DOI 10.1007/s40279-014-0231-5
SYSTEMATIC REVIEW
Dylan Morrissey
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1704 S. Lack et al.
reflex response time (p = 0.026), negative patella appre- landing have been identified as predictors of PFP devel-
hension, absence of chondromalacia patella, tibial tubercle opment [6]. Most of these studies utilized military popu-
deviation of \14.6 mm and greater total quadriceps cross- lations with resultant limited generalizability to most
sectional area on magnetic resonance imaging (p = 0.01), clinical populations. Put together, the findings from these
and reduced eccentric average quadriceps peak torque reviews highlight both the multifactorial nature of PFP and
(p = 0.015) significantly predicted exercise intervention the diversity of presenting characteristics that could be
success following multivariate statistical analysis. Limited addressed by treatment [6, 7].
evidence identified increased Q-angle (mean 0.38, 95 % CI Proximal [8–11], distal [12] and local [13, 14] inter-
0.05–0.72) and very limited evidence identified greater ventions have all demonstrated favourable PFP treatment
usual pain (mean 0.43, 95 % CI 0.01–0.85) to predict outcomes. Multimodal physiotherapy, including a combi-
taping intervention success. nation of patella taping, vasti retraining, gluteal strength-
Conclusions This systematic review provides a compre- ening, patella mobilisation and stretches, remains the gold
hensive summary of current derivation level studies iden- standard treatment option with the strongest reported evi-
tifying indicators of prediction for conservative PFP dence base [15]. Considering the multifactorial nature of
management. The overall strength of evidence was low. PFP, greater intervention efficacy could be achieved
With appropriate caution, clinicians should consider taping through better selection of treatment for a given patient,
for those with greater usual pain, orthoses for older indi- therefore improving clinical outcomes and future research.
viduals and exercise for younger individuals, and orthoses Furthermore, identification of outcome predictors that
intervention for patients with greater forefoot valgus and guide tailored intervention packages may reduce recur-
rearfoot eversion magnitude peak. RCTs with evaluation of rence, known to be high [16, 17].
outcome prediction as a primary aim are clearly warranted It is important to consider overall prognosis differently
to provide clinicians with robust evidence and facilitate from outcome prediction. For example, a retrospective
evidence-informed, tailored intervention to this heteroge- analysis of two high-quality (HQ), randomised controlled
neous patient population. trials (RCTs) described the characteristics of the 55 % of
individuals with PFP who had unfavourable overall out-
come from multimodal packages of care at 3 months and
1 Introduction 40 % at 12 months [18]. This prognostic analysis would
not guide clinicians’ specific intervention choice as a
Patellofemoral pain (PFP) has a high prevalence within function of positive outcome. Evaluating outcome predic-
both sporting and recreationally active populations [1, 2]. tors to identify subgroups likely to respond to specific
Among 2,002 patients presenting to a sports medicine interventions has therefore received increased attention in
clinic with running-related injuries, 842 (42.1 %) reported the literature in recent years [19–32]. Consequently, the
knee pain, with 331 (46 %) being diagnosed with PFP [2]. aim of this review was to identify potential outcome pre-
PFP is characterised by the gradual onset of diffuse pain in dictors for conservative interventions in the management of
the retropatellar or peripatellar region that is aggravated PFP in order to guide clinicians when considering the
during tasks that increase patellofemoral joint (PFJ) load- likelihood of intervention success and steer the direction of
ing (e.g. running, jumping, squatting) [3]. future research in this area.
Development and persistence of PFP is widely consid-
ered to be multifactorial [4], with both extrinsic and
intrinsic factors thought to contribute. Proposed extrinsic 2 Methods
factors include excessive training load, altered training
surface and/or inappropriate footwear. Proposed intrinsic 2.1 Inclusion and Exclusion Criteria
factors can be divided into local (around the knee), prox-
imal (thigh, hip, trunk or pelvis), and distal (foot and lower Eligibility criteria were modified from a published review
leg) characteristics [5, 6]. of musculoskeletal clinical prediction rules [33]. These
Larger quadriceps angle, sulcus sign, patella tilt angle, included peer-reviewed journal publication, the primary
and lower peak torque knee extension, hip abduction and study aim being development or evaluation of outcome
external rotation strength have proven association with PFP predictors, application to treatment selection for patients
[7]. However, these studies have methodological weak- with PFP, and clear evidence that the measurement tool was
nesses and the cross-sectional design inhibits determination appropriate to the evaluated outcome predictor (e.g. use of
of causality. Prospectively, limited quadriceps and gas- the Kujala pain questionnaire as an outcome measure for
trocnemius flexibility, knee extension weakness and individuals with PFP [34]). Unpublished work was not
increased knee valgus moment at initial contact when sought. Only papers published in English were considered.
