Sports Medicine

, Volume 28, Issue 4, pp 245–262 | Cite as

Patellofemoral Pain Syndrome

A Review of Current Issues
  • Roland ThomeéEmail author
  • Jesper Augustsson
  • Jon Karlsson
Review Article


There is no clear consensus in the literature concerning the terminology, aetiology and treatment for pain in the anterior part of the knee. The term ‘anterior knee pain’ is suggested to encompass all pain-related problems. By excluding anterior knee pain due to intra-articular pathology, peripatellar tendinitis or bursitis, plica syndromes, Sinding Larsen’s disease,Osgood Schlatter’s disease, neuromas and other rarely occurring pathologies, it is suggested that remaining patients with a clinical presentation of anterior knee pain could be diagnosed with patello-femoral pain syndrome (PFPS). Three major contributing factors of PFPS are discussed: (i) malalignment of the lower extremity and/or the patella; (ii) muscular imbalance of the lower extremity; and (iii) overactivity.

The significance of lower extremity alignment factors and pathological limits needs further investigation. It is possible that the definitions used for malalignment should be re-evaluated, as the scientific support is very weak for determining when alignment is normal and when there is malalignment. Consequently, pathological limits must be clarified, along with evaluation of risk factors for acquiring PFPS.

Muscle tightness and muscular imbalance of the lower extremity muscles with decreased strength due to hypotrophy or inhibition have been suggested, but remain unclear as potential causes of PFPS. Decreased knee extensor strength is a common finding in patients with PFPS. Various patterns of weaknesses have been reported, with selective weakness in eccentric muscle strength, within the quadriceps muscle and in terminal knee extension. The significance of muscle function in a closed versus open kinetic chain has been discussed, but is far from well investigated. It is clear that further studies are necessary in order to establish the significance of various strength deficits and muscular imbalances, and to clarify whether a specific disturbance in muscular activation is a cause or an effect (or both) of PFPS.

The most common symptoms in patients with PFPS are pain during and after physical activity, during bodyweight loading of the lower extremities in walking up/down stairs and squatting, and in sitting with the knees flexed. However, the source of patello-femoral pain in patients with PFPS cannot be sufficiently explained. There are several types of clinical manifestation of pain, and therefore a differentiated documentation of the patient’s pain symptoms is necessary. The connection between strength, pain and inhibition, as well as between personality and pain, needs further investigation.

Many different treatment protocols are described in the literature and recent studies advocate a comprehensive treatment approach allowing for an individual and specifically designed treatment. Surgical treatment is rarely indicated.

It is strongly suggested that, when presenting studies on PFPS, a detailed description should be provided of the diagnosis, inclusion and exclusion criteria of the patients should be specified along with a detailed methodology, and the conclusions drawn should be compared with those of other studies in the published literature. As this is not the case in most studies on PFPS found in the literature, it is only possible to make general comparisons. In order to further develop treatment models for PFPS we advocate prospective, randomised, controlled, long term studies using validated outcome measures. However, there is a strong need for basic research on the nature and aetiology of PFPS in order to better understand this mysterious syndrome.


