Proximal Exercises are Effective in Treating Patellofemoral Pain Syndrome: A Systematic Review
Peters JSJ & Tyson NL. International Journal of Sports Physical Therapy. 2013; 8 (5): 689-700. PMCID: PMC3811739
Take Home Message: Hip exercises consistently provide greater improvements for PFPS than knee exercises alone. However, any exercise provides alleviation from PFPS.
Patellofemoral pain syndrome (PFPS) is relatively common and a disabling condition. We often opt for conservative management, yet it remains unclear which exercises may yield the best results This systematic review evaluated the effectiveness of proximal strengthening exercises (lumbar, pelvic, & hip exercises) in comparison with knee-only strengthening exercises. The authors identified 8 relevant articles that met the inclusion criteria (studies on adults or adolescents with PFPS who underwent exercise programs focused on proximal OR knee musculature and reported functional outcomes). The authors then evaluated the methodological quality and extracted key data from each study. All studies were of moderate to high quality – three were randomized clinical trials. On average, the 4 studies that utilized proximal exercises demonstrated a 65.1% reduction in pain levels and a 37.5% improvement in function while only 3 of the 4 studies that focused on knee exercises demonstrated an improvement. Overall studies focused on knee exercises only found an average reduction of 36.8% in pain and a 20.5% improvement in function. Among the studies that focused on proximal exercises, all four targeted hip muscles with single joint movements (e.g., hip abduction), 1 included lumbo-pelvic exercises, and 2 included stretching.
Nearly all exercises provided some relief of pain; however, proximal exercises consistently and drastically alleviated symptoms associated with PFPS. This information confirms to clinicians that some form of activity is better than nothing. Despite pain or an inability to perform certain exercises, modifications should be made, and exercises should focus on strengthening the areas that a patient is able to. Furthermore, most of the proximal exercises can easily be done without the need for expensive equipment, which is commonly needed for knee exercises. The results of this review should be interpreted with caution as they did not focus on studies that did a direct comparison of proximal and knee exercises. Another limitation recognized by the authors was that interventions are recommended to be daily with 2 to 4 sets of 10 repetitions for more for six or more weeks; however, more than half of the included studies did less than this. The studies included a variety of length of programs, exercises, participants, and randomization among included studies, which can make interpreting the results challenging. There is a need for more high quality research to compare standardized exercise protocols that meet minimum recommendations. However, despite these limitations proximal exercises seem to be a good selection for addressing symptoms associated with PFPS.
Questions for Discussion: Given the multifactorial etiology of PFPS, are there any other variables that you have found to be potential culprits other than hip strength? Has anyone seen or addressed distal (foot/ankle) interventions to alleviate PFPS?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban