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BJSM Online First, published on May 31, 2016 as 10.1136/bjsports-2016-096268
Consensus statement

2016 Patellofemoral pain consensus statement from

the 4th International Patellofemoral Pain Research
Retreat, Manchester. Part 2: recommended physical
interventions (exercise, taping, bracing, foot
orthoses and combined interventions)
Kay M Crossley,1 Marienke van Middelkoop,2 Michael J Callaghan,3,4
Natalie J Collins,5 Michael Skovdal Rathleff,6 Christian J Barton1
1
La Trobe Sport and Exercise INTRODUCTION January 2010 and June 2015. To be eligible, publi-
Medicine Research Centre, Patellofemoral pain affects physically active and sed- cations were (i) the most current systematic reviews
College of Science, Health and
Engineering, La Trobe entary individuals, accounting for 11–17% of knee including meta-analyses and (ii) any RCTs pub-
University, Melbourne, Victoria, pain presentations to general practice1 2 and 25– lished subsequent to the most recent systematic
Australia 40% of all knee problems seen in a sports injury review.
2
Department of General clinic.3 4 Patellofemoral pain is characterised by Search terms used to search titles and abstracts of
Practice, Erasmus MC
anterior knee pain associated with activities such as papers relating to patellofemoral pain in each data-
University Medical Center,
Rotterdam, The Netherlands squatting, rising from sitting and stair ambulation. base were ( patella or patellofemoral) and (pain or
3
Centre for Musculoskeletal While traditionally viewed as self-limiting, increas- syndrome or dysfunction).13 To narrow the search
Research, University of ing research data suggest that patellofemoral pain is to identify systematic reviews, these diagnostic
Manchester, Manchester, UK often recalcitrant and can persist for many years,5–8 terms were combined with the keyword review.
4
Department of Health
Professions, Manchester
and may cause a decline in sports participation.8 9 To narrow the search to identify any contempor-
Metropolitan University, Despite its high prevalence among active indivi- ary randomised trials, diagnostic terms were com-
Manchester, UK duals9–12 and frequent presentations for treatment, bined with (controlled trial or clinical trial) and
5
School of Health and there are few published guidelines to help clinicians additional searching was completed in the
Rehabilitation Sciences, choose the appropriate evidence-based treatment for Physiotherapy Evidence Database (PEDro).
The University of Queensland,
Melbourne, Victoria, Australia patellofemoral pain. The most recent and relevant Additionally, all authors on this consensus state-
6
Research Unit for General paper from Barton and colleagues13 combined sys- ment were consulted to identify any missing
Practice in Aalborg and tematic review findings with qualitative interviews papers. To be included, randomised trials were
Department of Clinical from expert clinicians to provide a clinically relevant required to evaluate one or more conservative
Medicine, Aalborg University,
Aalborg, Denmark
synthesis, covering the literature up to September intervention compared with a control or alternative
2013. At the International Patellofemoral Pain conservative intervention, using an outcome
Correspondence to Research Retreat in Manchester 2015, we held a measure related to pain (eg, pain visual analogue
Professor Michael Callaghan, consensus meeting to update the current evidence scale (VAS)) or patient-reported improvement, and
Department of Health
base and produce consensus-based recommenda- using a randomised method for group allocation.
Professions, Manchester
Metropolitan University, tions regarding treatment for patellofemoral pain. Data were extracted from each included paper.
Manchester, UK; All retreat registrants were active researchers in Where multiple systematic reviews were available
michael.callaghan@mmu.ac.uk patellofemoral pain and presented their research for the same intervention from the same time
findings. Many of the world leading researchers (eg, period, findings from moderate–high quality
Accepted 3 May 2016
8 out of the top 10 researchers with the highest reviews were used in preference to low-quality
number of publications, when the term ‘patellofe- reviews. If no systematic reviews were available, all
moral pain’ was searched in Scopus, February 2016) published RCTs related to the intervention were
were in attendance and contributed to the consensus included. Findings from included reviews and trials
meeting. were used to generate a summary table, which
The consensus meeting during the retreat included study methodology, relevant outcomes
resulted in recommendations, based on evidence and effect sizes.
published between January 2010 and June 2015. The methodological quality of meta-analyses and
These recommendations should be combined with systematic reviews was graded with the Assessment
information gathered from individual patients, of Multiple Systematic Reviews (AMSTAR) tool;
regarding their preferences, experiences, presenta- and RCTs were graded with the PEDro rating scale.
tion and values, along with the values, expertise Rating was completed by two independent
and skills of individual practitioners to create a reviewers (CJB and MvM), and discrepancies
patient-centred treatment approach. resolved through a consensus meeting. A third
To cite: Crossley KM, van reviewer (KMC) was available to settle any dis-
Middelkoop M,
Callaghan MJ, et al. Br J
METHODS agreement but was not required.
Sports Med Published Online Literature review
First: [ please include Day CJB searched EMBASE, MEDLINE, CINAHL and Quality of evidence
Month Year] doi:10.1136/ Current Contents for systematic reviews and rando- For systematic reviews, the following allocation was
bjsports-2016-096268 mised controlled trials (RCTs) published between applied based on AMSTAR scores:
Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268 1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
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Consensus statement