123
Outcome Predictors for Patellofemoral Pain Management 1705
2.2 Search Strategy [standardised mean difference] and risk ratio calculations,
respectively, using Review Manager (RevMan v5.1, 2011,
The AMED, CINAHL, EMBASE, MEDLINE and Web of The Cochrane Collaboration, Copenhagen, Denmark). ES
Science databases were searched from inception up to and the associated 95 % confidence intervals (CIs) were
April 2013. The keyword ‘predict*.ti ab.’ was used in presented as forest plots to facilitate visual comparison.
combination with keywords relating to PFP to capture Where two or more outcome predictors and success deter-
papers relating to the development of clinical prediction minants were consistent between studies, data was pooled.
rules. The search criteria were modified from a previous Pooled results were reported as significant when the test for
PFP systematic review that evaluated the scope and quality overall effect (Z score) was p \ 0.05, and as a trend when
of systematic reviews on non-pharmacological conserva- p \ 0.1. Determinants of success were considered consis-
tive treatment for PFP [35]. The search strategy and results tent if a justified, clinically meaningful measure was used in
are reported in the electronic supplementary material the two or more studies pooled (e.g. ‘Marked improvement’
(ESM) Table S1. Citing, and cited, references were sur- on a 5-point Likert scale). If adequate data was not available
veyed in Google scholar and at source, respectively. to complete calculations from published reports, attempts
were made to contact corresponding authors. Where treat-
2.3 Review Process ment success was not defined, baseline measures of poten-
tial outcome predictors reported to significantly predict
All titles and abstracts found were downloaded into End- change of the primary outcome through multivariate sta-
note X4 (Thomson Reuters, Philadelphia, PA, USA), tistical analysis, were extracted. The primary outcome used
search returns collated and duplicates removed. Potential for each study is presented in Table 1.
papers were assessed by two independent reviewers (SL Interpretation of calculated individual or pooled ES
and CB) using an inclusion criteria checklist. If sufficient were categorised based on those used by Hume et al. [37]
information could not be obtained from the title and as small (B0.59), medium (0.60–1.19), or large (C1.20).
abstract, the full text was obtained for further evaluation. The level of statistical heterogeneity, defined as p \ 0.05,
Any disagreements were resolved by consensus, and a third for pooled data was established using the Chi-square and I2
reviewer (DM) was available if needed, but was not statistics. Definitions for ‘levels of evidence’ were guided
required. by recommendations made by van Tulder et al. [38].
Strong evidence = pooled results derived from three or
2.4 Quality Assessment of Reviews more studies, including a minimum of two HQ studies,
which are statistically homogenous (p [ 0.05)—may be
Methodological quality was assessed with a scale (ESM associated with a statistically significant or non-significant
Table S2) used previously for a PFP systematic review pooled result.
[36], and applied by two reviewers independently (SL and Moderate evidence = statistically significant pooled
CB), with discrepancies resolved by discussion, and a third results derived from multiple studies, including at least one
reviewer (DM) was available if required. The quality HQ study, which are statistically heterogeneous (p \ 0.05),
assessment scale consisted of 19 items divided into four or from multiple LQ studies which are statistically
components—participants, interventions, outcome mea- homogenous (p [ 0.05).
sures and data presentations. With RCTs considered the Limited evidence = results from multiple LQ studies
gold standard of predictor analysis, the scale is scored out which are statistically heterogeneous (p \ 0.05), or from
of 40, with the total possible score given as a percentage. one HQ study.
