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Review

Proximal muscle rehabilitation is effective for

patellofemoral pain: a systematic review with
Editor’s choice
meta-analysis
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Simon Lack,1 Christian Barton,1,2,3,4 Oliver Sohan,1 Kay Crossley,5 Dylan Morrissey1,6
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▸ Additional material is ABSTRACT and proximal13 factors proposed to contribute to it,

published online only. To view Background Proximal muscle rehabilitation is with good evidence that long axis femoral rotation
please visit the journal online
(http://dx.doi.org/10.1136/
commonly prescribed to address muscle strength and in relation to the patella is a key contributor to mal-
bjsports-2015-094723). function deficits in individuals with patellofemoral pain tracking and a valid rehabilitation target.14
1 (PFP). This review (1) evaluates the efficacy of proximal Consistent with the multifactorial nature of PFP,
Centre for Sports and Exercise
Medicine, Queen Mary musculature rehabilitation for patients with PFP; management of PFP has traditionally focused on a
University of London, UK (2) compares the efficacy of various rehabilitation variety of interventions, including rest, analgesia,
2
Complete Sports Care, protocols; and (3) identifies potential biomechanical general quadriceps and vastus medialis oblique
Melbourne, Australia mechanisms of effect in order to optimise outcomes rehabilitation exercises, proximal rehabilitation exer-
3
Pure Sports Medicine,
London, UK
from proximal rehabilitation in this problematic patient cises, patellar taping, foot orthoses and gait retrain-
4
Lower Extremity Gait Studies, group. ing.15 Each of these interventions has a varying level
Health Sciences, La Trobe Methods Web of Knowledge, CINAHL, EMBASE and of efficacy, with multimodal interventions appearing
University, Bundoora, Australia
5
Medline databases were searched in December 2014 for to be the most effective.16 17 Growing evidence for
School of Health and randomised clinical trials and cohort studies evaluating impaired proximal muscle strength18–20 and func-
Rehabilitation Sciences,
University of Queensland, proximal rehabilitation for PFP. Quality assessment was tion,21 combined with links between hip mechanics
Brisbance, Queensland, performed by two independent reviewers. Effect size and increased risk of PFP,5 22 has resulted in promo-
Australia
6
calculations using standard mean differences and 95% tion of rehabilitation aimed at addressing impair-
Physiotherapy Department, CIs were calculated for each comparison. ments in proximal musculature.14 Our recent mixed
Bart’s Health NHS Trust,
London, UK Results 14 studies were identified, seven of high methods study of international experts’ clinical
quality. Strong evidence indicated proximal combined reasoning when managing PFP supported this rec-
Correspondence to with quadriceps rehabilitation decreased pain and ommendation, but a lack of supporting level-one
Dr Dylan Morrissey, Centre for improved function in the short term, with moderate evidence was also identified.17 The effectiveness of
Sports and Exercise Medicine,
evidence for medium-term outcomes. Moderate evidence proximal rehabilitation protocols have been evalu-
William Harvey Research
Institute, Bart’s and the indicated that proximal when compared with quadriceps ated in high quality recent research,23–26 and
London School of Medicine rehabilitation decreased pain in the short-term and commonly consist of open and closed kinetic chain
and Dentistry, Queen Mary medium-term, and improved function in the medium exercises which reflect clinical practice.27
University of London, Mile End term. Limited evidence indicated proximal combined with A recent low quality (LQ) systematic review con-
Hospital, Bancroft road,
London E1 4DG, UK; quadriceps rehabilitation decreased pain more than cerning proximal rehabilitation for PFP28 con-
d.morrissey@qmul.ac.uk quadriceps rehabilitation in the long term. Very limited cluded that hip interventions were effective in
short-term mechanistic evidence indicated proximal improving pain and function in individuals with
Accepted 9 June 2015 rehabilitation compared with no intervention decreased PFP. However, the search for available evidence was
Published Online First
31 July 2015
pain, improved function, increased isometric hip strength limited to a 2-year period ( January 2011–January
and decreased knee valgum variability while running. 2013), with no attempt at data pooling nor mech-
Conclusions A robust body of work shows proximal anistic exploration and there is, therefore, a need
rehabilitation for PFP should be included in conservative for a more detailed and inclusive review in order to
management. Importantly, greater pain reduction and optimally guide practice.
improved function at 1 year highlight the long-term Our systematic review and meta-analysis aims to
value of proximal combined with quadriceps (1) evaluate the effects of proximal muscle rehabili-
rehabilitation for PFP. tation for patients with PFP, (2) compare the effects
of various rehabilitation protocols, and (3) evaluate
potential mechanism of action in order to opti-
mally guide clinical practice in rehabilitating
INTRODUCTION patients. Further, we aimed to promote clarity in
Patellofemoral pain (PFP) is one of the most rehabilitation programme design and reporting,
common presentations at both primary care and with particular respect to the term ‘strengthening’.
sports injury clinics.1 2 Prevalence rates in groups of
active individuals, including military recruits and METHODS
novice runners, are reported to be between 3% and The PRISMA statement was consulted prior to the
20%.3–5 PFP has been linked to reduced contact start of this review and the checklist completed.29
area and increased stress in the lateral patellofemoral
joint (PFJ)6 7 as a result of patellar maltracking, Inclusion and exclusion criteria
To cite: Lack S, Barton C, including greater lateral patellar translation,8–10 tilt8 Randomised clinical trials (RCTs) and cohort
Sohan O, et al. Br J Sports and spin.9 The cause of maltracking in PFP is studies evaluating proximal muscle rehabilitation
Med 2015;49:1365–1376. thought to be multifactorial with local,11 distal12 programmes were considered for inclusion. A
Lack S, et al. Br J Sports Med 2015;49:1365–1376. doi:10.1136/bjsports-2015-094723 1 of 13
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proximal muscle rehabilitation protocol was defined as progres- reported training methodology and accepted principles of
sive exercise directed at the hip or lumbopelvic musculature or ‘neuromuscular activation’ (exercise performed at <30% 1 repe-
both. Studies of multimodal interventions were included where tition maximum, for >20 repetitions), ‘strength’ (exercise per-
the effects of adding proximal rehabilitation could be clearly formed ≥70% 1 repetition maximum), ‘strength-endurance’
determined. Case reports and non-English studies were (exercise performed at 30–70% 1 repetition maximum) and
excluded. The inclusion criteria required participants to be ‘power’ (exercise performed at either 85–100% 1 repetition
described as having PFP, anterior knee pain or chondromalacia maximum or 0–60% 1 repetition maximum at an explosive vel-
patella in the absence of other knee pathologies, including patel- ocity).33 This was in response to concerns raised at the recent
lar tendinopathy, Osgood-Schlatters disease and Sinding- PFP research retreat in Vancouver15 that the word strengthening
Larsen-Johanssons syndrome. Studies evaluating all age ranges or strength training is used synonymously for all types of
were considered for inclusion, as well as studies involving both rehabilitation exercise consequently limiting the identification of
single sex and mixed sex sample groups. exercise prescription specificity. It was considered that evaluating
methods of exercise prescription (eg, focus on strength, endur-
Search strategy ance, etc.) and summarising the range of specific exercise
Web of Knowledge, CINAHL, EMBASE and Medline (via descriptors (% repetition maximum, repetitions, time-under-
OVID) databases were searched from inception to December tension) could maximise the clinical utility of this review and
2014, using the search strategy outlined in box 1. Reference lists facilitate translation to clinical practice.
of included publications were screened and citation tracking was Means and SDs for all baseline and follow-up data were
completed in Google Scholar. extracted and entered into Cochrane Review Manager (V.5.2) to
allow calculation of standard mean differences (SMDs).
Review process Meta-analysis was completed where studies evaluated similar
Titles and abstracts identified using the search strategy were interventions using comparable outcome measures (eg, VAS,
downloaded into EndNote X7.1 (Thomson Reuters, California, Visual Analogue Scale and NPRS, Numeric Pain Rating Scale).
USA). Duplicates were deleted before all abstracts were screened Where multiple measures were used, a consistent measure
for inclusion by two independent reviewers (SL and OS). A between studies was used for pooling (eg, stair ascent). Pooling
third reviewer (CB) was available to settle any disputes if neces- of data across time points was performed for studies that evalu-
sary. Full texts were obtained where necessary. ated outcomes in the ‘short term’ (<3 months), ‘medium term’
(3–12 months), and ‘longer term’ (≥12 months). All outcome
measure scores were converted so that favourable outcomes
Quality assessment
(reduced pain, improved function, improved strength, etc) were
Study methodological quality was assessed with the PEDro
entered as positive values into Cochrane Review Manager
scale30 and a PFP inclusion/exclusion criteria checklist31 by two
Software, to facilitate consistent visual representation of SMDs
independent reviewers (OS and SL). Discrepancies were resolved
and pooled findings along with 95% CIs. For studies without
by consensus, with a third reviewer (CB) available, if needed.
comparative groups, the results were extracted and reported in
Based on the PEDro scores,30 and guidance by Moher et al,32
the results section, but no meta-analysis performed. Following
studies scoring >6 were considered high quality (HQ) and ≤6
methodology proposed by Hume et al,34 individual and pooled
as LQ. The PFP diagnosis checklist31 is a seven-item scale that
SMDs were categorised as small (≤0.59), medium (0.60–1.19),
identifies key inclusion and exclusion criteria for the diagnosis
or large (≥1.20). These criteria were chosen to increase strin-
of PFP. Higher scores indicate a greater number of key criteria
gency compared to traditional criteria.35 Statistical heterogeneity
having been reported.
of pooled data was established using the X2 and I2 statistics (with
heterogeneity being defined as p<0.05). Levels of evidence were
Study analysis guided by recommendations proposed by Van Tulder et al:36
Sample sizes, participant demographics, interventions, variables Strong evidence=based on results derived from multiple studies,
evaluated and follow-up times were extracted from each study. including a minimum of two HQ studies, which are statistically
Further analysis of intervention programme design was com- homogenous (I2<50%).
pleted to determine the type of ‘rehabilitation’ that was pre- Moderate evidence=based on results derived from multiple
scribed (table 2) allowing for direct comparison between studies, including at least one HQ study, which are statistically
heterogeneous (I2>50%), or from multiple LQ studies which
are statistically homogenous (I2<50%).
Limited evidence=based on results derived from multiple LQ
Box 1 Search strategy
studies which are statistically heterogeneous (I2>50%), or from
one HQ study.
Patellofemoral Pain OR Anterior Knee Pain OR Patellofemoral Very limited evidence=based on results derived from one LQ
Syndrome OR retropatellar pain OR peripatellar pain OR study.
patellofemoral joint pain OR parapatellar pain OR PFP OR Conflicting evidence=based on insignificant pooled results
chondromalacia patellae derived from multiple studies regardless of quality, which are
AND statistically heterogeneous (I2>50%).
Proximal OR gluteal
AND RESULTS
Strength* The results of the database search are shown in figure 1. Fourteen
AND studies were identified for the final review. Eleven of these studies
Training OR program OR exercise OR rehab* were randomised or comparative control trials,23 24 26 37–44 and
three were cohort studies.25 45 46 Study details, including sample
*, a truncation indicator for searching.
sizes and participant demographics, are shown in online
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Table 1 PEDro scale