▸ High quality (HQ): ≥7 systematic reviews were identified. Consultation with consensus
▸ Moderate quality (MQ): 4–6 authors did not yield any additional reviews. The interventions
▸ Low quality (LQ): ≤3 were grouped into the following: (i) exercise therapy (with sep-
For RCTs, the following allocation was applied based on PEDro arate sections for exercise therapy targeting specific bodily
scores: regions, ie, knee or hip); (ii) combined interventions (combining
▸ High quality (HQ): ≥7 two or more of exercise therapy, patellar taping, mobilisation or
▸ Moderate quality (MQ): 4–6 foot orthoses); (iii) foot orthoses (in-shoe orthotic devices); (iv)
▸ Low quality (LQ): ≤3 patellar taping and bracing and (v) other adjunctive interven-
tions (eg, acupuncture, mobilisation, electrophysical agents).
Expert panel Some of the reviews covered several interventions.
The patellofemoral pain expert panel was composed of 35 of
the 50 attendees at the 2015 International Patellofemoral Available systematic reviews and available evidence
Research Retreat (Manchester). All attendees were actively This included 13 (5 moderate; 1 high quality) reviews related to
researching patellofemoral pain and included physiotherapists, exercise therapy, 2 (1 moderate quality) related to combined
doctors, podiatrists, biomechanists, epidemiologists and sports interventions, 5 (3 moderate; 1 high quality) related to foot
therapists. orthoses, 4 (2 moderate; 1 high quality) related to patellar
taping and bracing, and 7 (2 moderate quality) related to other
Recommendations adjunctive interventions. AMSTAR ratings for each of these sys-
Literature summary tables were developed by the consensus tematic reviews and the search date included in their methods
group (KMC, MvM, MJC, NJC, MSR, CJB) and distributed to are outlined in table 1.
all panel members prior to the consensus meeting. The summar-
ies contained the quality ratings and effect sizes. Duration of Additional RCT evidence
treatment effect was classified as follows: <6 months considered Subsequent searching for RCTs since 2010 revealed an add-
short term, between 6 and 12 months was medium term and itional 1631 citations. After taking into account the literature
>12 months considered long term, unless otherwise defined in covered by included systematic reviews, 36 of these were consid-
the systematic review. Statements were generated by the consen- ered for inclusion. Of these 36, an additional 7 randomised
sus group regarding each intervention, which reflected the evi- trials were identified. These included 1 on exercise therapy, 2
dence, and with respect to the interventions’ effect on pain, on combined interventions, 2 on foot orthoses, 1 on patellar
function and overall symptomatic improvement (ie, global rating taping and 1 on other adjunctive interventions. PEDro ratings
of change). The panel was instructed to vote on the appropriate- for each of these trials are outlined in table 2.
ness of each statement.
The panel was instructed to integrate the evidence for each
intervention with their expert opinions and knowledge in order Recommendations
to interpret the appropriateness of each intervention. At the Twenty-four statements (separated into time points and primary
Research Retreat, a 1-hour discussion of the summary tables outcomes) were voted on by the panel.
(led by the consensus group) enabled clarification of the study Results of this and associated evidence are outlined in figures
elements, and finalisation of the statements. Following the dis- 1–7, including 12 statements related to exercise therapy (figures
cussion, panel members voted on the appropriateness of each 1–3), 3 statements related to combined interventions (figure 4),
intervention. 2 statements related to foot orthoses (figure 5), 4 statements
related to patellar taping and bracing (figure 6) and 4 statements
related to other adjunctive interventions (figure 7).
Voting and scoring
Key areas of uncertainty included combined interventions for
A 10-point scale (0–9, where 0 is ‘not appropriate’ and 9 is
adolescents, prioritisation of hip or knee exercise, acupuncture
‘appropriate’) was used to evaluate the appropriateness of each
and patellar taping and bracing. We can make six recommenda-
intervention. This scale was based on one similar previously
tions based on consistency between consensus voting and the
used to generate the Osteoarthritis Research Society
current evidence:
International (OARSI) guidelines for the non-surgical manage-
ment of knee osteoarthritis.14
Exercise therapy
Not appropriate Appropriate 1. Exercise is recommended to reduce pain in the short,
medium and long term, and improve function in the
0 1 2 3 4 5 6 7 8 9 medium and long term.
2. Combining hip and knee exercises is recommended to
A pooled score provided a median appropriateness score for reduce pain and improve function in the short, medium and
each intervention. A score of 0–3 was considered ‘inappropri- long term, and this combination should be used in prefer-
ate’, 4–6 ‘uncertain’ and 7–9 ‘appropriate’. ence to knee exercises alone.

