Patellofemoral pain in athletes: clinical perspectives

Figures & data

Table 1 Potential intrinsic risk factors, tests for assessment and their reliability

Potential risk factor	Tests	Reliability
Weakness of quadriceps muscle, especially VMO^Citation29,Citation32^–^Citation35	One-legged hop test. Test is performed by jumping and landing on the same foot with the hands behind the back and the hop distance is measured from toe.^Citation36 A quotient (%) between the injured and noninjured legs is registered and defined as abnormal if the quotient is <85%^Citation37	Good reliability^Citation36,Citation38,Citation39
Hip muscle dysfunction (particularly, the abductors and external rotators)^Citation30,Citation40,Citation41	The Trendelenburg test (for hip abductors) to assess the ability to hold the pelvis level, while the subject performs a single-leg stance. Lateral pelvic shift or lowering of one side of the pelvis indicates weakness of hip abductors^Citation42,Citation43	Good sensitivity, good to excellent specificity^Citation44
Poor core muscle endurance^Citation45,Citation46	Front plank, modified Biering-Sorensen and side bridge for anterior, posterior and lateral core muscle endurance^Citation45,Citation47	Good reliability^Citation47
Tightness of hamstring^Citation3,Citation48^–^Citation50	Passive knee extension test with goniometric measurement of popliteal angle.^Citation3,Citation49 Test is considered positive when a knee extension angle of >20° is measured^Citation51,Citation52	Excellent inter-rater and good test- retest reliability^Citation53^–^Citation55
Tightness of iliopsoas and quadriceps^Citation3,Citation48,Citation56,Citation57	Modified Thomas test.^Citation58,Citation59 Two angles were measured for each limb. Lengths of iliopsoas and quadriceps were determined by measuring the angles of hip and knee flexion, respectively. Inability of the opposite thigh to extend to a neutral position or drop below the horizontal constitutes a positive test for iliopsoas. The angle of knee flexion of <80° determines the quadriceps shortness	Very good to excellent inter-rater and good test-retest reliability^Citation55
Tightness of iliotibial band^Citation60^–^Citation62	Ober test.^Citation61^–^Citation64 Positive test occurs when the leg remains in an abducted position (rests above the horizontal)^Citation65	Excellent intra-rater and inter-rater reliability^Citation66
Tightness of gastrosoleus complex^Citation32,Citation67	Weight-bearing lunge test.^Citation68 Test is considered positive when 1) the distance between the wall and the big toe measured is <9 cm or 2) the angle made by the anterior tibia/shin to vertical is <35°^Citation69	Excellent intra-rater and inter-rater reliability^Citation69
Excessive foot pronation^Citation32,Citation70,Citation71	FPI-6.^Citation72,Citation73 Scores of +6 to +9 and +9 to +12 are regarded pronated and highly pronated, respectively^Citation74	High intra-rater and inter-rater reliability among PFPS patients^Citation73,Citation74
Limb length discrepancy^Citation75	Gauging the distance between the anterior superior iliac spine and the medial malleolus of both legs (average of two measures). Limb length inequalities of >10 mm is considered clinically significant^Citation76	High intra-rater and inter-rater reliability^Citation77,Citation78
Patellar malalignment^Citation34,Citation79,Citation80	Patellar tilt and mediolateral glide tests.^Citation34,Citation81,Citation82 Tilt occurs when the digit palpating one of the patellar borders is more anterior than the other. The glide is positive when the distance from the midpatella to each femoral epicondyle is not equal^Citation81	Fair intra-rater and poor inter-rater reliability^Citation81,Citation83
Patellar hypermobility^Citation3,Citation34	Patellar mobility test, with the knee flexed 20°–30° and the quadriceps relaxed.^Citation84 Patellar mobility of more than three quadrants suggests a hypermobile patella^Citation34	Good intra-rater and variable inter-rater reliability^Citation84
GJL^Citation3,Citation34,Citation85	BHJMI, in which the range of scoring is between 0 and 9, with high scores denoting greater joint laxity	Good to excellent reliability^Citation86^–^Citation88
Genu varum^Citation89	Goniometric measurement in a standing position and barefoot, with toes placed forward and feet shoulder-width apart^Citation90	Correlated well with the angle measured on the full-limb radiograph (gold standard)^Citation90
Abnormal trochlear morphology^Citation91	Measurement of sulcus angle in plain radiography (skyline or tangential patellar views performed in 25° of flexion; normal value 138°, SD 6°)^Citation92 or evaluation of lateral trochlear inclination, medial trochlear inclination, sulcus angle and trochlear angle on the axial MRI	Excellent intraobserver and interobserver reliability (ICCs of 0.94 and 0.92, respectively),^Citation92,Citation93 but some newer evidence recommended MRI^Citation94
Abnormal proprioception^Citation95,Citation96	Measurement of knee joint position sense using five active tests under non-weight-bearing and uni- and bilateral weight-bearing conditions^Citation95	Good reliability^Citation97
Gait abnormalities (heel strike in a less pronated position and there is roll over more on the lateral side)^Citation98	Plantar pressure measurements during walking using a foot scan pressure plate^Citation98	Reliable (ICC: 0.75)^Citation99