Author I II III IV V VI VII VIII IX X XI Total score

Baldon et al44 1 1 1 1 1 0 1 1 1 1 1 10
Nakagawa et al40 0 1 1 1 1 0 1 1 1 1 1 9
Ismail et al39 1 1 1 1 0 0 0 1 1 1 1 8
Fukuda et al23 1 1 1 1 0 0 1 1 1 1 1 8
Fukuda et al38 1 1 1 1 0 0 1 1 1 1 1 8
Ferber et al42 1 1 1 0 0 0 1 0 1 1 1 7
Khayambashi et al43 1 1 0 1 0 0 0 1 1 1 1 7
Razeghi et al37 1 1 1 0 0 0 0 1 1 1 1 6
Dolak et al24 0 1 1 1 0 0 0 0 1 1 1 6
Ferber et al46 1 0 0 1 0 0 0 1 1 1 1 5
Khayambashi et al26 0 0 0 1 0 0 0 1 1 1 1 5
Avraham et al41 0 1 0 0 0 0 1 0 1 1 0 4
Tyler et al45 1 0 0 0 0 0 0 1 1 0 1 3
Earl and Hoch25 1 0 0 0 0 0 0 1 1 0 1 3
I=Eligibility criteria specified, II=Random allocation, III=Concealed allocation, IV=Similar at baseline, V=Subject blinding, VI=Therapist blinding, VII=Assessor blinding, VIII=Outcome
measures obtained from >85%, IX=Treatment received as allocated, X=Between-group statistical comparison, XI=Point measures and measures of variability.