Final recommendations Combined interventions

Final recommendations were made on interventions where the 1. Combined interventions are recommended to reduce pain in
outcome was consistent between voting and the evidence asso- adults with patellofemoral pain in the short and medium
ciated with this statement. term.

RESULTS Foot orthoses

The initial literature search for systematic reviews yielded 586 1. Foot orthoses are recommended to reduce pain in the short
citations. Following screening for eligibility, a total of 22 term.
2 Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268
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Consensus statement

Table 1 AMSTAR quality assessment of included systematic reviews

Score per AMSTAR item
Systematic review i ii iii iv v vi vii viii ix x xi Total score Search date

Exercise therapy
Bolgla and Boling15 0 CA 0 1 0 0 0 0 0 0 0 1 2010—December
Clijsen et al16 0 CA 1 0 0 0 1 1 1 1 0 5 2013—December
Collins et al17 0 0 1 0 0 0 1 1 1 0 0 4 2009—November
Frye et al18 0 CA 0 0 0 0 1 0 0 0 0 1 2010—September
Harvie et al 19 0 CA 1 0 0 0 1 0 0 0 0 2 2010—January
Kooiker et al20 0 CA 1 CA 1 1 1 1 1 0 0 6 2014—January
Lack et al21 0 CA 1 CA 0 0 1 1 1 0 0 4 2014—December
Nobre22 0 CA 0 CA 0 0 0 0 0 0 0 0 2011—Unclear
Page23 0 CA 0 CA 0 0 0 0 0 0 0 0 2010—August
Peters and Tyson24 0 0 1 0 0 0 1 0 1 0 0 3 2013—January
Regelski et al25 0 CA 0 0 0 0 1 CA 0 0 0 1 Unclear
van der Heijden et al26 1 1 1 1 1 1 1 1 1 1 0 10 2014—May
Wasielewki 2011 0 1 0 0 1 1 1 1 1 0 0 6 2010—Unclear
Combined intervention
Bolgla et al15 0 CA 0 1 0 0 0 0 0 0 0 1 2010—December
Collins et al17 0 0 1 0 0 0 1 1 1 0 0 4 2009—November
Foot orthoses
Barton et al27 0 CA 1 0 1 1 1 1 1 0 0 6 2008—December
Bolgla et al15 0 CA 0 1 0 0 0 0 0 0 0 1 2010—December
Collins et al17 0 0 1 0 0 0 1 1 1 0 0 4 2009—November
Hossain et al28 1 1 1 CA 1 0 1 1 1 1 0 8 2010—March
Swart et al29 0 1 1 0 0 1 1 1 1 0 0 6 2010—January
Patellar taping and bracing
Barton et al30 0 CA 1 CA 0 0 1 1 1 0 0 4 2013—January
Callaghan and Selfe31 1 1 1 1 1 1 1 1 1 0 0 9 2011—August
Kalron and Bar-Sela32 0 CA 1 0 0 0 1 0 1 0 0 3 2012—March
Swart et al29 0 1 1 0 0 1 1 1 1 0 0 6 2010—January
Other adjunctive interventions
Bolgla et al15 0 CA 0 1 0 0 0 0 0 0 0 1 2010—December
Brantingham et al 33 0 CA 0 0 0 0 0 0 0 0 0 0 2011—May
Collins et al17 0 0 1 0 0 0 1 1 1 0 0 4 2009—November
Dos Santos et al34 0 CA 0 CA 0 0 0 0 0 0 0 0 2011—Unclear
Lake and Wofford35 0 CA 1 0 0 0 1 0 0 0 0 2 2010—August
Wasielewskiet al36 0 1 0 0 1 1 1 1 1 0 0 6 2010—Unclear
Bold text=Reviews considered to be moderate or high quality.
i=‘a priori’ design; ii=duplicate study selection and data extraction; iii=comprehensive literature search; iv=search for grey literature; v=list of studies included and excluded provided;
vi=characteristics of included studies provided; vii=scientific quality assessed; viii=scientific quality used to formulate conclusions; ix=methods to combine study findings appropriate;
x=publication bias assessed; xi=conflict of interest.
0, no; 1, yes; AMSTAR, Assessment of Multiple Systematic Reviews; CA, cannot assess.

Other adjunctive interventions Six recommendations from the expert panel

1. Patellofemoral, knee and lumbar mobilisations may not The six recommendations were as follows:
improve outcomes. 1. Exercise-therapy is recommended to reduce pain in the
2. Electrophysical agents may not improve outcomes. short, medium and long term, and improve function in the
medium and long term.
DISCUSSION 2. Combining hip and knee exercises is recommended to
The International Patellofemoral Research Retreat Consensus reduce pain and improve function in the short, medium and
meeting resulted in six evidence-based recommendations. These long term, and this combination should be used in prefer-
recommendations will guide medical and health practitioners ence to knee exercises alone.
when they treat patients with patellofemoral pain. 3. Combined interventions are recommended to reduce pain in
Recommendations may also be taken up by patients, other care adults with patellofemoral pain in the short and medium
providers, and government agencies and other organisations term.
responsible for funding patellofemoral pain treatment. The 4. Foot orthoses are recommended to reduce pain in the short
recommendations are not intended to standardise patient care, term.
but to be used in combination with individualised assessments 5. Patellofemoral, knee and lumbar mobilisations are not
of patient’s needs, preferences and presentations, and clinical recommended.
expertise to inform patient-centred management.44 6. Electrophysical agents are not recommended.
Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268 3
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Consensus statement