Scores C70 % were considered to be ‘high quality’ and Very limited evidence = results from one LQ study.
scores \70 % considered to be ‘low quality’. Conflicting evidence = pooled results insignificant and
derived from multiple studies, regardless of quality, which
2.5 Data Extraction and Analysis are statistically heterogeneous (p \ 0.05, i.e. inconsistent).
123
Table 1 Study design characteristics for each included study
1706
Study Sample size Treatment No. of Statistical analysis used Outcome measures Success Determinant Length of Significant predictors of
variables for prediction defined of success follow-up intervention success
123
tested Y/N
Kannus and 49 Rest 22 Forward stepping VAS N NA 6 weeks and Younger age at both 6 weeks
Niittymaki NSAIDs regression analysis Lysholm 6 months and 6 months
[31]
Quadriceps Tegner
strength
For 6/52
Natri et al. [26] 49 Rest 19 Forward stepping VAS N NA 7 years Negative patellar
NSAIDs regression analysis Lysholm apprehension test
Quadriceps Tegner
strength
For 6/52
Witvrouw et al. 30 Seated leg press 13 Multiple stepwise Kujala N NA 5 weeks and Faster reflex response time
[27] 2/1 knee bends regression analysis 3 months vastus medialis oblique
Stationary bike Shorter duration of symptoms
Rowing machine
Step up and down
Progressive
jumping
For 5/52
Selfe et al. [29] 77 Stretching 1 Analysis of covariance Critical angle knee N NA 3 months Not self-reporting ‘cold legs’
(60 at 3/12) Vastus medialis flexion
training Angular velocity knee
Patella taping/ flexion
biofeedback Treadmill test
7 sessions Modified Functional
Index Questionnaire
Sutlive et al. 45 21/7 of pre- 14 Sensitivity, specificity and VAS Y C50 % improvement 20–23 days Forefoot alignment (2° or more
[23] fabricated likelihood ratios ([2.0) GRCQ VAS valgus)
orthoses use Passive great toe extension (78°
Limitation of or less)
physical activity Navicular drop (3 mm or less)
Lesher et al. 50 Patella taping 19 Sensitivity, specificity and NPRS Y C50 % improvement 0 days Tibial angulation ([5° varum)
[22] Immediate effect likelihood ratios GRCQ mean NPRS or C?4 Ankle dorsiflexion knee flexed
GRC (B15°)
Positive patellar tilt
Relaxed calcaneal stance ([4°
varus)
Iverson et al. 49 Lumbopelvic 43 Sensitivity, specificity and NPRS Y C50 % improvement 0 days Difference in hip IR ([14°)
[21] manipulation likelihood ratios GRCQ NPRS or C?4 GRC Ankle dorsiflexion knee flexed
([16°)
Navicular drop ([3 mm)
No stiffness sitting [20 mins
Squatting most painful activity
S. Lack et al.
Table 1 continued
Study Sample size Treatment No. of Statistical analysis used Outcome measures Success Determinant Length of Significant predictors of
variables for prediction defined of success follow-up intervention success
tested Y/N
Wittstein et al. 30 Quadriceps, hip 4 Sensitivity, specificity and Patient seeking further Y Complete resolution of 2 months No evidence of chondromalacia
[28] abduction, hip likelihood ratios treatment symptoms at follow- Patella
external rotation up Tibial tubercle deviation
and core \14.6 mm
strengthening
Quadriceps,
hamstring and
iliotibial band
stretching
For 8 weeks
Piva et al. [24] 51 Quadriceps 14 Multiple forward Activity of daily living N NA 8 weeks Positive change in fear
strengthening regression analysis scale of the knee avoidance beliefs
Quadriceps, outcome survey
hamstring and NPRS
calf stretches
Outcome Predictors for Patellofemoral Pain Management
Taping
For 8 weeks
Vicenzino et al. 42 Prefabricated foot 16 Sensitivity, specificity and 5-point Likert scale Y ‘Marked improvement’ 12 weeks Age ([25 years)
[19] orthoses likelihood ratios on Likert scale Height (\165 cm)
12 weeks Worst pain (\53.25 mm)
Mid-foot width diff
([10.96 mm)
Lan et al. [30] 100 Patella taping 9 Multivariate logistic VAS Y ‘Marked improvement’ 0 days Lower body mass index
regression analysis on Likert scale Smaller mean lateral
patellofemoral angle
Larger mean quadriceps angle
Barton et al. 60 Prefabricated foot 15 Sensitivity, specificity and 5-point Likert scale Y ‘Marked improvement’ 12 weeks Footwear motion control
[20] orthoses likelihood ratios on Likert scale properties [\5 (less
For 12 weeks supportive)]
Usual pain (\22 mm)
Ankle dorsiflexion knee bent
(\41.3°)
Immediately reduced pain
during single-leg squat with
orthoses
Barton et al. 26 Prefabricated foot 12 Discriminant analysis 5-point Likert scale Y ‘Marked improvement’ 12 weeks Greater peak rearfoot eversion
[32] orthoses on Likert scale relative to the laboratory
For 12 weeks
Pattyn et al. 36 Tailored 26 Linear regression model Kujala N NA 7 weeks Cross-sectional area total
[25] strengthening, quadriceps at mid-thigh level
stretching and Eccentric average peak torque
mobilisation quadriceps at 60/s
For 7 weeks Frequency of pain
1707
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1708 S. Lack et al.
