Accepted Manuscript

The effect of adding myofascial techniques to an exercise programme for patients

with anterior knee pain - A randomized clinical trial

G. Telles, PT, D.R. Cristovão, PT, F.A.T.C. Belache, MsC, Doctoral student of
Science in Rehabilitation (UNISUAM), M.R.A. Santos, PT, R.S. Almeida, PhD, Dr.
L.A.C. Nogueira, PhD., Professor of Instituto Federal do Rio de Janeiro (IFRJ)
PII: S1360-8592(16)00018-8
DOI: 10.1016/j.jbmt.2016.02.007
Reference: YJBMT 1323

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 26 April 2015

Revised Date: 4 February 2016
Accepted Date: 11 February 2016

Please cite this article as: Telles, G., Cristovão, D.R., Belache, F.A.T.C., Santos, M.R.A., Almeida, R.S.,
Nogueira, L.A.C., The effect of adding myofascial techniques to an exercise programme for patients with
anterior knee pain - A randomized clinical trial, Journal of Bodywork & Movement Therapies (2016), doi:
10.1016/j.jbmt.2016.02.007.

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 ACCEPTED MANUSCRIPT
The effect of adding myofascial techniques to an exercise programme for patients with

anterior knee pain - A randomized clinical trial

G. Telles1; D. R. Cristovão2; F. A. T. C. Belache3; M. R. A. Santos4; R. S. Almeida5; L. A. C.

Nogueira6

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Gustavo Telles – PT. Physical Therapy of Hospital Universitário Gaffrée e Guinle and
Delfim Physical Therapy Service, Rio de Janeiro, Brazil.

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2
Delmany R. Cristovão - PT. Physical Therapy of Hospital Universitário Gaffrée e Guinle,
Rio de Janeiro, Brazil.

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Fabiana Azevedo Terra Cunha Belache – MsC. Doctoral student of Science in
Rehabilitation (UNISUAM), Physical Therapy of Hospital Universitário Gaffrée e Guinle,
Rio de Janeiro, Brazil.

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4
Mariana Rezende de Araujo Santos – PT.
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5
Renato Santos de Almeida - PhD. Physical Therapy of Hospital Universitário Gaffrée e
Guinle. Professor of Centro Universitário Serra dos Órgãos (UNIFESO), Rio de Janeiro,
Brazil.
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Leandro Alberto Calazans Nogueira - PhD. Professor of Instituto Federal do Rio de Janeiro
(IFRJ), Postgraduation Progam of Reabilitation Science of Centro Universitário Augusto
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Motta (UNISUAM), Rio de Janeiro, Brazil.

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The Authors declares that there is no conflict of interest.

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Correspondence should be sent to Dr. Leandro Alberto Calazans Nogueira at Instituto Federal
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do Rio de Janeiro, Campus Realengo, Rua Carlos Wenceslau, 343, Realengo.

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CEP 21715-000, Rio de Janeiro, RJ, Brasil.

Phone +55 (21) 3463-4497

Emails should be sent to leandro.nogueira@ifrj.edu.br

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Abstract

Anterior knee pain is a common complaint and can cause difficulty with its inability to bear

weight. The aim of the study was to analyse the effect of adding myofascial techniques to an

exercise programme for patients with anterior knee pain. A clinical trial with 18 patients with

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a clinical diagnosis of anterior knee pain was conducted. One group (E) with nine individuals

was treated with hip muscle strengthening exercises; another group (EM), with nine

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individuals, had myofascial techniques added. To quantify the results, the Numerical Pain

Rating Scale (NPRS) and the Lower Extremity Functional Scale (LEFS) were used. The E

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group showed an improvement in pain (p = 0.02), but not in the mean degree of disability.

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The EM group showed an improvement in pain (p = 0.01), as well as the degree of disability
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(p = 0.008). The effect size analysis showed that participants of the EM group had a greater

impact on clinical pain and disability (Cohen`s d = 0.35 and 0.30, respectively). The addition
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of myofascial techniques should be considered to improve the functionality of the lower

limbs and reduce pain in patients with anterior knee pain.