within the scientific literature and remains a recommendation as

Table 2 PEDro quality assessment of included RCTs
a stand-alone treatment from our consensus based on the
Score per PEDro item
Total strength of evidence supporting it. In contrast, interventions
Study i* ii iii iv v vi vii viii ix x xi score such as acupuncture have very limited supporting evidence.
Appropriateness of acupuncture was voted as uncertain, and
Exercise therapy hence was not recommended in the current consensus meeting.
Ferber et al37 1 1 1 0 0 0 0 0 1 1 1 5 However, acupuncture is frequently used by clinicians who treat
Combined intervention patellofemoral pain, and this highlights a nexus between evi-
Mason et al38 1 1 0 0 0 0 1 0 1 0 1 4 dence and practice which requires high-quality clinical trials.
Rathleff et al39 1 1 1 1 0 0 0 1 1 1 1 7 The consensus meeting has also made recommendations against
Foot orthoses interventions such as mobilisation and electrotherapy, which
Lewinson et al40 1 1 0 1 1 0 0 1 0 1 1 5 current evidence indicates are ineffective. The consensus
Mills et al41 1 1 1 1 1 0 1 1 1 1 1 9 meeting was also unable to make any recommendations related
Patellar taping and bracing to patient education in isolation, due to a paucity of research in
Osorio et al42 1 1 1 0 0 0 0 0 0 1 1 4 this area. Considering the perceived importance of providing
Other adjunctive interventions patient education from clinicians,13 further research and devel-
Hains and Hains43 0 1 1 1 1 0 1 1 1 1 1 9 opment on patient education interventions is encouraged.
i=eligibility criteria; ii=random allocation; iii=concealed allocation; iv=baseline
comparability; v=blind subjects; vi=blind therapists; vii=blind assessors; viii=adequate
follow-up; ix intention-to-treat analysis; x=between-group comparisons; xi=point Exercise therapy: the treatment of choice
estimates and variability.
*Eligibility criteria item does not contribute to total score. Exercise therapies had the most statements in support of their
0, no or unable to determine; 1, yes; PEDro, Physiotherapy Evidence Database; RCTs, short-term, medium-term and long-term use, reflecting the large
randomised controlled trials. body of evidence underpinning this treatment. Exercise therapy
was the only intervention tested in isolation to be supported by
the expert group. The evidence clearly shows that exercise
Our recommendations differ from those described in the therapy is effective, regardless of the type of exercise (eg, in
‘Best Practice Guide to Conservative Management of weight bearing or not; targeting hip or knee). There was also
Patellofemoral Pain’.13 The best practice guide did not recom- support for emerging but convincing evidence that combining a
mend exercise therapy as a stand-alone treatment, but recom- hip-focused with knee-focused exercise therapy regimen resulted
mended consideration of acupuncture, and provided no in superior outcomes to isolated knee-focused exercise therapy.
recommendations regarding treatments which may not improve This is consistent with results from the combined intervention
outcomes. These differences likely reflect the qualitative input studies, which have included hip-focused and knee-focused exer-
from clinicians in the paper.13 In contrast, the consensus voting cise therapies. The uncertainty around the superiority of hip-
that led to our recommendations involved some researchers focused when compared head-to-head with knee-focused treat-
who had a clinical role and some who did not. For example, it ments may reflect lack of clarity regarding implementation of
appears that clinicians have a stronger preference for combined targeted exercise therapies, and the potential for the reported
interventions (using a combination of exercise therapy, targeting exercise therapy regimens to truly only target either the hip or
knee and hip musculature, patellofemoral taping, mobilisation the knee. For example, knee-focused programmes including
and foot orthoses), which was a recommendation from our con- single-leg squatting or stair climbing activities will also target
sensus, than for stand-alone treatments, such as exercise therapy. the hip, while standing exercises to target the hip with resistance
However, exercise therapy has been evaluated considerably will also involve a knee focus on the weight-bearing limb.

Figure 1 Synthesis of current evidence with consensus voting and recommendations for exercise therapy. First quartile=left whisker; second
quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right whisker.
4 Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268
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Consensus statement

Figure 2 Synthesis of current evidence with consensus voting and recommendations for hip combined with knee targeted exercise therapy. First
quartile=left whisker; second quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right
whisker.