NSAIDs non-steroidal anti-inflammatory drugs, GRCQ Global Rating of Change Questionnaire, NPRS Numeric Pain Rating Scale, VAS visual analogue scale, Y yes, N no, NA not assessed, GRC global rating of change,
(Fig. 1). No RCTs were found. Two studies included data
Significant predictors of
from the same PFP population [26, 31], however they
reported findings from different follow-up durations and
intervention success
0 days
3.4.1 Pain
tested
IR internal rotation
3.4.2 Demographics
Crowell et al.
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Outcome Predictors for Patellofemoral Pain Management 1709
95 % CI -0.52 to 0.34, p = 0.68) did not predict foot positive changes in Kujala scores following exercise
orthoses intervention success [19, 20]. Pooled results from intervention [27]. Multiple stepwise regression (forward
three LQ studies [19, 20, 23] showed a trend for older age to stepping) identified negative patella apprehension at
predict successful outcomes from foot orthoses intervention baseline to predict positive changes in Tegner and Lys-
(mean 0.29, 95 % CI -0.06 to 0.65, p = 0.1) (Fig. 3). holm scores at 7-year follow-up in one LQ exercise
Younger age predicted positive changes in pain intervention study [26]. An absence of chrondomalacia
(decreased visual analogue scale score), Tegner and Lys- patella and tibial tubercle deviation \14.6 mm on mag-
holm scores at 6 weeks, and Tegner and Lysholm scores at netic resonance imaging (MRI) predicted resolution of
6 months’ follow-up after exercise intervention [31]. symptoms at 5 weeks following exercise intervention in
one LQ study [27]. A further LQ exercise intervention
3.4.3 Knee study identified a lack of self-reported ‘cold legs’
(p = 0.019) predicted delayed onset of pain during a
No local knee characteristics were shown to predict foot treadmill test [29]. Single variables added to a linear
orthoses intervention success (Fig. 4). regression model identified greater CSA of the total
Faster vastus medialis oblique (VMO) reflex response quadriceps at mid-thigh level (p = 0.01) and reduced
time (p = 0.041 and p = 0.026, respectively) predicted eccentric average quadriceps peak torque at 60°/s
Fig. 1 Flow diagram summarising study selection for inclusion. PFP patellofemoral pain
123
1710 S. Lack et al.
Fig. 2 Baseline pain characteristics for ‘successful’ and ‘unsuccess- SLRsitbase single-leg rises from sitting at baseline, U.P. usual pain,
ful’ groups following lumbopelvic manipulation, foot orthoses and W.P. worst pain, SD standard deviation, IV inverse variance, CI
taping interventions. AKP Sc anterior knee pain score, FIQ Sc confidence interval, df degrees of freedom. Barton 2011a [20], Barton
functional index questionnaire score, SDatBase step-down at baseline, 2011b [32]
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Outcome Predictors for Patellofemoral Pain Management 1711
Fig. 3 Baseline demographic characteristics for ‘successful’ and SD standard deviation, IV inverse variance, CI confidence interval, df
‘unsuccessful’ groups following lumbopelvic manipulation, foot degrees of freedom. Barton 2011a [20], Barton 2011b [32]
orthoses, exercise and taping interventions. BMI body mass index,
Fig. 4 Baseline knee characteristics for ‘successful’ and ‘unsuccess- patellar displacement, TibTor tibial torsion, TibValgum tibial valgum,
ful’ groups following lumbopelvic manipulation, foot orthoses and SD standard deviation, IV inverse variance, CI confidence interval, df
taping interventions. LPA lateral patellofemoral angle, LPD lateral degrees of freedom
interventions and indicators of the probable course of PFP We identified evaluation of 205 conservative man-
symptoms (prognostic factors) is limited by an absence of agement outcome predictors within 15 LQ cohort studies.
control groups. Of this comprehensive range, 19 (9 % of total) were
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1712 S. Lack et al.