supplementary file 1. Intervention and control/comparison group progressively higher resistant elastic band (see online supplemen-
protocols, outcome measures and follow-up duration findings are tary file 2 for further programme details), reduces pain (VAS)
presented in online supplementary files 2–5. (SMD, 95% CI 2.80,1.71 to 3.88), and improves function
(Western Ontario and McMaster osteoarthritis index (WOMAC))
Quality assessment (SMD, 95% CI 2.88, 1.78 to 3.98) in the short term.
Results from the PFP diagnostic checklist and the PEDro scale
are shown in online supplementary file 6 and table 1, respect- Proximal rehabilitation—compared with—quadriceps
ively. All 12 studies scored five or greater out of seven on the rehabilitation
PFP diagnostic checklist, demonstrating a good level of consist- Pain
ency between studies for diagnostic inclusion/exclusion criteria. Three HQ42–44 and one LQ study24 compared proximal rehabili-
Scores ranged between 3 and 10 for the PEDro scale. Of the 14 tation to quadriceps rehabilitation in the short and medium term
studies, 7 were classed as HQ,23 38–40 42–44 and 7 were classed (see online supplementary file 3 for further programme details;
as LQ.24–26 37 41 45 46 figure 3). Moderate evidence (3 HQ42–44 and 1 LQ24 study) of a
small effect indicated greater pain reduction following a prox-
Exercise prescription and mechanobiological analysis imal rehabilitation programme compared with a quadriceps
Results of exercise prescription and mechanobiological analysis rehabilitation protocol in the short term (I2=81%, p=0.001;
are shown in tables 2 and 3, respectively. Three of the 14 SMD, 95% CI 0.36, 0.13 to 0.59). In the medium term, there
included studies23 38 44 were considered to have evaluated the was strong evidence (2 HQ studies43 44) of a medium effect indi-
same exercise approach as stated in their title and methodology. cating greater pain reduction following a proximal rehabilitation
Commonly (10 of 14 studies), studies reported evaluation of a programme compared with a quadriceps rehabilitation protocol
strength protocol, despite exercise programmes being consid- (I2=45%, p=0.18; SMD, 95% CI 1.07, 0.55 to 1.59).
ered to be of an intensity to evoke strength-
endurance24 37 39 42 45 46 or neuromuscular25 26 40 43 activation Function
changes. In one study, the description of exercise prescribed was Moderate evidence (3 HQ42–44 and 1 LQ24 study) indicated no
unclear and could not be interpreted.41 Analysis of mechanobio- difference in functional patient-reported outcome measures
logical descriptors of exercise prescription from within the 14 (Lower Extremity Functional Scale, LEFS; Anterior Knee Pain
included studies highlighted the absence of all ‘classical descrip- Score; AKPS and WOMAC) within a pooled group of statistic-
tors’ (eg, load magnitude, % of maximum) and rest period ally heterogeneous studies comparing proximal and quadriceps
between sets (s/min)) in all but one study39 (table 3). The seven rehabilitation protocols in the short term (I2=69%, p=0.02;
new descriptors proposed by Toigo and Boutellier47 were SMD, 95% CI 0.18, −0.05 to 0.42). In the medium term,
absent, in their entirety, in the methodology of all included strong evidence (2 HQ studies43 44) of medium effect indicated
studies. Inclusion of the 13 descriptors in future studies is proximal rehabilitation improves functional patient-reported
reported to be imperative for the delivery of effective and tai- outcome measures (LEFS and WOMAC) when compared with
lored exercise prescription.47 quadriceps rehabilitation protocols (I2=0%, p=0.54; SMD,
95% CI 0.87, 0.36 to 1.37). Limited evidence (1 HQ study44)
Effects of proximal rehabilitation of a medium effect indicated improved objective function, as
Proximal rehabilitation—compared with—control measured by single leg hop performance, following proximal
Pain and function compared to quadriceps rehabilitation in the short term.
One LQ study26 compared proximal rehabilitation in PFP patients
to a control group receiving only Omega-3 and calcium supple- Proximal combined with quadriceps rehabilitation—compared
mentation in the short term (figure 2). Very limited evidence (1 with—quadriceps rehabilitation
LQ study26) with large effect indicated proximal rehabilitation, Four HQ23 38–40 and three LQ24 37 41 studies compared prox-
using exclusively open kinetic chain (OKC) exercises with imal combined with quadriceps rehabilitation to quadriceps
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Table 2 Analysis of programme design and aims

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Stated exercise Method exercise aim Reviewers’ interpretation of Fit of stated exercise aim (in text)
Author aim (title) (within text) actual exercise aim and actual exercise Outcome measure suitability for reviewer defined exercise aim and comment