The terms ‘exercise’ and ‘exercise therapy’ were discussed at reporting standards for patellofemoral pain studies, similar to
length at the meeting. There is distinct lack of clarity regarding those published for groin pain studies,45 and these standards are
the taxonomy and reporting of exercise therapy treatments. published by Morrisey et al.
Even when well reported, the type of exercise in the current evi-
dence base varies with respect to the targets of the exercise (eg, Combined interventions
strength, cardiovascular fitness, coordination/neuromuscular Combined interventions (combining exercise therapy, targeting
retraining).21 Furthermore, measurement of the effectiveness of knee and hip musculature, patellofemoral taping, mobilisation
such interventions to achieve their target, such as increasing and foot orthoses) were considered appropriate for patients with
strength, endurance and neuromuscular coordination, was rarely patellofemoral pain, which is consistent with the strongest rec-
undertaken. Perhaps most importantly, the lack of detailed ommendation from the ‘Best Practice Guide’.13 A combined
description of the exercise therapy interventions limits the trans- approach to management best reflects clinical practice and pro-
lation of the research findings into clinical practice. This lack of vides the treating practitioner with the scope to address a
reporting rigour for exercise therapy extends to other interven- number of contributing factors (not just one in isolation).
tions described in this consensus statement. As a result of this However, an important recommendation made in the ‘Best
discussion, a recommendation was made to adopt minimum Practice Guide’ regarding combined interventions is the need to

Figure 3 Synthesis of current evidence with consensus voting and recommendations for hip targeted exercise therapy. First quartile=left whisker;
second quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right whisker.
Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268 5
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Consensus statement

Figure 4 Synthesis of current evidence with consensus voting and recommendations for combined interventions. First quartile=left whisker; second
quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right whisker. RCT, randomised controlled
trial.

individualise treatments to each patient, as not all patients will less ankle dorsiflexion and immediate improvements in patello-
require all treatments.13 Current research evidence to guide the femoral pain when performing a single-leg squat with foot
tailoring of interventions is very limited,46 and efforts to address orthoses.52
this are encouraged. Uncertainty around the recommendation
supporting combined interventions for adolescents with patello- Patellar taping
femoral pain most likely reflected the lack of studies, as there is Whether patellar taping should be first-line treatment for patel-
currently only one RCT39 and no systematic reviews. Outcomes lofemoral pain was unclear to this expert panel. This conclusion
for adolescents were consistent with the pooled standardised was consistent with the ‘Best Practice Guide’13 findings. Patellar
mean difference (SMD) for a similar intervention in adults,47 taping approaches vary considerably with respect to the type
but the overall rates of recovery after treatment may be lower in and duration of taping, and the systematic reviews29–31 that syn-
adolescents than in adults.48 We welcome further studies investi- thesise these studies have dealt with the variability inconsist-
gating treatment options in this group, especially given evidence ently. Lack of clarity from systematic reviews may partially
of symptoms persisting well beyond adolescence.49 explain the uncertainty around the consensus voting and asso-
ciated recommendations to support patellar taping.
Foot orthoses Uncertainty around the recommendations for taping might
Foot orthoses were recommended for short-term pain relief in also reflect that greater consideration of individual patient needs
people with patellofemoral pain, and this is consistent with the may be required. For example, in Barton et al’s13 synthesis, the
‘Best Practice Guide’.13 However, an important consideration is experts described that targeting the taping to suit individual
that the average pain reduction facilitated by prefabricated foot patient presentations was an important consideration. Patellar
orthoses may be considered to lack clinical significance, due to taping and bracing could play a role in patellofemoral pain man-
substantial individual variability in response.50 The key point is agement in combination with other treatments (ie, as part of a
that foot orthoses may not be beneficial for all patients with combined intervention as described above), but their role in iso-
patellofemoral pain, and identifying those most likely to benefit lation is yet to be fully determined. Other adjunctive treatments,
from foot orthoses is important. Published studies have reported such as joint mobilisations ( patella, knee, lumbar), and electro-
clinical features that can be used to predict success with foot physical agents were not recommended for use in patellofemoral
orthoses intervention, including greater midfoot mobility,41 51 pain.

