A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works?

Figures & data

Figure 1 CONSORT (Consolidated Standards of Reporting Trials) diagram summarizing search and selection process.

Abbreviation: RCT, randomized controlled trial.

Table 1 The search PICO used to develop keywords

Population	Aged 14–65 years of either gender clinically diagnosed with PFJ pain
Intervention	Exercise-based rehabilitation for PFJ
Comparison	Other interventions including placebo/other exercise/nonexercise-based therapy
Outcome	Psychometrically sound measure of pain and function

Abbreviation: PFJ, patellofemoral joint.

Table 2 Characteristics of effective exercise interventions for patellofemoral pain

Study	Intervention				Program parameters
	Type of exercise	Duration (weeks)	Frequency	Exercises	Intensity/resistance	Reps	Sets
Clark et al^Citation15	CKC including proprioceptive/balance exercises	6	Daily	Stationary cycle (warm-up)	NR	NR	NR
				Wall squats		10 × 10-second holds, progressed to 3 minutes	1
				Sit to stand		NR	NR
				Progressive step down exercise
				Specific gluteus medius and maximus exercises
				Balance work using trampet
Crossley et al^Citation16	CKC, isometric exercises including selective VMO	6	Daily	Week 1–2:
				Isometric VMO (knee at 90°)	NR	10	4
				Squats to 40° knee flexion + isometric gluteals		10	4
				Isometric abduction against a wall in standing		15-second hold	4
				Week 3–6:
				Step downs 10–20 cm depth		5–10	3
				Isometric hip abduction in standing		30-second hold	4
				All week 1–2 exercises
Nakagawa et al^Citation9	OKC and CKC including proximal stability	6	5×/week	Week 1–2:
				TrA contractions in quadruped kneel	NR	15 × 10-second holds	2
				Isometric combined hip abduction and lateral rotation in side lying, hips and knees slightly flexed		15 × 10-second holds	2
				Isometric hip abduction with knees extended		15 × 10-second holds	2
				Isometric hip abduction and lateral rotation in quadruped		15 × 10-second holds	2
				Isometric quadriceps (knee at 90°)		15 × 10-second holds	2
				ASLR		10	3
				Squat to 40° flexion		10	4
				Week 3–4:
				Wall squat 0°–60° flexion		10	3
				Step up/down (20 cm depth)		5	3
				Lunges 0°–45° flexion		10	3
				Pelvic drop exercise on 20 cm step		15	2
				Single arm extension against elastic resistance in contralateral single leg stance		10	4
				Contralateral body rotation in single leg stance against elastic resistance, maintaining lower limb static		15 × 10-second holds	2
				Weeks 5–6:		As per week 3–4
				As for week 3 and 4 + balance exercises and additional elastic resistance around the affected leg in forward lunges, encouraging active lateral rotation and abduction of the hip.
				Begin progress walk or run program
Bakhtiary and Fatemi^Citation7	Group 1: OKC	3	2×/day	Supine straight leg raise to 45° hip flexion	NR	Group 1 and 2: 20 × 3–4-second hold, increased by 5 reps every 2 days	1
	Group 2: CKC	3	2×/day	Single leg squat to 15°–20° to knee flexion whilst holding stable surface
Witvrouw et al^Citation19	Group 1: OKC	5	3×/week	Static quadriceps contractions in full knee extension	Groups 1 and 2: 60% of 10RM, new 10RM established at the end of each week. “Maximal contractions” for static tasks	Group 1: 10 × 6-second hold	3
				Straight leg raise in supine
				Knee extension from 10° flexion to full extension
				Leg adduction exercises in side lying
	Group 2: CKC	5	3×/week	Seated leg press		Group 2: 10	3
				Double or single leg squat
				1/3 knee bend
				Stationary biking
				Rowing machine exercise
				Step up and down exercise
Herrington and Al-Sherhi^Citation8	Group 1: OKC	6	3×/week	Knee extension exercises in seated position from 90° of flexion to full extension	Groups 1 and 2:	10	4
					Set 1 50% 6RM	10
					Set 2 75% 6RM	Max possible
	Group 2: CKC	6	3×/week	Leg press in seated position from 90° of knee flexion to full extension	Set 3 100% 6RM	Max possible
				Group 1 and 2: 5-minute static cycle warm-up	Set 4 Progressed according set 3 max (Next session progressed based on set 4 max)
Syme et al^Citation10	Group 1: General non-VMO selective	8	2×/week	3–5 lower limb exercises focusing on quadricep strengthening. Actual exercises not specified.	60%–70% of 1RM	10	1–3
	Group 2: VMO selective	8	Daily HEP + >6 EMG biofeedback sessions	Lower limb exercises focusing on selective activation and retraining of the VMO relative to the VL using a dual channel surface electromyographic (EMG) biofeedback unit.	NR	NR	NR
				Daily home exercises
Van Linschoten et al^Citation11	OKC and CKC including balance exercises	12	25 minutes daily	Stationary cycle (warm-up), static and dynamic strengthening exercises for quadriceps, adductors, and gluteal muscles and balance work	NR – though progressed fortnightly during the first 6 weeks	NR – though progressed fortnightly during the first 6 weeks	NR
Song et al^Citation17	CKC	8	3×/week	SL leg press, 45°–0° flexion	60% 1RM (1RM reset every 2 weeks)	10	5
Kettunen et al^Citation23	OKC and CKC	8	Daily	Weeks 1–4:	NR	Weeks 1–2:	2
				Standing hamstring curl		10–20
				All fours, transverse plane single leg bent knee hip abduction		Weeks 2–4:	4
				Knee extension		10–40
				Straight leg raise		Weeks 4–6:	2
				Weeks 4–8:		10–20
				Standing hip extension against resistance band with straight knee		Weeks 6–8:	4
				Standing hip extension against resistance band moving from knee flexion to extension		10–40
				Lateral step down/up
				Sit to stand