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Key words: Patellofemoral pain syndrome, Anterior knee pain, Physiotherapy and Muscle
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Strengthening.
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Introduction

Musculoskeletal disorders are usual in the clinical practice of a physiotherapist. In

general, the knee joint is the second most affected part, just behind the vertebral spine region

(Nogueira et al, 2011). The most common complaint is the presence of anterior knee pain. It

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is usually an indication of several knee pathologies, such as patellar chondromalacia,

patellofemoral pain syndrome, osteoarthritis, patellar tendinopathy and meniscal injuries.

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Anterior knee pain is common in patients with knee injuries despite the fact that the

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injury of the structure contributes little to symptomatology. Recent studies have shown that

there is no direct relationship between anterior knee pain and chondromalacia patella,

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osteoarthritis (Astephen Wilson et al, 2011), patellar tendinopathy (Fairley et al, 2014), and
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meniscal injury (Sihvonen et al, 2013); it is also common to find such lesions in

asymptomatic individuals (Beattie et al, 2005). Thus, the evaluation of clinical and functional
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limitations are being analysed in studies that are more recent.

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Symptoms commonly found in patients with complaints about the knees are: acute or
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chronic pain in the anterior patellar region and the patellar tendon, blocking and friction,

weight bearing difficulty, and worsening symptoms during prolonged sitting, crouching,
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when climbing stairs, running or kneeling (Lankhorst et al, 2012; Werner, 2014). Several
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instruments have been designed to measure the functional limitation of patients with anterior
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knee pain, from clinical trials to self-administered questionnaires. Self-administered

questionnaires are best used in clinical trials due to the easy application. One of the most

recommended tools is the Lower Extremity Functional Scale, which was developed based on

the concepts established by the feature model and disability produced by the World Health

Organization (Binkley et al, 1999).

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There is a wide variety of therapeutic modalities in the literature to recover

functionality and improve anterior knee pain. Usually, therapeutic exercise is based on the

strengthening of the quadriceps muscle, the hip abductors, extensors, and hip lateral rotators

by stretching, terminal knee extension, patellar taping, and improved ankle mobility, in

addition to observing the behaviour of structures during dynamic activities (Bolgla & Boling,

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2011; Powers et al, 2012). Patients are encouraged to do some exercises at home (Liebenson,

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2006). The most recent studies show a trend in incorporating exercise therapy for the hip

region by presenting improvements in pain and functional capacity (Santos et al, 2013).

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General therapeutic exercise programmes have clearly demonstrated clinical benefits for

patients with anterior knee pain due to knee osteoarthritis (Fitzgerald, 2005).

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Previous studies in patients with anterior knee pain showed that strengthening hip

muscles can lead to knee pain relief (Avraham et al, 2007; Bennell et al, 2010; Dolak et al,
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2011; Fukuda et al, 2012; Fukuda et al, 2010; Nakagawa et al, 2008; Sled et al, 2010).

However, it has already been shown that myofascial techniques for the rectus femoris muscle
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reduce anterior knee pain (Pedrelli et al, 2009). There are studies that combine different
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approaches in the same intervention group to improve knee pain and function (Syme et al,
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2009). To the best of our knowledge, no study has examined the effect of combining hip

muscles strengthening and myofascial techniques for reducing pain and improving function
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in patients with anterior knee pain, despite this being a common clinical practice. Thus, the
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aim of the study was to analyse the effect of adding myofascial techniques to an exercise

programme for patients with anterior knee pain manoeuvres.

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Methods

Study Design

This used a randomised clinical trial with two parallel-groups: one group was treated

with hip muscles strengthening and home exercises, the other group was treated with hip

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muscles strengthening and home exercises plus myofascial techniques and stretching.

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Subjects

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Patients with a clinical diagnosis of anterior knee pain were recruited from the

physiotherapy department of Gaffrée and Guinle University Hospital. Both genders were

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admitted with patient age range from 27 to 73 years of age. Patients were included if they had
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located pain in the patellar region for at least one month or pain for at least three of the

following conditions: squatting, going up and / or down stairs, being seated for long periods,
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kneeling and pain on palpation in the patellar region and the patellar tendon. Exclusion

criteria were previous physiotherapy treatment for patients with these symptoms, knee
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surgery less than a year ago, full knee prosthesis, previous trauma, patellar fracture, patellar
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dislocation and rheumatoid conditions. All patients read and signed the informed consent
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form. The project was approved by the Ethics Committee in Research of the Gaffrée and

Guinle University Hospital under protocol number 243 344.