Figure 5 Synthesis of current evidence with consensus voting and recommendations for prefabricated foot orthoses. First quartile=left whisker;
second quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right whisker.
6 Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268
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Consensus statement

Figure 6 Synthesis of current evidence with consensus voting and recommendations for patellar taping and bracing. First quartile=left whisker;
second quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right whisker.

LIMITATIONS rigour) as well as a limitation (some members have no experi-

Our consensus on physical and exercise treatments for patellofe- ence in patient management). Furthermore, there was no patient
moral pain was limited to the treatments with evidence regard- input into the voting on our recommendations, and we recom-
ing their usefulness. The inclusion of evidence stemming from mend that their values and preferences be considered when
moderate-quality and high-quality systematic reviews means that applying recommendations clinically.44
not all potentially valuable interventions were covered. For
example, while gait retraining shows emerging evidence sup- FUTURE DIRECTIONS
porting its use in patellofemoral pain,53 more rigorous research Our consensus group recommended some future directions
is required before it can be considered as a recommended regarding interventions for patellofemoral pain. We recognised
intervention. the need for minimum reporting standards for clinical research
Our expert panel self-selected participants who attended the on patellofemoral pain, similar to that published for groin pain
International Patellofemoral Pain Research Retreat. While all in athletes,45 which is being undertaken. We recommended that
participants were active in patellofemoral research and most of future trials should publish details of the intervention in suffi-
the productive researchers worldwide were in attendance, the cient detail to enable clinicians to apply these in clinical practice
panel was not specifically chosen, based on their expertise. The (possibly as supplementary files). We require greater understand-
inclusion of researchers and clinicians is a strength (ensuring ing of potential mechanisms underpinning treatment effects. We
expertise with research methodology and respect for scientific recognise that there is uncertainty regarding the usefulness of

Figure 7 Synthesis of current evidence with consensus voting and recommendations for other adjunctive interventions. First quartile=left whisker;
second quartile=yellow box; median=yellow and green box intersection; third quartile=green box; fourth quartile=right whisker. *Statement worded
opposite for voting, that is, based on evidence (eg, does not improve pain).
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Consensus statement

