Sports Medicine

, Volume 44, Issue 12, pp 1703–1716 | Cite as

Outcome Predictors for Conservative Patellofemoral Pain Management: A Systematic Review and Meta-Analysis

  • Simon Lack
  • Christian Barton
  • Bill Vicenzino
  • Dylan Morrissey
Systematic Review

Abstract

Background

Patellofemoral pain (PFP) is highly prevalent within both sporting and recreationally active populations. Multiple treatment approaches have been advocated for the management of PFP, attempting to address both intrinsic and extrinsic factors thought to contribute to the development and persistence of pain. A number of predictors of treatment success have been proposed, and evaluated, for directing intervention choice.

Objective

Our aim was to systematically review the literature that identifies outcome predictors of specific conservative interventions in the management of PFP, including quality of the current evidence, to guide clinical practice and future studies investigating outcome predictors within this population.

Data Sources

The AMED, CINAHL, EMBASE, MEDLINE and Web of Science databases were searched from inception to April 2013.

Study Selection

Randomized controlled trials (RCTs) and cohort studies.

Study Appraisal and Synthesis Methods

Following initial searching, all potential papers were assessed by two independent reviewers for inclusion using a checklist developed from the inclusion criteria. Cited, and citing, references were also searched in Google Scholar, but unpublished work was not sought. Methodological quality was assessed using a previously designed quality assessment scale. Definitions for levels of evidence were guided by recommendations made by van Tulder et al.

Results

Fifteen low-quality (LQ) cohort studies were included. No RCTs were found. This systematic review identified the evaluation of 205 conservative management outcome predictor variables. Of this large number of variables that have been assessed, 19 (9 %) were found to significantly predict a successful outcome. Where two or more outcome predictors and success determinants were consistent between studies, data were pooled. Within these studies, the low number of participants per output variable, and absence of controls, is likely to compromise the validity of the predictor’s accuracy. Very limited evidence identified higher functional index questionnaire scores (mean 0.82, 95 % confidence interval [CI] 0.18–1.46), greater forefoot valgus (mean 0.67, 95 % CI 0.05–1.28) and greater rearfoot eversion magnitude peak (mean −0.93, 95 % CI −1.84 to −0.01) to significantly predict improved outcomes with orthoses interventions. Shorter symptom duration (p = 0.019), lower frequency of pain (p = 0.012), younger age, faster vastus medialis oblique reflex response time (p = 0.026), negative patella apprehension, absence of chondromalacia patella, tibial tubercle deviation of <14.6 mm and greater total quadriceps cross-sectional area on magnetic resonance imaging (p = 0.01), and reduced eccentric average quadriceps peak torque (p = 0.015) significantly predicted exercise intervention success following multivariate statistical analysis. Limited evidence identified increased Q-angle (mean 0.38, 95 % CI 0.05–0.72) and very limited evidence identified greater usual pain (mean 0.43, 95 % CI 0.01–0.85) to predict taping intervention success.

Conclusions

This systematic review provides a comprehensive summary of current derivation level studies identifying indicators of prediction for conservative PFP management. The overall strength of evidence was low. With appropriate caution, clinicians should consider taping for those with greater usual pain, orthoses for older individuals and exercise for younger individuals, and orthoses intervention for patients with greater forefoot valgus and rearfoot eversion magnitude peak. RCTs with evaluation of outcome prediction as a primary aim are clearly warranted to provide clinicians with robust evidence and facilitate evidence-informed, tailored intervention to this heterogeneous patient population.

Supplementary material

40279_2014_231_MOESM1_ESM.docx (62 kb)
Supplementary material 1 (DOCX 238 kb)

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Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Simon Lack
    • 1
  • Christian Barton
    • 1
    • 2
    • 3
    • 4
  • Bill Vicenzino
    • 5
  • Dylan Morrissey
    • 1
  1. 1.Centre for Sports and Exercise Medicine, William Harvey Research Institute, Bart’s and the London School of Medicine and DentistryQueen Mary University of London, Mile End HospitalLondonUK
  2. 2.Complete Sports CareMelbourneAustralia
  3. 3.Pure Sports MedicineLondonUK
  4. 4.Lower Extremity Gait Studies, Health SciencesLa Trobe UniversityBundooraAustralia
  5. 5.Division of Physiotherapy, School of Health and Rehabilitation SciencesThe University of QueenslandBrisbaneAustralia

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