Abbreviations: BHJMI, Beighton and Horan Joint Mobility Index; FPI-6, Foot Posture Index-Version 6; GJL, generalized joint laxity; ICC, Intraclass Correlation Coefficient; MRI, magnetic resonance imaging; PFPS, patellofemoral pain syndrome; SD, standard deviation; VMO, vastus medialis obliques.

Figure 1 Vastus medialis coordination test.

Figure 2 Patellar apprehension test.

Figure 3 Eccentric step test.

Figure 4 Waldron’s test: (A) Phase I and (B) Phase II.

Figure 5 Clarke’s test.

Figure 6 Standard stepdown test.

Figure 7 Single-leg squat.

Figure 8 Practical algorithmic approach to diagnosis and treatment of patellofemoral pain in athletes.

Abbreviation: MRI, magnetic resonance imaging.

PowersCMRehabilitation of patellofemoral joint disorders: a critical reviewJ Orthop Sports Phys Ther19982853453549809282

 PubMed Web of Science ®Google Scholar

ColladoHFredericsonMPatellofemoral pain syndromeClin Sports Med201029337939820610028

 PubMed Web of Science ®Google Scholar

LankhorstNEBierma-ZeinstraSMvan MiddelkoopMRisk factors for patellofemoral pain syndrome: a systematic reviewJ Orthop Sports Phys Ther2012422819422031622

 PubMed Web of Science ®Google Scholar

AgebergEZätterströmRMoritzUStabilometry and one-leg hop test have high test-retest reliabilityScand J Med Sci Sports1998841982029764440

 PubMed Web of Science ®Google Scholar

SteinkampLADillinghamMFMarkelMDHillJAKaufmanKRBiomechanical considerations in patellofemoral joint rehabilitationAm J Sports Med19932134384448346760

 PubMed Web of Science ®Google Scholar

RiceJBennettGRuhlingRComparison of two exercises on VMO and VL EMG activity and force productionIsokinet Exerc Sci1995526167

 Google Scholar

InsallJCurrent concepts review: patellar painJ Bone Joint Surg19826411477033228

 PubMed Web of Science ®Google Scholar

DavisISPowersCMPatellofemoral pain syndrome: proximal, distal, and local factors, an international retreat, April 30–May 2, 2009, Fells Point, Baltimore, MDJ Orthop Sports Phys Ther2010403A1A16

 Web of Science ®Google Scholar

RobinsonRLNeeRJAnalysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndromeJ Orthop Sports Phys Ther200737523223817549951

 PubMed Web of Science ®Google Scholar

PrinsMRvan der WurffPFemales with patellofemoral pain syndrome have weak hip muscles: a systematic reviewAust J Physiother200955191519226237