subgroups,54 or individualised (clinical reasoning) approaches to 12 Boling M, Padua D, Marshall S, et al. Gender differences in the incidence and
optimise treatments. As with all exercise interventions, adher- prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports
2010;20:725–30.
ence is paramount, and methods to advance adherence are 13 Barton CJ, Lack S, Hemmings S, et al. The ‘Best practice guide to conservative
urgently needed. It is still unclear which specific pain pathways management of patellofemoral pain’: incorporating level 1 evidence with expert
(local and central pain mechanisms) are primarily involved in clinical reasoning. Br J Sports Med 2015;49:923–34.
patellofemoral pain, but it appears that central pain mechanisms 14 McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the
non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage
may be altered in people with patellofemoral pain.55–57 This
2014;22:363–88.
clearly indicates the need to evaluate non-mechanical interven- 15 Bolgla LA, Boling MC. An update for the conservative management of
tions to address these factors in some individuals. We recom- patellofemoral pain syndrome: a systematic review of the literature from 2000 to
mend future trials investigating interventions for patellofemoral 2010. Int J Sports Phys Ther 2011;6:112–25.
pain across the lifespan (ie, adolescents and those with patellofe- 16 Clijsen R, Fuchs J, Taeymans J. Effectiveness of exercise therapy in treatment of
patients with patellofemoral pain syndrome: systematic review and meta-analysis.
moral osteoarthritis). Phys Ther 2014;94:1697–708.
There was overarching support from the International 17 Collins NJ, Bisset LM, Crossley KM, et al. Efficacy of nonsurgical interventions for
Patellofemoral Pain Research Retreat for the Enhancing the anterior knee pain systematic review and meta-analysis of randomized trials. Sports
QUality And Transparency Of health Research (EQUATOR) Med 2012;42:31–49.
18 Frye JL, Ramey LN, Hart JM. The effects of exercise on decreasing pain and
guidelines (http://www.equator-network.org) for reporting, and
increasing function in patients with patellofemoral pain syndrome: a systematic
we encourage investigators to follow the appropriate reporting review. Sports Health 2012;4:205–10.
guideline in future patellofemoral pain publications. 19 Harvie D, O’Leary T, Kumar S. A systematic review of randomized controlled trials
on exercise parameters in the treatment of patellofemoral pain: what works?
J Multidiscip Healthc 2011;4:383–92.
CONCLUSION
20 Kooiker L, van de Port IG, Weir A, et al. Effects of physical therapist-guided
The consensus meeting at the 4th International Patellofemoral quadriceps-strengthening exercises for the treatment of patellofemoral pain
Pain Research Retreat (Manchester 2015) provided six recom- syndrome: a systematic review. J Orthop Sports Phys Ther 2014;44:391–B1.