Abbreviations: reps, repetitions; NR, not reported; CKC, closed kinetic chain; OKC, open kinetic chain; SLR, straight leg raise; ASLR, active straight leg raise; RM, repetition max; TrA, transversus abdominus; VMO, vastus medialis oblique.

Figure 2 Graph showing PEDro scores for each of the included studies.

Table 3 Details of stretching and co-interventions reported

Study	Stretching parameters				Co-intervention
	Muscle/stretch	Reps	Duration	Frequency	Nonmedical	Medical
Clark et al^Citation15	H/S ITB Quadriceps gastrocnemius	10	10 seconds	Daily	Taping Education	NR
Crossley et al^Citation16	Sitting H/S Anterior hip in prone	3	30 seconds	Daily	Taping (daily), PFJ mobilization	Allowed paracetamol only
Nakagawa et al^Citation9	Sitting H/S Standing quadriceps Standing calf Standing ITB	3	30 seconds	5×/week	Sitting patella mobilization	NR
Bakhtiary and Fatemi^Citation7	NR				NR	NR
Witvrouw et al^Citation19	Quadriceps H/S Gastrocnemius	3	30 seconds	3×/week	Asked not to participate in sport	NR
Herrington and Al-Sherhi^Citation8	NR				Nil	Nil
Syme et al^Citation10	Quadriceps H/S ITB Gastrocnemius Soleus Anterior hip	3	30 seconds	2×/week	Taping Education Patellar mobilizations	Advised not to change current use
Van Linschoten et al^Citation11	Flexibility exercises for major thigh muscles, specifics NR	NR	NR	Daily	Education Brace/bandage 20% Insoles 26%	NSAIDs 6% Topical agents 3%
Song et al^Citation17	Quadriceps H/S ITB Calf	3	30 seconds	3×/week	Hot pack to quadriceps for 15 minutes pre exercise, cold pack to knee for 10 minutes post exercise	Nil
Kettunen et al^Citation23	Calf H/S Quadriceps	3–5	20 seconds	2×/day	Avoidance of symptom producing activities	NR

Abbreviations: reps, repetitions; NR, not reported; H/S, hamstring; ITB, iliotibial band; NSAID, nonsteroidal anti-inflammatory drug; PFJ, patellofemoral joint.

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