in England
between 1997 and 2006: the Health Survey
for England. Br J Sports Med 2008;42:
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Nichols AW. Sports medicine clinical trial
research publications in academic medical
journals between 1996 and 2005: an audit of
the PubMed MEDLINE database. Br J Sports
Med 2008;42:609–21. should be Nichols
AW. Sports medicine clinical trial research
publications in academic medical journals
between 1996 and 2005: an audit of the
PubMed MEDLINE database. Br J Sports Med
2008;42:909–21.
Shimada H, Suzuki T, Kimura Y, et al.
Effects of an automated stride assistance
system on walking parameters and muscular
glucose metabolism in elderly adults. Br J
Sports Med 2008;42:622–29. should be
PostScript
Shimada H, Suzuki T, Kimura Y, et al.
Effects of an automated stride assistance
system on walking parameters and muscular
glucose metabolism in elderly adults. Br J
Sports Med 2008;42:922–9.
Allison GT, Morris SL. Transversus abdo-
minis and core stability: has the pendulum
swung? Br J Sports Med 2008;42:630–1.
should be Allison GT, Morris SL.
Transversus abdominis and core stability:
has the pendulum swung? Br J Sports Med
2008;42:930–1.
Kasahara S, Mashiko H, Niwa S-I. Superior
performance in WAIS-R block design among
top-level rugby players. Br J Sports Med
2008;42:632–3. should be Kasahara S,
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in WAIS-R block design among top-level
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Blatteau J-E, Pény C, Pontier J-M, et al.
Influence of repetitive open sea dives and
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in healthy divers. Br J Sports Med
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311
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Patellofemoral pain syndrome: a review on

the associated neuromuscular deficits and
current treatment options
V Fagan and E Delahunt

Br J Sports Med 2008 42: 789-795 originally published online April 18,
2008
doi: 10.1136/bjsm.2008.046623

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