Nakagawa et al40 Str Str NM 0 1 No patient capacity specific loading; no additional load; Assessed muscle
EMG and isokinetic strength
Ismail et al39 Str Str StrEnd 1 2 Proximal rehabilitation performed at 60% of 10 RM; No patient specific
training intensity for CKC exercises reported
Fukuda et al23 Str Str Str 2 1 Programme used 70% of ‘estimated 1 RM’ that could be performed pain
free
Fukuda et al38 Str Str Str 2 1 Programme used 70% of ‘estimated 1 RM’ that could be performed pain
free
Razeghi et al37 Str Str StrEnd 1 2 McQueen method of load progression used
Dolak et al24 Str Str StrEnd 1 2 Load progression as % of body weight, not of muscle capacity
Ferber et al46 Str Str StrEnd 1 1 Progression offered if exercise performed ‘too easily’, definition of ‘too
easily’ not reported
Ferber et al42 Str NM StrEnd 1 1 Clinician led load prescription, ensuring last 3 of 10 repetitions were
Lack S, et al. Br J Sports Med 2015;49:1365–1376. doi:10.1136/bjsports-2015-094723

‘challenging’
Khayambashi Str Str NM 0 2 Resistance progression was generic, 3×20–25 repetitions were performed
et al26 for each exercise
Baldon et al44 NM/Str NM/Str NM/Str 2 2 NM programme 20 repetitions plus isometric holds; Str performed at 75%
1 RM 3×12 repetitions
Khayambashi Str Str NM 0 1 Generic progression of resistance, 3×20–25 repetitions were performed
et al43 for each exercise
Avraham et al41 Str Str Unclear Unclear Unclear Programme not clearly defined, repetitions dependent on patient
‘capability’; no additional load described
Tyler et al45 Not stated Str StrEnd/NM/P 0 1 Programme described as ‘progressive resistive exercise’ but exact number
of repetitions and load not described
Earl and Hoch25 Str NM NM 1 1 Assessed kinematic change, but also assessed strength
0=No, 1=In part, 2=Yes.
CKC, closed kinetic chain; EMG, electromyography; NM, neuromuscular (>20 repetitions, <30% 1 RM); P, power (85–100% 1 RM or 0–60% 1 RM at explosive velocity); RM, repetition maximum; Str, strength (≥70% 1 RM); StrEnd, strength endurance
(30–70% 1 RM).
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Figure 1 Flow chart of included studies. PFP, patellofemoral pain.

rehabilitation alone (see online supplementary file 4 for further following proximal combined with quadriceps rehabilitation
programme details), covering short,23 24 37 39–41 46 compared to quadriceps rehabilitation alone (SMD, 95% CI
medium,23 24 and longer23 follow-up (figures 4 and 5). 2.99, 2.16 to 3.83).

Pain Function
Strong evidence (3 HQ38–40 and 2 LQ studies24 37) of a small Strong evidence (2 HQ38 39 and 1 LQ24 study) of a small effect
effect indicated greater pain reduction favouring proximal com- indicated greater functional patient-reported improvement (how
bined with quadriceps rehabilitation using both OKC and CKC measured) following proximal combined with quadriceps
exercises compared to a quadriceps rehabilitation alone in the rehabilitation compared to quadriceps rehabilitation alone in
short term (I2=14%, p=0.33; SMD, 95% CI 0.55, 0.22 to the short term (I2=18%, p=0.30; SMD, 95% CI 0.42, 0.03 to
0.88). In the medium term, there was moderate evidence 0.81). Limited evidence (1 HQ study38) indicated no difference
(1 HQ23 and 1 LQ study24) of a large effect indicating greater in functional performance measured with the single leg hop test
pain reduction following proximal combined with quadriceps scores (SMD, 95% CI 0.32, −0.30 to 0.93) in the short term.
rehabilitation using OKC and CKC compared to quadriceps In the medium term, moderate evidence (1 HQ23 and 1 LQ24
rehabilitation alone in the medium term (I2=92%, p=0.0003; study) of a large effect indicated increased patient reported
SMD, 95% CI 1.36, 0.83 to 1.90). Within the same HQ study, at function, measured by LEFS (I2=96%, p<0.00001; SMD, 95%
6 months, there was limited evidence (1 HQ study23) of a large CI 1.32, 0.75 to 1.89). Limited evidence (1 HQ study23) of a
effect indicating greater reduction in pain following proximal large effect indicated increased patient-reported function mea-
combined with quadriceps rehabilitation compared to quadriceps sured by AKPS (SMD, 95% CI 1.86, 1.18 to 2.54). Limited evi-
rehabilitation alone (SMD, 95% CI 2.58, 1.81 to 3.35). dence (1 HQ study23) of large effect indicates increased
In the longer term, there was limited evidence (1 HQ performance-based function, measured by single leg hop scores
study23) of a large effect indicating greater pain reduction (SMD, 95% CI 1.54, 0.89 to 2.18). Within the same study, at
Lack S, et al. Br J Sports Med 2015;49:1365–1376. doi:10.1136/bjsports-2015-094723 5 of 13
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Table 3 Analysis of specific descriptors of exercise prescription
Classical set of descriptors New set of descriptors
Fractional and
temporal
Number of distribution of the Time Recovery time
Rest exercise Duration of the contraction modes Rest under in-between Anatomical
in-between interventions experimental per repetition and in-between tension Volitional Range exercise definition of
Load Repetitions Sets sets ([s] or (per [day] or period ([day] or duration [s] of one repetitions ([s] or muscular of sessions ([h] or the exercise
Author magnitude (n) (n) [min]) week) weeks) repetition ([s] or [min]) [min]) failure motion [d]) (exercise form)

Nakagawa X Y Y X Y Y X X X X Y X Y
et al40
Ismail et al39 Y Y Y Y Y Y Y X X X Y X X
Fukuda et al23 Y Y Y X Y Y X X X X Y X X
Fukuda et al38 Y Y Y X Y Y X X X X Y X X
Lack S, et al. Br J Sports Med 2015;49:1365–1376. doi:10.1136/bjsports-2015-094723

Razeghi X Y X X X Y X X X X X X X
et al37
Dolak et al24 Y Y Y X Y Y X X X X X X X
Ferber et al46 X Y Y X Y Y Y X X X X X X
Ferber et al42 X Y Y X Y Y X X X X X X Y
Khayambashi X Y Y X Y Y X X X X Y X X
et al26
Baldon et al44 Y Y Y X Y Y X X X X X X X
Khayambashi X Y Y X Y Y X X X X Y X X
et al43
Avraham X X X Y Y Y X Y X X Y X X
et al41
Tyler et al45 X X X X Y Y X X X X X X X
Earl and X Y Y X Y Y X X X X X X Y
Hoch25
Y=Incorporated in study, X=Not incorporated in study.
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Figure 2 Proximal rehabilitation compared with control group for pain and function (WOMAC, Western Ontario and McMaster osteoarthritis index;
‘short term’, <3 months; IV, inverse variance; Std., standard mean difference).