 PubMed Web of Science ®Google Scholar

WilsonECore stability: assessment and functional strengthening of the hip abductorsStrength Condition J20052722123

 Web of Science ®Google Scholar

PresswoodLCroninJKeoghJWLWhatmanCGluteus medius: applied anatomy, dysfunction, assessment, and progressive strengtheningStrength Condition J200830541

 Web of Science ®Google Scholar

ReimanMPGoodeAPHegedusEJCookCEWrightAADiagnostic accuracy of clinical tests of the hip: a systematic review with meta-analysisBr J Sports Med2013471489390222773321

 PubMed Web of Science ®Google Scholar

EarlJEHochAZA Proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndromeAm J Sport Med2011391154163

 PubMed Web of Science ®Google Scholar

FerberRBolglaLEarl-BoehmJEEmeryCHamstra-WrightKStrengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trialJ Athl Train201550436637725365133

 PubMed Web of Science ®Google Scholar

McGillSMChildsALiebensonCEndurance times for low back stabilization exercises: clinical targets for testing and training from a normal databaseArchiv Phys Med Rehabil1999808941944

 PubMed Web of Science ®Google Scholar

WitvrouwELysensRBellemansJCambierDVanderstraetenGIntrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective studyAm J Sports Med200028448048910921638

 PubMed Web of Science ®Google Scholar

WaryaszGRMcDermottAYPatellofemoral pain syndrome (PFPS): a systematic review of anatomy and potential risk factorsDyn Med20087918582383

 PubMedGoogle Scholar

PivaSRGoodniteEAChildsJDStrength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndromeJ Orthop Sports Phys Ther2005351279380116848100

 PubMed Web of Science ®Google Scholar

WhiteLCDolphinPDixonJHamstring length in patellofemoral pain syndromePhysiotherapy2009951242819627682

 PubMed Web of Science ®Google Scholar

DavisDSQuinnROWhitemanCTWilliamsJDYoungCRConcurrent validity of four clinical tests used to measure hamstring flexibilityJ Strength Cond Res200822258358818550977

 PubMed Web of Science ®Google Scholar

DavisDSAshbyPEMcCaleKLMcQuainJAWineJMThe effectiveness of 3 stretching techniques on hamstring flexibility using consistent stretching parametersJ Strength Cond Res2005191273215705041

 PubMed Web of Science ®Google Scholar

YoudasJWKrauseDAHollmanJHHarmsenWSLaskowskiEThe influence of gender and age on hamstring muscle length in healthy adultsJ Orthop Sports Phys Ther200535424625215901126

 PubMed Web of Science ®Google Scholar

GabbeBBennellKWajswelnercHFinchCReliability of common lower extremity musculoskeletal screening testsPhys Ther Sport2004529097

 Web of Science ®Google Scholar

TylerTFNicholasSJMullaneyMJMcHughMPThe role of hip muscle function in the treatment of patellofemoral pain syndromeAm J Sports Med200634463063616365375

 PubMed Web of Science ®Google Scholar

PostWRPatellofemoral pain: results of nonoperative treatmentClin Orthop Relat Res20054365559

 Web of Science ®Google Scholar

BartlettMDWolfLSShurtleffDBStahellLTHip flexion contractures: a comparison of measurement methodsArch Phys Med Rehabil19856696206254038029

 PubMed Web of Science ®Google Scholar

HarveyDAssessment of the flexibility of elite athletes using the modified Thomas testBr J Sports Med199832168709562169

 PubMed Web of Science ®Google Scholar

WinslowJYoderEPatellofemoral pain in female ballet dancers: correlation with iliotibial band tightness and tibial external rotationJ Orthop Sports Phys Ther199522118217550298

 PubMed Web of Science ®Google Scholar

HudsonZDarthuyEIliotibial band tightness and patellofemoral pain syndrome: a case-control studyMan Ther200914214715118313972