found to be significant. Of the 15 included studies, none exercise intervention. Of interest, higher pain severity at
have reached the validation stage of prediction develop- baseline and longer pain duration have also shown
ment important for ensuring predictors accurately identify association with poor prognosis in other musculoskeletal
individuals who will benefit from specific interventions pain conditions [43]. Irrespective of being predictive or
[33]. We found all studies used a single-arm design, prognostic, these findings highlight the clinical impor-
without the inclusion of a control group, and did not tance of implementing an effective intervention pro-
recruit adequate participants relative to the number of gramme early in the pain experience in order to increase
variables investigated [42]. Although this single-arm the likelihood of intervention success and reduce the risk
design can be a useful tool in the derivation stage of of chronicity.
outcome prediction, it is not powerful enough to provide In contrast, greater usual pain was identified within one
definitive information on factors that can modify treat- LQ study to be predictive of patellar taping success (mean
ment effects. As such, the outcome predictors identified 0.43, 95 % CI 0.01–0.85) [40]. The most significant limi-
in these studies have a high risk of being non-specific tation of these findings is that only immediate effects were
predictors of outcome—that is, predictive of outcome assessed. With literature pertaining to the mechanisms and
regardless of management care plan rather than response effect of taping beyond the short-term being limited [13],
to specific interventions—or prognostic factors [33]. the strength of clinical inference for this predictor is
Variability in outcome measures and follow-up duration somewhat limited. Further research exploring longer-term
was evident across the included studies, further limiting taping efficacy and the ability of greater usual pain to
evidence synthesis and therefore the strength of conclu- predict its outcome is needed.
sions drawn.
Fig. 5 Baseline hip characteristics for ‘successful’ and ‘unsuccess- range, Hip IR Diff hip internal rotation range difference, Pel. Crest
ful’ groups following lumbopelvic manipulation, foot orthoses and pelvic crest height, LL Diff leg-length difference, SD standard
taping interventions. Craig’s Craig’s test, Hip IR hip internal rotation deviation, IV inverse variance, CI confidence interval
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Outcome Predictors for Patellofemoral Pain Management 1713
Fig. 6 Baseline foot and ankle characteristics for ‘successful’ and FF.RF.DF.MP forefoot relative to rearfoot motion dorsiflexion
‘unsuccessful’ groups following lumbopelvic manipulation, foot magnitude peak, FF.RF.DF.TP forefoot relative to rearfoot motion
orthoses and taping interventions. A.df/KE ankle DF with knee dorsiflexion timing to peak, FF.RF.DF.ROM forefoot relative to
extended, A.df/KF ankle DF with knee flexed, CalcSt relaxed rearfoot motion dorsiflexion range of motion, FF.RF.AB.MP forefoot
calcaneal stance, FFalign forefoot alignment, GtToeEx great toe relative to rearfoot motion abduction magnitude peak, FF.RF.AB.TP
extension, NavDrop navicular drop, RF STJN rearfoot in subtalar joint forefoot relative to rearfoot motion abduction timing peak,
neutral position, MFW WB mid-foot width (weight-bearing), MFW FF.RF.AB.ROM forefoot relative to rearfoot motion abduction range
NWB mid-foot width (non-weight-bearing), MFW Dif mid-foot width of motion, RF.LAB.EV.MP rearfoot relative to laboratory eversion
difference (MFW WB-MFW NWB), AchHght arch height, AH Rat magnitude peak, RF.LAB.EV.TP rearfoot relative to laboratory
arch height ration, STJN NWB subtalar joint neutral non-weight- eversion timing peak, RF.LAB.EV.ROM rearfoot relative to laboratory
bearing, RF.TIB.EV.MP rearfoot relative to tibia eversion magnitude eversion range of motion, SD standard deviation, IV inverse variance,
peak, RF.TIB.EV.TP rearfoot relative to tibia eversion timing to peak, CI confidence interval, df degrees of freedom. Barton 2011a [20],
RF.TIB.EV.ROM rearfoot relative to tibia eversion range of motion, Barton 2011b [32]
following exercise intervention. Validation of demographic of patient age in the clinical setting may be an important
characteristics predicting orthoses and exercise interven- characteristic for determining foot orthoses or exercise
tion warrants further investigation; however, consideration intervention success.
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Outcome Predictors for Patellofemoral Pain Management 1715
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