6 months, limited evidence (1 HQ study23) of a large effect 95% CI 1.69, 1.03 to 2.36) (figure 6). Very limited evidence (1
indicated increased patient-reported function, as measured by LQ study26) of a large effect indicated increased isometric hip
LEFS (SMD, 95% CI 2.49, 1.73 to 3.25), AKPS (SMD, 95% CI external rotation strength in the OKC rehabilitation group in
1.86, 1.18 to 2.54), and performance-based function measured both the left (SMD, 95% CI 2.45, 1.43 to 3.46) and right
as single leg hop scores (SMD, 95% CI 1.85, 1.17 to 2.52). (SMD, 95% CI 2.73, 1.66 to 3.80) hip. Very limited evidence
In the longer term, limited evidence (1 HQ study23) of a (1 LQ study46) of a large effect indicated OKC proximal
large effect indicated greater patient-reported functional rehabilitation reduced the degree of knee valgum variability
improvement as measured by LEFS (SMD, 95% CI 2.65, 1.86 during consecutive footfalls while running (SMD, 95% CI 2.68,
to 3.43), AKPS (SMD, 95% CI 1.76, 1.09 to 2.42), and 1.54 to 3.82), but did not change peak knee genu valgum
performance-based function measured with the single leg hop angles while running (SMD, 95% CI 0.83, −0.01 to 1.67).
(SMD, 95% CI 2.06, 1.36 to 2.77) at 12 months, with proximal
and quadriceps rehabilitation compared to quadriceps rehabilita-
tion alone. Proximal rehabilitation—compared with—quadriceps
rehabilitation
Mechanisms of proximal rehabilitation Moderate evidence (1 HQ and 1 LQ study24 42) indicated no
Ten24–26 37 39 40 42 44–46 of the 14 studies explored variables difference in maximal isometric strength for hip abduction
with potential to explain proximal rehabilitation effects in the (I2=60%, p=0.11; SMD, 95% CI 0.18, −0.08 to 0.44), exter-
short term. No studies investigated mechanisms of effect at nal rotation (I2=0%, p=0.44; SMD, 95% CI 0.11, −0.15 to
medium or longer-term follow-up. 0.37) or knee extension (I2=0%, p=0.33; SMD, 95% CI 0.09,
−0.17 to 0.35) following a proximal (OKC) rehabilitation pro-
Proximal rehabilitation—compared with—control gramme, as compared to a quadriceps (OKC/CKC) rehabilita-
Limited evidence (2 LQ study26 46) of a large effect indicated tion programme (figure 7). Limited evidence (1 HQ study42)
that proximal rehabilitation using OKC band exercises increased indicated no difference in hip extension (SMD, 95% CI 0.09,
isometric hip abduction strength (I2=81%, p<0.00001; SMD, −0.19 to 0.37) or internal rotation (SMD, 95% CI 0.02, −0.26

Figure 3 Proximal rehabilitation compared with quadriceps rehabilitation for pain and function (LEFS, Lower Extremity Functional Score; AKPS,
Anterior Knee Pain Score; ‘short term’, <3 months; IV, inverse variance; Std., standard mean difference).

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Figure 4 Proximal and quadriceps rehabilitation compared with quadriceps rehabilitation for pain (‘short term’, <3 months; ‘medium term’, 3–
12 months; ‘longer term’, ≥12 months; IV, inverse variance; Std., standard mean difference).

to 0.30) strength when comparing an OKC proximal with a extensor (SMD, 95% CI 0.97, 0.22 to 1.72) torque (nm/kg)
CKC quadriceps rehabilitation programme. increased in the proximal rehabilitation group when compared
Limited evidence (1 HQ study44) indicated proximal rehabili- with quadriceps rehabilitation.44
tation using CKC exercises, when compared with a CKC quadri-
ceps rehabilitation protocol, increased the degree of pelvis Proximal combined with quadriceps rehabilitation—compared
anteversion (SMD, 95% CI 1.21, 0.43 to 1.98), hip flexion with—quadriceps rehabilitation alone
(SMD, 95% CI 1.16, 0.39 to 1.92), trunk contralateral inclin- Strong evidence (2 HQ studies39 40) indicated no difference in
ation (SMD, 95% CI 0.90, 0.16 to 1.65), pelvis elevation isokinetic, concentric and eccentric hip abduction, and external
(SMD, 95% CI 0.94, 0.19 to 1.68), hip abduction (SMD, 95% rotation strength following a proximal (OKC) combined with
CI 2.20, 1.28 to 3.11), and knee adduction (SMD, 95% CI quadriceps (CKC) rehabilitation programme when compared to
0.81, 0.07 to 1.55) during a single leg squatting task. a quadriceps rehabilitation (CKC) programme alone (figure 8).
Additionally, anterior (SMD, 95% CI 2.03, 1.14 to 2.92), Very limited evidence (1 LQ study24) indicated no difference in
lateral (SMD, 95% CI 2.50, 1.53 to 3.46), and posterior (SMD, isometric hip abduction (SMD, 95% CI 0.54, −0.16 to 1.23) or
95% CI 1.54, 0.73 to 2.36) trunk endurance (seconds), and external rotation (SMD, 95% CI 0.63, −0.07 to 1.33) strength
proximal abductor (SMD, 95% CI 1.24, 0.47 to 2.02) and knee following a proximal combined with quadriceps rehabilitation

Figure 5 Proximal and quadriceps rehabilitation compared with quadriceps rehabilitation for function (LEFS, Lower Extremity Functional Score;
AKPS, Anterior Knee Pain Score; ‘short term’, <3 months; ‘medium term’, 3–12 months; ‘longer term’, ≥12 months; IV, inverse variance; Std.,
standard mean difference).