 PubMed Web of Science ®Google Scholar

PunielloMSIliotibial band tightness and medial patellar glide in patients with patellofemoral dysfunctionJ Orthop Sports Phys Ther19931731441488472078

 PubMed Web of Science ®Google Scholar

WangTGJanMHLinKHWangHKAssessment of stretching of the iliotibial tract with Ober and modified Ober tests: an ultrasonographic studyArchiv Phys Med Rehabil2006871014071411

 Web of Science ®Google Scholar

MelchioneWESMReliability of measurements obtained by use of an instrument designed to indirectly measure iliotibial band lengthJ Orthop Sports Phys Ther19931835115158298633

 PubMed Web of Science ®Google Scholar

ReeseNBandyWUse of an inclinometer to measure flexibility of the iliotibial band using the Ober test and the modified Ober test: differences in magnitude and reliability of measurementsJ Orthop Sports Phys Ther200333632633012839207

 PubMed Web of Science ®Google Scholar

Sanchis-AlfonsoVRosello-SastreEMartinez-SanjuanVPathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active youngAm J Knee Surg1999121294010050691

 PubMedGoogle Scholar

DennisRJFinchCFElliottcBCFarhartPJThe reliability of musculoskeletal screening tests used in cricketPhys Ther Sport200891253319083701

 PubMed Web of Science ®Google Scholar

BennellKLTalbotRCWajswelnerHTechovanichWKellyDHHallAJIntra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexionAust J Physiother199844317518011676731

 PubMedGoogle Scholar

BartonCJBonannoDLevingerPMenzHBFoot and ankle characteristics in patellofemoral pain syndrome: a case control and reliability studyJ Orthop Sports Phys Ther201040528629620436240

 PubMed Web of Science ®Google Scholar

PowersCMMaffucciRHamptonSRearfoot posture in subjects with patellofemoral painJ Orthop Sports Phys Ther19952241551608535473

 PubMed Web of Science ®Google Scholar

BartonCJLevingerPCrossleyKMWebsterKEMenzHBRelationships between the Foot Posture Index and foot kinematics during gait in individuals with and without patellofemoral pain syndromeJ Foot Ankle Res201141021401957

 PubMed Web of Science ®Google Scholar

RedmondACrosbieJOuvrierRDevelopment and validation of a novel rating system for scoring standing foot posture: the Foot Posture IndexClin Biomech (Bristol, Avon)20062118998

 PubMed Web of Science ®Google Scholar

RedmondACCraneYZMenzHBNormative values for the foot posture indexJ Foot Ankle Res200811618822155

 PubMed Web of Science ®Google Scholar

KannusPNiittymakiSWhich factors predict outcome in the nonoperative treatment of patellofemoral pain syndrome? A prospective follow-up studyMed Sci Sports Exerc19942632892968183092

 PubMed Web of Science ®Google Scholar

BradyRJDeanJBSkinnerTMGrossMTLimb length inequality: clinical implications for assessment and interventionJ Orthop Sports Phys Ther200333522123412774997

 PubMed Web of Science ®Google Scholar

GogiaPPBraatzJHValidity and reliability of leg length measurementsJ Orthop Sports Phys Ther19868418518818802226

 PubMedGoogle Scholar

HoyleDLatourMBohannonRIntraexaminer, interexaminer, and inter-device comparability of leg length measurements obtained with measuring tape and metrecomJ Orthop Sports Phys Ther199114626326818796809

 PubMedGoogle Scholar

DixitSDiFioriJPBurtonMMinesBManagement of patellofemoral pain syndromeAm Fam Phys2007752194202

 PubMed Web of Science ®Google Scholar

FredericsonMYoonKPhysical examination and patellofemoral pain syndromeAm J Phys Med Rehabil200685323424316505640

 PubMed Web of Science ®Google Scholar

HaimAYanivMDekelSAmirHPatellofemoral pain syndrome: validity of clinical and radiological featuresClin Orthop Relat Res200645122322816788411

