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Six treatments have positive effects at 3 months for people with patellofemoral pain: asystematic review with meta-analysis
Key Points
- Six interventions were found to improve pain and function in the short term (i.e. at 3 months).
- There was a lack of high-quality evidence for longer term outcomes.
- Combined approaches and ‘active rehabilitation’ should be considered rather than a ‘wait-and-see’ approach.
BACKGROUND & OBJECTIVE
Patellofemoral Pain (PFP) is a common condition which can result in persistent pain. Despite recent guidelines and systematic reviews, the efficacy of non-surgical treatment options remains unclear.
This systematic review and meta-analysis sought to address this by synthesizing data from high quality randomized controlled trials (RCTs) using broader eligibility criteria than previous reviews.
For patellofemoral pain it makes sense to prioritize active over passive treatments to empower the patient to successfully manage this condition.
METHODS
- A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.
- MEDLINE, Web of Science, and Scopus were searched using appropriate key terms (as guided by previous research in this field).
- Additional references were also identified using Google Scholar and by hand searching the reference list of eligible studies.
- Only data from RCTs with adequate quality were included and synthesized in this review.
- Methodological quality was assessed using the PEDro Scale and studies that scored 7 or above were included.
- The use of clear diagnostic criteria in trials was appraised and efficacy and certainty of evidence were also assessed. Meta-analysis was performed where studies were considered to be ‘methodologically homogeneous and treatment modalities comparable’.
RESULTS
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170 RCTs were identified that were eligible to be appraised.
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105 were excluded as they were of low quality, 65 trials were included within the review with a total of 3796 participants.
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Some interventions had no indication for efficacy and the authors commented that, “There is no role for dry needling, vibration therapy, or hyaluronic acid injection combined with exercise therapy when treating PFP”
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Twenty interventions were inadequately tested so their efficacy is currently unclear.These included education, patellar bracing and step rate retraining.
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Six interventions improved pain and function in the short term (at 3 months) for people with persistent PFP:
- Knee-targeted exercise
- Combined interventions
- Foot orthoses
- Lower-quadrant manual therapy
- Knee-targeted exercise combined with perineural dextrose injection
- Hip-and-knee-targeted exercise
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Interventions 1, 2, 3 and 4 from this list demonstrated primary proof of efficacy (a significant difference compared to sham/ placebo).
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The remaining 2 (numbers 5 and 6) had secondary proof of efficacy (a significant difference when compared to an intervention with primary proof of efficacy).
LIMITATIONS
The minimum mean symptom duration of the included RCTs was 6 months so no firm conclusions can be made about these treatment options for patients with a shorter duration of symptoms.
There is a lack of high quality RCTs examining long term outcomes in PFP and likely to be significant differences in individual responses to any specific treatment.
CLINICAL IMPLICATIONS
The authors concluded that a ‘wait-and-see’ approach is not indicated for patients with persistent PFP given that a number of interventions have been found to be effective, if only in the short term. Instead, patients should be offered ‘active rehabilitation’.
They also recommend an honest and open discussion with patients about the treatment options and the current lack of evidence of long-term efficacy. Patients can then make informed choices about their care.
It does appear that combined interventions may be more effective than a stand-alone treatment. Alongside patient preference our assessment can help guide treatment selection, although the review mentions that our ability to predict responses may be limited.
A clinical example may be a patient who presents with reduced strength in the quadriceps and gluteal muscles on assessment. They report pain on a single leg squat which is then reduced significantly when it is repeated with an orthosis within their footwear. A combined intervention of hip and knee exercises alongside orthoses could be discussed with the patient and justified as a treatment approach.
Research in PFP has reported that while hip strength improved after hip exercise, strength did not mediate improvements in pain (1). So, questions remain about the mechanism of effect and how accurate our current assessment approaches are in identifying rehab needs.
As there appears to be little benefit of dry needling or vibration therapy in PFP it makes sense to prioritize active over passive treatments to empower the patient to successfully manage this condition. This is in line with previous research recommendations (2) which also recommend education and activity modification. These appear key in clinical practice, but we must be aware that there is little high-quality evidence to support them at present.
+STUDY REFERENCE
SUPPORTING REFERENCE
- Holden S, Matthews M, Rathleff MS, Kasza J; Fohx Group, Vicenzino B. How Do Hip Exercises Improve Pain in Individuals With Patellofemoral Pain? Secondary Mediation Analysis of Strength and Psychological Factors as Mechanisms. J Orthop Sports Phys Ther. 2021 Dec;51(12):602-610.
- Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. The 'Best Practice Guide to Conservative Management of Patellofemoral Pain': incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med. 2015 Jul;49(14):923-34.