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Sample Size

Sample size calculation for the groups was performed based on the mean value of the

difference in lower extremity disability observed before and after the treatment proposed by

Fukuda et al. (Fukuda et al, 2012). In this study, the value of the difference observed in the

hip and knee exercise group was 22.4 (on a disability scale), while, in the only knee exercise

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group, it was 0.4. The standard deviation considered for the calculation was 10.5. Sample size

calculation revealed that four participants were required to detect significant differences in

disability scale between the hip and knee exercise group and other intervention group (power,

80%; α=0.01; independent-samples t-test).

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Procedures

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A physiotherapist, who explained the clinical protocol, interviewed patients eligible

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for the study. Then, participants were referred for an initial evaluation consisting of medical

history and physical examination performed by a blinded physiotherapist who knew the

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group allocation of the patient after randomization. Patients who had any of the conditions
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described in the exclusion criteria were forwarded to the medical sector of origin.
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In the initial evaluation, demographics and pain characteristics, degree of pain

intensity and lower extremity disability level information was collected by self-administered
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questionnaires. The degree of intensity of knee pain was evaluated every session. The
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disability level of the lower extremity was reassessed on the last day of attendance. The
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improvement percent in pain intensity and lower extremity disability were calculated using

the following equation: (IV-FV / FV) * 100: IV is the initial value and FV is the final value.
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In individuals complaining of bilateral pain, the knee that was treated was the one that had
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greater functional impairment. The flowchart of the allocation of patients can be seen in

Figure 1.

Figure 1: CONSORT flowchart of the study.

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Outcome Measures

For pain measurement, the numeric pain rating scale (NPRS) was utilized. It has

values ranging from zero (no pain) to ten (worst pain imaginable), which help patients

identify their pain intensity.

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The knee disability was evaluated with the Lower Extremity Functional Scale (LEFS),

which consists of 20 items, each with a minimum score of four points and a maximum score

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of 80 points, which equates to a normal functional state. The questionnaire can be self-

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administered, with an approximate time of two minutes needed to complete all items. This

questionnaire has already been translated to Portuguese and validated in the Brazilian culture

(Metsavaht et al, 2012).

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Intervention
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After the initial evaluation and data collection, participants were randomly assigned to
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one of two intervention groups. Randomization was performed electronically on

http://graphpad.com/quickcalcs/index.cfm using simple random sampling. Patients were

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treated for a maximum of 10 sessions, each session lasting about 30 minutes each week for

two sessions. The maximum duration of treatment was five weeks. A physiotherapist was
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responsible for the screening of eligible patients and the random allocation of participants.
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Two physiotherapists performed the interventions: one being responsible for the group to

strengthen the hip muscles and home exercises (E group), and the other responsible for the

intervention treatment group strengthening the hip muscles, myofascial techniques, stretching

and home exercises (EM group). The two physiotherapists involved had three years' work

experience in an outpatient department treating patients with musculoskeletal disorders, and

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previously had undergone the same training. The programme for the two treatment groups is

shown in Table I.

Participants performed an individual sessions of strengthening exercises two times per

week for five weeks, lasting 30 min. Five exercises to strengthen hip muscles were performed

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lying on the side, sitting, and standing (three sets of ten repetitions) with ankle cuff weights

or elastic bands. The therapists were trained to deliver the exercises prior to the study. They

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adjusted exercise intensity as determined by the participant's ability to complete ten

repetitions for a given exercise. The participants were encouraged to repeat the exercises at

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home with no resistance, five days per week.

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The myofascial release technique was performed in the supine position for the rectus
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femoris muscle and side lying position for tensor fasciae latae muscle and iliotibial band. The

therapist used a your thumb to apply gentle sustained pressure in the muscle`s longitudinal
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direction, regardless of the sense of direction. Once a tissue barrier was located, a static
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pressure was applied initially.

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Each muscle stretching technique was performed passively in the supine position for

hamstring muscles, side lying position for tensor fasciae latae muscle, and prone position for
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rectus femoris muscle. Each stretch was held for 30 seconds to the point of tightness or slight
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discomfort. Each stretch was performed two times, accumulating 60 seconds per stretch.
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Table I: Treatment protocol for both groups

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Statistical Analysis

Means and standard deviations were calculated for each variable. Data distribution

was assessed by the Shapiro-Wilk test. The pre-values were compared using a measures test

for independent variables and the Mann-Whitney U test. Comparisons within groups were

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performed using the Wilcoxon test for independent variables. The calculation of the effect

size was calculated considering the difference between the mean intensity of pain and

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functionality in both groups. The effect size (Cohen`s d) of 0.2 was considered small, 0.5 was

considered medium, and above 0.8 was large (Cohen, 1988). The level of significance was

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0.05 for all statistical tests. The programme used for statistical analysis was the Statistical

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Package for Social Sciences (SPSS - version 17).
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Results

Forty-eight individuals were selected for telephone contact , of which only 22 met the

eligibility criteria of the study after the evaluation. Among these, four participants were

excluded because they started the treatment and then dropped out. All 18 subjects who

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continued in the study performed 10 interventions, and the whole population completed the

treatment after five weeks. There were no complaints of adverse effects due to the exercise

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programmes from either group.

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The two groups had similar characteristics at baseline, because there was no

significant difference between mean age, weight, height and Body Mass Index (BMI). The

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demographics data of the observed population is shown in Table II.
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Table II: Demographic data of the population included in the study

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The E group showed improvement of pain (NPRS), with a difference in mean values

before (8.0 ± 2.2) and after treatment (5.2 ± 2.4, p = 0.02); however, there was no statistically
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significant difference in disability mean before (42 ± 18.5) and after treatment (49.8 ± 10.8, p
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= 0.09). The EM group showed improvement in pain (NPRS), with a statistically significant
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difference in mean before (6.5 ± 2.6) and after treatment (3.4 ± 2.8, p = 0.01), as well as

improvement in the disability index before (45 ± 15.4) and after intervention (56.2 ± 14.3, p =

0.008). These values are shown in Table 3. Although the variables presented differences in

the means in both groups, there was no statistically significant difference when comparing the

E and EM group for any variable observed, as shown in Table III.

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The effect size analysis showed that participants in the EM group had a greater

reduction in pain intensity and improvement in the disability index of the lower extremity,

with a greater clinical effect (Cohen`s d = 0.35 and 0.30, respectively).

Table III: Results of measured variables in both groups before and after treatment

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Discussion

Patients with anterior knee pain had reduced pain intensity and improved functionality

with the two protocols of treatments; however, the disability improvement of the lower

extremity was statistically significant only in the group that used myofascial techniques plus

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muscle recruitment exercises. This group showed a clinical effect for outcomes higher than

the hip strengthening group.

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The present study demonstrated a reduction in pain in all participants, and a

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disability improvement in 89% of participants. Our findings suggest that both interventions

may offer clinical benefits; however, the results of the present study point to the potential

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for myofascial techniques as useful additions to strengthening programmes for anterior knee
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pain patients. The study of Bennell et al. (Bennell et al, 2010) showed improvement in pain

and function in 80% of patients with knee osteoarthritis who underwent hip strengthening.
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The effectiveness of exercise for improving physical function and reducing pain in knee
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osteoarthritis has been demonstrated in several studies, including meta-analyses; however, it

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is still necessary to identify which technique would be superior for different profiles of

patients with knee joint dysfunction (Uthman et al, 2013). Thus, clinical trials comparing
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different techniques and exercises have great clinical relevance for physiotherapy.
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Our results showed an average improvement of 18.2% in disability for the exercise
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group, while the exercise plus myofascial techniques group improved by 20.4%. Fukuda et

al. (Fukuda et al, 2010) showed a greater improvement in disability when adding hip and

knee exercises (25.3%) when compared to exercises only for the knee (15.2%) and a control

group (4.7%) in patients with Patellofemoral pain syndrome. In another study, Fukuda et al.