 PubMed Web of Science ®Google Scholar

WatsonCJProppsMGaltWReddingADobbsDReliability of McConnell’s classification of patellar orientation in symptomatic and asymptomatic subjectsJ Orthop Sports Phys Ther1999297378385 discussion 386–39310416177

 PubMed Web of Science ®Google Scholar

PowersCMMortensonSNishimotoDSimonDCriterion-related validity of a clinical measurement to determine the medial/lateral component of patellar orientationJ Orthop Sports Phys Ther199929737237710416176

 PubMed Web of Science ®Google Scholar

WatsonCJLeddyHMDynjanTDParhamJLReliability of the lateral pull test and tilt test to assess patellar alignment in subjects with symptomatic knees: student ratersJ Orthop Sports Phys Ther200131736837411451307

 PubMed Web of Science ®Google Scholar

SmithTODaviesLDonellSTThe reliability and validity of assessing medio-lateral patellar position: a systematic reviewMan Ther200914435536218824392

 PubMed Web of Science ®Google Scholar

al-RawiZNessanAHJoint hypermobility in patients with chondromalacia patellaeBr J Rheumatol19973612132413279448595

 PubMedGoogle Scholar

BoyleKLWittPRiegger-KrughCIntrarater and interrater reliability of the beighton and horan joint mobility indexJ Athl Train200338428128514737208

 PubMed Web of Science ®Google Scholar

RemvigLJensenDVWardRCAre diagnostic criteria for general joint hypermobility and benign joint hypermobility syndrome based on reproducible and valid tests? A review of the literatureJ Rheumatol200734479880317295436

 PubMed Web of Science ®Google Scholar

LunVMeeuwisseWStergiouPStefanyshynDRelation between running injury and static lower limb alignment in recreational runnersBr J Sports Med200438557658015388542

 PubMed Web of Science ®Google Scholar

KrausVBVailTPWorrellTMcDanielGA comparative assessment of alignment angle of the knee by radiographic and physical examination methodsArthritis Rheumatol200552617301735

 PubMed Web of Science ®Google Scholar

MacriEMStefanikJJKhanKKCrossleyKMIs tibiofemoral or patellofemoral alignment or trochlear morphology associated with patellofemoral osteoarthritis? A systematic reviewArthritis Care Res2016681014531470

 Web of Science ®Google Scholar

DaviesAPCostaMLDonnellSTGlasgowMMShepstoneLThe sulcus angle and malalignment of the extensor mechanism of the kneeBone Joint J200082811621166

 Google Scholar

SmithTCoganAPatelSShakokaniMTomsADonellSThe intra-and inter-rater reliability of X-ray radiological measurements for patellar instabilityKnee201320213313822727319

 PubMed Web of Science ®Google Scholar

DuranSCavusogluMKocadalOSakmanBAssociation between trochlear morphology and chondromalacia patella: an MRI studyClin Imaging20174171027723501

 PubMed Web of Science ®Google Scholar

BakerVBennellKStillmanBCowanSCrossleyKAbnormal knee joint position sense in individuals with patellofemoral pain syndromeJ Orthop Res200220220821411918299

 PubMed Web of Science ®Google Scholar

CallaghanMJWhat does proprioception testing tell us about patellofemoral pain?Man Ther2011161464720702131

 PubMed Web of Science ®Google Scholar

StillmanBCAn investigation of the clinical assessment of joint position sense [PhD thesis]The University of MelbourneAustralia2000

 Google Scholar

ThijsYVan TiggelenDRoosenPDe ClercqDWitvrouwEA prospective study on gait-related intrinsic risk factors for patellofemoral painClin J Sport Med200717643744517993785

 PubMed Web of Science ®Google Scholar

De CockADe ClercqDWillemsTWitvrouwETemporal characteristics of foot roll-over during barefoot jogging: reference data for young adultsGait Posture200521443243915886133

 PubMed Web of Science ®Google Scholar