Sports Medicine Research: In the Lab & In the Field: Rehabilitation + Manual Therapy = Reduced Patellofemoral Pain (Sports Med Res)


Wednesday, July 5, 2017

Rehabilitation + Manual Therapy = Reduced Patellofemoral Pain

Effectiveness of Manual Therapy Combined With Physical Therapy in Treatment of
Patellofemoral Pain Syndrome: Systematic Review

Espi-Lopez GV, Amal-Gomez A, Balasch-Bernat M, & Ingles M. J Chiropr Med. 2017; 16(2): 139-146.

Take Home Message: Rehabilitation with manual therapy are effective at managing patellofemoral pain syndrome.  The benefits are further augmented when the hip is targeted in rehabilitation. 

Patellofemoral pain syndrome (PFPS) is a common cause of knee pain in the athletic and physically active populations.  Treatment and management can be challenging, but often include therapeutic exercises, in addition to other approaches such as anti-inflammatory medication, taping/supporting, and manual therapy.  The authors conducted a systematic review of randomized controlled clinical trials to determine if manual therapy with other rehabilitation components (e.g, therapeutic exercises, taping, modalities) was effective at managing PFPS.   The authors included “high quality” trials (Jadad score ≥3 out of 5) conducted within the last 10 years on adults with PFPS.  The 5 included studies investigated a variety of manual therapy techniques including mobilizations, stretching, & proprioceptive neuromuscular facilitation (PNF) stretching.  Overall, the authors reported that rehabilitation components combined with manual therapy is effective at reducing pain affiliated with PFPS.  The pain relief was further aided when the treatment targeted other joints in the closed kinetic chain, such as hip strengthening.

Clinically, the findings of this review confirm that a multi-modal and multi-joint approach are beneficial when dealing with PFPS.  The trials explored a variety of manual therapy techniques, which prevented the authors from doing a meta-analysis to determine which technique was most effective.  There is a need to investigate certain approaches rather than an all-encompassing “manual therapy” group.  Stretching was deemed a manual therapy, however, it is much different than mobilizations.  It would be interesting to see whether self-stretching versus clinician-guided stretching were drastically different.  The authors of this study echoed previous findings that an approach that includes the entire lower extremity kinetic chain is important in managing PFPS.  However, there is still more comparison needed as to whether the addition of manual therapy is better than just rehabilitation alone.  It would also be interesting to see if joint mobilizations (or other manual therapy techniques) applied to the hip or ankle joints would have an effect on pain associated with PFPS.  Ultimately, this systematic review confirms that our patients with PFPS can benefit from a rehabilitation program for the entire kinetic chain that includes manual therapy techniques.

Questions for Discussion:  What exercises are you sure to include when dealing with PFPS?  What manual therapy techniques have you found to provide relief in dealing with PFPS? 

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Note: The last two courses are still pending review for EBP CEU status but are available for regular BOC CEUs.


Amy Virostek said...

Thank you for this article! It was very interesting to see a compilation of patellofemoral pain syndrome research and information. I have seen an anterior to posterior hip joint mobilization to be effective in a track and field hurdler who experienced knee pain while hurdling and stiffness during the day, especially while walking up stairs. The joint mobilization relieved the pain caused by the hip external rotation, and was maintained with stretches and rehabilitation, focusing on the hip and external rotation. I will keep in mind the other techniques shown to be effective in your review for my clinical practice, thank you!

Kate Hill said...

Thanks for this article! It was very informative and made me re-think about my typical practice. It was very interesting to see that the manual therapy used over the entire kinetic chain can be helpful in decreasing pain in people with PFPS. Although it makes sense and should be obvious since everything is in the kinetic chain I feel as if sometimes we just look at the specific location and just treat the injury rather than looking at the whole body. I also liked how some rehabilitation programs incorporated not only quadricep strengthening exercises but gluteal, and hip musculature exercises as well. In my experience I have used a rehabilitation similar in track athletes with PFPS and have seen great results.

Nicole Cattano said...

Amy - thank you for sharing what worked for the athlete that you worked with. Just curious- was she limited in any hip ROM other than ER? I like hip mobilizations for many hip pathologies but you bring up a great point about remembering the entire kinetic chain. When mobilizing the hip - what grades did you use and what was your positioning (how much hip flexion and do you like to use a belt)?

Juliana Jimenez said...

Nicole thank you for writing this review. I am a huge fan of incorporating manual therapy techniques in my clinical practice! I like the idea of working up the kinetic chain and targeting the hip joint as well. I would be curious to see if there would be even better results by incorporating rehabilitation exercises higher up the kinetic chain and targeting core stabilization. I would also love to see more research with the manual therapy techniques. I have seen Active Release Technique on different quadricep muscles work very well for basketball players with PFPS.

Nicole Cattano said...

Juliana I couldn't agree with you more that the CORE is KEY! The hip rehabilitation has been well-established to be effective. But thinking about manual therapy at that joint is exciting too.

I think the problem with researching manual therapy is targeting a specific pathology, it is very time intensive, and is difficult to standardize force of pull, positioning, etc. But I do agree that more research would be beneficial.

What active release technique did you use on the basketball players with PFPS? (I love having many tools in my clinical toolbox to try on patients.)

Allison Wagner said...

This article is very thought provoking. I completely agree with the multi-modal and multi-joint approach! It seems that everyone is looking for the be-all-end-all, when so many problems are multi-factorial. If there are several causes to an injury, why not have several interventions. I am also a big fan of manual therapy, especially when thrown in with other methods. I would also love to see if there is a difference between self-stretching and clinician-guided stretching. Thank you for this article!

Nicole Cattano said...

Allison- thanks for your comments. Multimodal approaches seem to be good, however the concern is once it becomes to "just do everything" and virtually throwing the kitchen sink at the patient, then it is hard to justify as to what actually helped make their symptoms better. Especially with the potential or possibility of third-party reimbursement and patient-reported outcomes starting to become involved.

There are some articles out there on self stretching vs position guided stretching. The only real benefits that I have seen or when there is a mobilization in combination with a stretch. Unfortunately, many patients enjoy passive stretching or other treatments and I would rather teach them how to help themselves. It seems to be more sustainable long-term.

Kim Twait said...

When rehabbing an athlete with PFPS, I usually focus most of the exercises at the hip with the hip abductors. I have found great results with this approach with added superior-inferior and medial-lateral patellofemoral mobilizations. And I agree with Allie about seeing if there is a difference in ROM after an athlete self-stretches compared to a clinician stretching the athlete. Thank you for the article!

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