mendations for use in patients with patellofemoral pain: exer- 21 Lack S, Barton C, Sohan O, et al. Proximal Muscle Rehabilitation is effective for
cise therapy, particularly combining hip and knee exercises, patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med
2015;49:1365–76.
combined interventions and foot orthoses. Patellofemoral, knee 22 Nobre T. Comparison of exercise open kinetic chain and closed kinetic chain in the
and lumbar mobilisations and electrophysical agents were not rehabilitation of patellofemoral dysfunction: an updated revision. Clin Med Diagn
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Research Retreat is scheduled for Brisbane, Australia, July 2017. 23 Page P. Effectiveness of elastic resistance in rehabilitation of patients with
patellofemoral pain syndrome: what is the evidence? Sports Health 2011;3:190–4.
Twitter Follow Christian Barton at @DrChrisBarton 24 Peters JS, Tyson NL. Proximal exercises are effective in treating patellofemoral pain
syndrome: a systematic review. Int J Sports Phys Ther 2013;8:689–700.
Competing interests None declared. 25 Regelski C, Ford B, Hoch M. Hip strengthening compared with quadriceps
Provenance and peer review Not commissioned; externally peer reviewed. strengthening in conservative treatment of patients with patellofemoral pain:
a critically appraised topic. Int J Athl Ther Train 2015;20:4–12.
Open Access This is an Open Access article distributed in accordance with the 26 van der Heijden RA, Lankhorst NE, van Linschoten R, et al. Exercise for treating
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which patellofemoral pain syndrome. Cochrane Database Syst Rev 2015;1:CD010387.
permits others to distribute, remix, adapt, build upon this work non-commercially, 27 Barton CJ, Munteanu SE, Menz HB, et al. The efficacy of foot orthoses in the
and license their derivative works on different terms, provided the original work is treatment of individuals with patellofemoral pain syndrome: a systematic review.
properly cited and the use is non-commercial. See: http://creativecommons.org/ Sports Med 2010;40:377–95.
licenses/by-nc/4.0/ 28 Hossain M, Alexander P, Burls A, et al. Foot orthoses for patellofemoral pain in
adults. Cochrane Database Syst Rev 2011;(1):CD008402.
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Crossley KM, et al. Br J Sports Med 2016;0:1–9. doi:10.1136/bjsports-2016-096268 9

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2016 Patellofemoral pain consensus

statement from the 4th International
Patellofemoral Pain Research Retreat,
Manchester. Part 2: recommended physical
interventions (exercise, taping, bracing, foot
orthoses and combined interventions)
Kay M Crossley, Marienke van Middelkoop, Michael J Callaghan, Natalie
J Collins, Michael Skovdal Rathleff and Christian J Barton

Br J Sports Med published online May 31, 2016

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http://bjsm.bmj.com/content/early/2016/05/31/bjsports-2016-096268

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