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Figure 6 Proximal rehabilitation compared with control group for strength and biomechanics in the short term (<3 months) (LHER, left proximal
external rotation; RHER, right proximal external rotation; IV, inverse variance; Std., standard mean difference).

programme compared to quadriceps rehabilitation alone. (p=0.1) core endurance, and hip abduction moment ( p=0.06)
Moderate evidence (2 LQ studies24 37) indicated no difference was reported in the same study.25 However, no change in rear
in isometric knee extension strength (I2=0%, p=0.37; SMD, foot eversion, knee abduction, hip adduction and internal rota-
95% CI 0.07, −0.42 to 0.56) following comparison of proximal tion angles, rear foot inversion or hip external rotation
and quadriceps rehabilitation with quadriceps rehabilitation moments were reported during a running task.25
alone.
DISCUSSION
Proximal rehabilitation alone This systematic review and meta-analysis evaluated the effects of
One LQ study45 divided their cohort into ‘successful’ (≥1.5 cm proximal muscle rehabilitation on pain and function in indivi-
reduction in VAS) and ‘unsuccessful’ groups, reporting an duals with PFP and the potential mechanisms for effectiveness.
improvement in isometric proximal abduction and adduction Fourteen studies of varying quality were identified, including 11
strength was unrelated to success. Very limited evidence (1 LQ RCTs.23 24 26 37–44 In the short term, strong evidence indicates
study25) indicated an improvement in lateral core endurance proximal combined with quadriceps rehabilitation is signifi-
( p=0.001), hip abduction ( p=0.008) and external rotation cantly better at reducing pain than quadriceps rehabilitation
( p=0.03) isometric strength, and knee abduction internal alone,23 24 37 39–41 46 moderate evidence indicates proximal
moments ( p=0.05) after an 8-week OKC and CKC neuromus- rehabilitation is better at improving pain compared to quadri-
cular activation intervention directed at the proximal muscula- ceps rehabilitation alone,24 42–44 and very limited evidence indi-
ture. A trend in increased anterior ( p=0.06) and posterior cates proximal rehabilitation reduces pain compared to a no

Figure 7 Proximal rehabilitation compared with quadriceps rehabilitation for isometric strength in the short term (<3 months) (IV, inverse variance;
Std., standard mean difference).
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Figure 8 Proximal and quadriceps rehabilitation compared with quadriceps rehabilitation for strength in the short term (<3 months) (Abd,
abduction; ER, external rotation; Ecc, eccentric; Ext, extension; HABD, hip abduction; HER, hip external rotation; IV, Inverse variance; Std., standard
mean difference.

intervention control.26 In the medium term, strong and moder- significant differences in pain reduction between groups, but
ate evidence indicates proximal and proximal combined with reported significant pain reduction within both groups in the
quadriceps rehabilitation, respectively, is more effective at redu- short term.42 Adding proximal rehabilitation to quadriceps
cing pain then quadriceps rehabilitation alone.23 43 44 In the appears to offer the most favourable short-term outcome;
longer term, limited evidence indicates proximal combined with however, it is clear that further research to identify the most
quadriceps rehabilitation is more effective at reducing pain than effective rehabilitation programme design is required to maxi-
quadriceps rehabilitation alone.23 Greater improvements in mise effectiveness.
function were also reported for proximal, and proximal com- In the medium term, pooled results indicate proximal
bined with quadriceps rehabilitation compared with quadriceps rehabilitation more effectively reduced pain when compared to
rehabilitation alone in the short (strong evidence), medium quadriceps rehabilitation alone. Among the pooled studies, exer-
(strong to moderate evidence) and longer (limited evidence) cise programme design differed significantly, with one utilising
term.23 24 38 39 Put together, these findings support the imple- exclusively neuromuscular OKC43 and the other using neuro-
mentation of proximal muscle rehabilitation programmes for muscular and strength CKC44 exercises. Of these protocols, the
the management of PFP in clinical practice. neuromuscular OKC protocol resulted in the greatest positive
symptom change, but further research directly comparing these
Effects of proximal rehabilitation different protocols is needed. Proximal combined with quadri-
Pain ceps rehabilitation was more effective than quadriceps rehabili-
Strong evidence suggests that a combined proximal and quadri- tation in reducing pain in the medium and longer term, with
ceps rehabilitation protocol using both OKC and CKC exercises treatment effects of large magnitude. The single study reporting
results in superior short term outcomes of pain reduction when significant pain reduction in the long-term used a combination
compared to CKC quadriceps rehabilitation alone. This pooled of both OKC and CKC at an intensity assessed to be sufficient
result is, however, driven by one LQ study37 that reported sig- to evoke strength changes (ie, >70% 1 RM).23 These exercise
nificant improvement in pain. In contrast, three24 38 40 of the parameters may be relevant to the successful outcome given that
five pooled studies reported no greater short-term pain reduc- OKC exercises are commonly used clinically to allow for specific
tion when compared to a quadriceps rehabilitation programme. isolation of proximal musculature48 while attempting to reduce
An important consideration when interpreting these findings is loading of the PFJ. These preliminary findings require further
that the CKC quadriceps exercises adopted within the three research to determine the most efficacious protocol to reduce
equivocal studies24 38 40 would also facilitate activation of prox- pain, in the medium and long term.
imal musculature and as such, could also be considered a com-
bined proximal and quadriceps intervention. A similar story Function
emerges when comparing proximal and quadriceps rehabilita- Fewer studies evaluated the effects of proximal muscle rehabili-
tion. Specifically, within a pooled group of heterogeneous tation on functional outcomes, which limits the conclusions that
studies that evaluated proximal compared with quadriceps can be drawn. Greater improvements in self-reported measures
rehabilitation, a large multicentre trial that compared an OKC (WOMAC, LEFS, AKPS) and performance-based measures
proximal to a CKC quadriceps protocol demonstrated no (Single Leg hop test) of function were observed in the short
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term following proximal rehabilitation compared to a no inter- Clinical implications