(Fukuda et al, 2010) also observed a greater short-term improvement of 30.2% in the group

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that used hip and knee exercises, while there was no difference in the group that underwent

exercises only for the knee.

The improvement in pain for our patients was greater than the improvement of

disability. The group that performed myofascial techniques showed a greater reduction in

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pain (51.0% versus 32.6%). Akyol et al. (Akyol et al, 2010) also evidenced a superior pain

improvement in a combination group compared to an isokinetic exercise programme alone

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(54.5% versus 43.3%). Nakagawa et al. (Nakagawa et al, 2008) showed a bigger

improvement in pain intensity (71.1%) when compared to our results. However, Nakagawa et

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al. (Nakagawa et al, 2008) underwent other therapeutic intervention modalities covering

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other regions, such as lumbar stabilization and functional training, and performed the
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treatment four times a week. The difference in treatment modalities and the frequency of

treatment should have contributed to a more attenuated effect on our participants.

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Our findings corroborate other studies that have demonstrated the effectiveness of
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strengthening hip muscles for patients with knee pain. In a similar approach, Khayambashi et
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al. (Khayambashi et al, 2012) analysed the effectiveness of strengthening hip abductors and

lateral rotators to improve hip pain, disability and strength. A six-month follow-up showed
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that this specific treatment brought more clinical benefits when compared to an overall

strengthening protocol for the limb. Dolak et al. (Dolak et al, 2011) also reported that isolated
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strengthening exercises of the hip decreased pain more quickly when compared to quadriceps
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strengthening exercises; however, both interventions were effective with regard to pain and

function.

Several studies consider the influence of dynamic valgus in anterior knee pain, both in

the patellofemoral pain syndrome and osteoarthritis of the knee. We did not control for

dynamic valgus in this study, and this may be a limitation of the research. However, Sled et

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al. (Sled et al, 2010) reported a decrease in pain, disability and a strengthening of hip

abductors in patients with knee osteoarthritis, independent of changing the knee adduction

moment during gait. Other authors also reported an improvement in pain and function of the

knee using a programme to strengthen the hip muscles in patients with osteoarthritis, but

showed no changes in knee adduction moment (Bennell et al, 2010). These findings suggest

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that the variables in this population may possibly be linked to other causes aside from the

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dynamic valgus. This fact highlights the need for multifactorial approaches for different

patient profiles.

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The proposed intervention with myofascial techniques plus exercises showed a

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favorable clinical impact compared to the intervention only with exercises for pain and
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disability. The myofascial and stretching techniques used in this study were applied in some

specific points that usually present tension in patients with knee pain and, consequently, can
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interfere with muscle recruitment. Myofascial intervention is important because it stimulates

mechanoreceptor sites that will generate a reflex stimulation for pain relief and also interferes
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in tissue extensibility (Schleip, 2003; Simmonds et al, 2012). Pedrelli et al. (Pedrelli et al,
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2009) demonstrated that the Fascial Manipulation® in the quadriceps of subjects with
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anterior knee pain was effective for reducing pain and improving the pattern of muscle

recruitment in functional tasks. The results of this study corroborate these findings.
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Even though the strengthening plus myofascial techniques group has not
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demonstrated significant differences when compared to the other group, it was found that the

multimodal treatment presented a greater clinical effect. Thus, the realization of myofascial

techniques together with hip exercises proved to be an effective alternative treatment for this

population, since these techniques are simple and quick to be realized. The myofascial release

technique has been demonstrated to be effective to improve pain and disability when used as

an adjunct to specific exercises to chronic low back pain patients (Ajimsha et al, 2014).

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A potential weakness of this study may be the small number of participants. We can

identify, as a limitation, the difficulty of controlling the home exercise programme and the

lack of monitoring long-term results that may interfere with the clinical results. The

combination of myofascial techniques presented here does not identify which technique was

the most determinant of the difference observed. It is recommended that others research

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separately the myofascial techniques in different groups to identify each contribution for

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patients with anterior knee pain. Other factors have been described to influence the results

and should be monitored in future studies, such as quadriceps activation failure, knee

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alignment, knee instability, and peak torque of the lateral core stability (hip abductors and

extensors) (Almeida et al, 2015; Fitzgerald, 2005).