vention control; and following proximal combined with quadri- Interventions that aim to improve strength, strength-endurance
ceps rehabilitation compared to quadriceps rehabilitation. and neuromuscular activity of proximal musculature are effect-
Moderate evidence indicated no difference in function when ive in the management of PFP, and should be incorporated in
comparing proximal with quadriceps rehabilitation, which clinical practice. From within the largest high quality study that
differs from findings related to pain. It is possible that interven- explored the effect of proximal compared with quadriceps
tions that address the deficits in gluteal strength20 19 and activa- rehabilitation, OKC proximal rehabilitation in isolation was not
tion21 and quadriceps strength19 that are evident in individuals more effective at reducing pain than a CKC quadriceps rehabili-
with PFP could be sufficient to result in the short-term improve- tation programme42 in the short term. These findings suggest
ment of function, but not in the medium and longer term. CKC quadriceps rehabilitation is as effective at increasing prox-
Importantly, greater functional improvements are provided by imal strength as an isolated OKC proximal rehabilitation pro-
proximal compared to quadriceps rehabilitation (strong evi- gramme and have potentially important clinical implications for
dence), and a combined proximal and quadriceps rehabilitation exercise intervention design. These suggest that clinicians could
compared to quadriceps rehabilitation alone (limited to moder- choose different treatment approaches and achieve the same or
ate evidence) in the medium and longer term. It is possible that similar strength gains. Subsequently, this would allow clinicians
superior pain outcomes with proximal compared to quadriceps to be guided by patient response, preference or available equip-
rehabilitation in the short-term results from the quadriceps ment, without negatively impacting on patient care.
loading causing irritation to the PFJ, although further research Proximal rehabilitation combined with quadriceps rehabilita-
documenting pain levels during exercise is needed to clarify tion using both OKC and CKC exercises produced better pain
this. These findings suggest that incorporating proximal rehabili- and functional outcomes in the short,44 medium and longer
tation into the management of PFP is beneficial to functional term23 compared to quadriceps rehabilitation alone. Therefore,
outcomes. However, considering the currently limited to moder- therapists treating PFP should aim to prescribe exercise interven-
ate supporting evidence, further high quality studies are needed tions targeting the quadriceps and proximal musculature in indi-
to confirm these positive results. viduals with PFP using a combination of OKC and CKC
exercises.
Mechanisms of proximal rehabilitation Rehabilitation exercises from studies included in this review
This review evaluated potential short-term mechanisms of treat- were completed between 3 and 7 times per week, with the
ment effect, with studies reporting improvement in isomet- intensity of the programmes varying significantly. Exercise fre-
ric24 26 46 and isokinetic strength,39 40 eccentric torque,44 trunk quency did not appear to be dependent on the type and inten-
muscle endurance,44 single leg squat kinematics,44 reduced knee sity of the rehabilitation protocols prescribed. Given established
joint motion variability, 46 and reduced peak knee abduction guidelines33 that indicate neuromuscular training has greater
internal moments.25 Changes in strength were measured in 10 effect if performed frequently (daily) and strength training less
of the 14 included studies. Limited evidence of large effect indi- frequently (2–3×per week) on physiological adaptation, the spe-
cated greater improvement in isometric hip abduction strength cificity of exercise frequency in the management of PFP is
in the short-term following a neuromuscular or strength- lacking within the current evidence base and requires further
endurance resistance band intervention when compared to no research.
intervention, offering a potential mechanism for changes in pain Given that the primary goal of PFP treatment is often pain
and function.26 46 However, given the absence of significant dif- reduction, utilising exercise parameters that do not aggravate
ference in maximal isometric hip abduction, extension, external symptoms is important. Consequently, utilising OKC exercises
and internal rotation, and knee extension strength when com- in the short term or CKC exercises within finite pain limits
paring OKC proximal rehabilitation to CKC quadriceps rehabili- throughout the rehabilitation process is advocated by the
tation,42 it is also plausible that the positive effects of a current evidence.23 24 44 It is unclear at present whether these
rehabilitation intervention are not exclusively derived through parameters are essential for a successful outcome; further
changes in strength, but through a combination of more global research is required to determine the most effective protocol
lower limb strength changes, a change in lower limb biomechan- design. Furthermore, identification of individuals who are more
ics, possible central or systemic mechanisms,49 or most likely a likely to respond to a specific proximal intervention approach is
combination of these factors. an important consideration given the dearth of evidence explor-
Three studies exploring kinematic and/or kinetic change result- ing indicators for proximal intervention success.51
ing from proximal rehabilitation reported small but significant
changes about the hip and knee25 44 46 that offer potential
mechanisms for treatment effects. Increased hip adduction and Limitations
internal rotation has been identified previously as a risk factor for There are limitations that need to be considered when interpret-
and is associated with PFP symptoms.5 14 Consequently interven- ing the results of this review. Variability in study design, type of
tions that demonstrate capacity to modify these parameters protocol (OKC or CKC), and differing outcome measures
warrant further investigation. Although some evidence reports limited further data pooling. Where pooling was possible, het-
clinical measures are able to identify individuals with movement erogeneity of rehabilitative exercise prescription remained
deficits and detect biomechanical change of small magnitude,50 it evident in both exercise frequency and intensity. Nonetheless,
is important to ensure clinical tools are sufficiently sensitive to given the paucity of available evidence, we felt that data pooling
direct intervention choice and determine treatment effects. was valuable to strengthening the findings of the review.
Further exploration of the mechanisms for treatment effects Non-English language publications were not sought in this
following a rehabilitation intervention on muscle structure, review. While it is arguable that high-quality RCTs would aim to
neural innervation, systemic systems and biomechanics is needed be published in higher impact journals written in the English
to guide a tailored exercise approach to address patient-specific language, identification of further trial data may have influenced
deficits and predict outcomes in individuals with PFP. the outcomes of analysis. Assessment of methodological quality
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was completed using the PEDro scale. It was identified that only 6 Heino Brechter J, Powers CM. Patellofemoral stress during walking in persons
43% of the included 11 studies blinded the assessor to the inter- with and without patellofemoral pain. Med Sci Sports Exerc 2002;34:
1582–93.
vention delivered and only one study attempted to blind the 7 Farrokhi S, Keyak JH, Powers CM. Individuals with patellofemoral pain exhibit
participants to their group allocation. Given growing evidence greater patellofemoral joint stress: a finite element analysis study. Osteoarthritis
for proximal intervention efficacy, future studies should aim to Cartilage 2011;19:287–94.
blind the participants and researchers to the allocated group. 8 Draper CE, Besier TF, Santos JM, et al. Using real-time MRI to quantify
altered joint kinematics in subjects with patellofemoral pain and to evaluate
Finally, it has been identified that mechanobiological determi-
the effects of a patellar brace or sleeve on joint motion. J Orthop Res
nants of exercise prescription are poorly reported or defined 2009;27:571–7.
within the included rehabilitation studies. To ensure clinical 9 Wilson NA, Press JM, Koh JL, et al. In vivo noninvasive evaluation of abnormal
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future studies, these determinants must be detailed. Surg Am 2009;91:558–66.
10 Souza RB, Draper CE, Fredericson M, et al. Femur rotation and patellofemoral joint
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The best available evidence indicates that proximal rehabilitation 11 Giles LS, Webster KE, McClelland JA, et al. Does quadriceps atrophy exist in
with or without simultaneous quadriceps rehabilitation is benefi- individuals with patellofemoral pain? A systematic literature review with
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12 Barton CJ, Levinger P, Crossley KM, et al. Relationships between the Foot Posture
medium term. While fewer studies have evaluated long-term Index and foot kinematics during gait in individuals with and without patellofemoral
effects, the limited evidence available indicates proximal and pain syndrome. J Foot Ankle Res 2011;4:10.
quadriceps rehabilitation combined has greater positive benefit 13 Noehren B, Pohl MB, Sanchez Z, et al. Proximal and distal kinematics in female
on pain and function than quadriceps rehabilitation alone. A runners with patellofemoral pain. Clin Biomech 2012;27:366–71.
14 Powers CM. The influence of abnormal hip mechanics on knee injury:
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a biomechanical perspective. J Orthop Sports Phys Ther 2010;40:42–51.
result in favourable outcomes. Given variability in rehabilitation 15 Witvrouw E, Callaghan MJ, Stefanik JJ, et al. Patellofemoral pain:
protocols within the current literature, further studies designed consensus statement from the 3rd International Patellofemoral Pain Research
to identify the most effective protocol by considering exercise Retreat held in Vancouver, September 2013. Br J Sports Med 2014;48:
type, load and dose are required. To improve clinical applicabil- 411–14.
16 Collins NJ, Bisset LM, Crossley KM, et al. Efficacy of nonsurgical interventions for
ity, these studies must detail specific exercise descriptors. anterior knee pain: systematic review and meta-analysis of randomized trials.
Regardless, proximal rehabilitation should be incorporated into Sports Med 2012;42:31–49.
clinical reasoning paradigms for the management of PFP. 17 Barton CL, Lack S, Hemmings S, et al. The ‘Best Practice Guide to Conservative
Management of Patellofemoral Pain’—incorporating level 1 evidence with expert
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18 Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak
Summary box hip muscles: a systematic review. Aust J Phys 2009;55:9–15.
19 Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Factors associated with
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▸ Proximal combined with quadriceps rehabilitation reduces 2013;47:193–206.
pain and improves function more than quadriceps 20 Rathleff MS, Rathleff CR, Crossley KM, et al. Is hip strength a risk factor for
patellofemoral pain? A systematic review and meta-analysis. Br J Sports Med
rehabilitation in the short, medium and long term. 2014;48:1088.
▸ Proximal rehabilitation is more effective than quadriceps 21 Barton CJ, Lack S, Malliaras P, et al. Gluteal muscle activity and patellofemoral pain
rehabilitation in decreasing pain in the short term, and syndrome: a systematic review. Br J Sports Med 2013;47:207–14.
decreasing pain and improving function in the medium term. 22 Boling MC, Padua DA, Marshall SW, et al. A prospective investigation of
▸ Maximum hip muscle isometric strength can be increased by biomechanical risk factors for patellofemoral pain syndrome the joint undertaking to
monitor and prevent ACL injury ( JUMP-ACL) cohort. Am J Sports Med
proximal rehabilitation compared to no exercise controls, but 2009;37:2108–16.
not significantly more than a closed kinetic chain quadriceps 23 Fukuda TY, Melo WP, Zaffalon BM, et al. Hip posterolateral musculature
focused rehabilitation programme. strengthening in sedentary women with patellofemoral pain syndrome:
a randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys
Ther 2012;42:823–30.
Funding #TEAM_PFP would like to acknowledge the Private Physiotherapy 24 Dolak KL, Silkman C, Medina McKeon J, et al. Hip strengthening prior to functional
Education Fund (PPEF) for funding some of SL’s time to complete this review. DM is exercises reduces pain sooner than quadriceps strengthening in females with
part funded by the NIHR/HEE Senior Clinical Lecturer scheme. This article presents patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther
independent research part funded by the National Institute for Health Research 2011;41:560–70.
(NIHR). The views expressed are those of the authors and not necessarily those of 25 Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and
the NHS, the NIHR or the Department of Health. biomechanics in women with patellofemoral pain syndrome. Am J Sports Med
2011;39:154–63.
Competing interests None declared.
26 Khayambashi K, Mohammadkhani Z, Ghaznavi K, et al. The effects of isolated hip
Provenance and peer review Not commissioned; externally peer reviewed. abductor and external rotator muscle strengthening on pain, health status, and hip
strength in females with patellofemoral pain: a randomized controlled trial. J Orthop
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Proximal muscle rehabilitation is effective for

patellofemoral pain: a systematic review with
meta-analysis
Simon Lack, Christian Barton, Oliver Sohan, Kay Crossley and Dylan
Morrissey

Br J Sports Med2015 49: 1365-1376 originally published online July 14,

2015
doi: 10.1136/bjsports-2015-094723

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