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Conclusion

Exercises for the hip region added to myofascial techniques showed better clinical

effects than isolated exercises for patients with anterior knee pain. The addition of myofascial

techniques should be considered to improve the functionality of the lower limbs and reduce

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pain in patients with anterior knee pain.

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Funding Acknowledgements

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This work was supported in part by Federal Institute of Rio de Janeiro and National

Counsel of Technological and Scientific Development (CNPq), Brazil.

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Tables

Table I: Treatment protocol for both groups

TREATMENT PROTOCOL FOR THE TREATMENT PROTOCOL FOR THE

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EXERCISE GROUP (E) (3 X 10 repetitions) EXERCISE PLUS MYOFASCIAL

TECHNIQUE GROUP (EM)

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Strengthening exercises for hip abductor
Strengthening exercises:
muscles The same exercises as the E Group

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1- Side lying hip abduction
Myofascial Release technique
2-Patient in an orthostatic position produces a 1-Rectus femoris muscle

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hip abduction against an elastic resistance 2- Tensor fasciae latae muscle
band (Thera Band®, black color)
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Muscle Stretching technique

Strengthening exercises for lateral hip rotator 1- Tensor fasciae latae muscle
muscles 2- Rectus femoris muscle
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3- Hip lateral rotation in side lying position 3- Hamstrings muscles

(both knee and hip flexed at 60º)
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4- Hip lateral rotation against elastic band

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(Thera Band®; black color) while sitting

bedside (both hip and knee flexed at 90º)

Strengthening exercises for Gluteus Maximus
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5- Hip extension in prone position (15º) and

knee flexed at 90º
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Home Based Exercises

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Patient was oriented to realize all described

exercise above without resistance

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Table II: Demographic data of the population included in the study

E GROUP (n=9) EM GROUP (n=9) P Value

AGE years 61.8 (±17.3) 63.3 (±12.1) .578

HEIGHT cm 1.61 (±0.11) 1.66 (±0.9) .559

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WEIGH kg 71.8 (±13.5) 75.5 (±11.7) .279

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BMI kg/cm2 27.7 (±4.5) 27.2(5.1) .899

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Table III: Results of measured variables in both groups before and after treatment

MEASURED BEFORE AFTER P EFFECT IMPROVEMENT

VARIABLES TREATMENT TREATMENT VALUE SIZE# (%)

Wthin-group

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comparison *
NPRS

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E Group 8.0 ±2.2 5.2 ±2.4 .02 -
(6.2–9.7) (3.3–7.4) 32.6% (22.9)

EM Group 6.5 ±2.6(4.5–8.5) 3.4 ±2.8 .01 -

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(1.2–5.6) 51.0% (31.6)

LEFS

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E Group 42.0 ±18.5 49.8 ±10.8 .09 - 18.2% (27.3)
(27.7–56.2) (41.5–58.2)
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EM Group 45.3 ±15.4 56.2 ±14.3 .008 - 20.4% (13.9)
(33.4–57.2) (44.7–67.6)
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Between groups
comparison*
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Dif. NPRS
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E Group 2.56±2.0 - -
(1.0–4.1)
EM Group 2.89±2.3 .17 .35
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(1.1–4.67)

Dif. LEFS
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E Group 7.89±12.2 - -
(1.51–17.28)
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EM Group 10.89±7.59 .74 .30

(5.05–16.72)

Legend: LEFS - Lower Extremity Functional Scale; E Group - Exercise group; EM Group -
Exercise plus myofascial techniques group; Dif. NPRS - values of difference in mean
(numeric pain rating scale) before and after treatment; Dif. LEFS - values of difference in
mean (Lower Extremity Functional Scale) before and after treatment. *Values showed as
mean ± standard deviation and 95% confidence interval. # Cohen's d values.

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Figure

Figure 1: CONSORT flowchart of the study.

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