Adis International Limited Knee Extensor Anterior Knee Pain Patellofemoral Joint Patellofemoral Pain 
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  1. 1.
    Cutbill JW, Ladly KO, Bray RC, et al. Anterior knee pain: a review. Clin J Sport Med 1997; 7: 40–5PubMedCrossRefGoogle Scholar
  2. 2.
    Grayson TH, editor. Disorders of the patellofemoral joint. 2nd ed. Baltimore (MD): Williams & Wilkins, 1990Google Scholar
  3. 3.
    Reid DC. The myth, mystic and frustration of anterior knee pain. Clin J Sport Med 1993; 3: 139–43CrossRefGoogle Scholar
  4. 4.
    Insall JN. Current concepts review: patellar pain. J Bone Joint Surg Am 1982; 64 (1): 147–52PubMedGoogle Scholar
  5. 5.
    Thomeé R, Renström P, Karlsson J, et al. Patellofemoral pain syndrome in young women: I. A clinical analysis of alignment, common symptoms and functional activity level. Scand J Med Sci Sports 1995; 5: 237–44PubMedCrossRefGoogle Scholar
  6. 6.
    Webster’s seventh new collegiate dictionary. Springfield (MA): GC Merriam Co., 1969Google Scholar
  7. 7.
    Aleman, O. Chondromalacia post-traumatica patellae.Acta Chir Scand 1928; 63: 149–63Google Scholar
  8. 8.
    Büdinger K. Uber traumatische knorpelrisse in kniegeleuk. Dtsch Z Chir 1908; 92: 510CrossRefGoogle Scholar
  9. 9.
    Abernethy P, Wilson G, Logan P. Strength and power assessment. Sports Med 1995; 19: 401–17PubMedCrossRefGoogle Scholar
  10. 10.
    Darracott J, Vernon-Roberts B. The bony changes in ‘chondromalacia patellae’. Rheum Phys Med 1971; 11: 175–9CrossRefGoogle Scholar
  11. 11.
    DeHaven KE, Dolan WA, Mayer PJ. Chondromalacia patellae in athletes. Am J Sports Med 1979; 7: 5–11PubMedCrossRefGoogle Scholar
  12. 12.
    Hvid I, Andersen LI. The quadriceps angle and its relation to femoral torsion. Acta Orthop Scand 1982; 53: 577–9PubMedCrossRefGoogle Scholar
  13. 13.
    Kelly MA, Insall JN. Historical perspectives of chondromalacia patellae. Orthop Clin North Am 1992; 23: 517–21PubMedGoogle Scholar
  14. 14.
    Leslie IJ, Bentley G. Arthroscopy in the diagnosis of chondromalacia patellae. Ann Rheum Dis 1978; 37: 540–7PubMedCrossRefGoogle Scholar
  15. 15.
    Tria AJ, Palumbo RC, Alicea JA. Conservative care for patellofemoral pain. Orthop Clin North Am 1992; 23: 545–54PubMedGoogle Scholar
  16. 16.
    Ficat R, Hungerford D. Disorders of the patellofemoral joint. Baltimore (MD): Williams & Wilkins, 1977Google Scholar
  17. 17.
    Hughston JC, Walsh WM, Puddu G. Patellar subluxation and dislocation. Philadelphia (PA): WB Saunders, 1984Google Scholar
  18. 18.
    Hungerford DS, Barry M. Biomechanics of the patellofemoral joint. Clin Orthop 1979; 144: 9–15PubMedGoogle Scholar
  19. 19.
    Lieb FJ, Perry J. Quadriceps function. An electromyographic study under isometric conditions. J Bone Joint SurgAm 1971; 53 (4): 749–58Google Scholar
  20. 20.
    Reynolds L, Levin TA, Medieros JM, et al. EMG activity of the vastus medialis oblique and the vastus lateralis in their role in patellar alignment. Am J Phys Med 1983; 62: 61–70PubMedGoogle Scholar
  21. 21.
    James S. Chondromalacia of the patella in the adolescent. In: Kennedy JC, editor. The injured adolescent knee. Baltimore (MD): Williams & Wilkins, 1979: 205–251Google Scholar
  22. 22.
    Clement DB, Taunton JE, Smart GW, et al. A survey of running injuries. Phys Sports Med 1981; 9: 47–58Google Scholar
  23. 23.
    Fairbank JC, Pynsent PB, van Poortvliet JA, et al. Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg Br 1984; 66 (5): 685–93PubMedGoogle Scholar
  24. 24.
    Hörding G. Chondromalacia patellae bland skolungdom. Nord Med 1983; 98: 207–8PubMedGoogle Scholar
  25. 25.
    Kannus P, Aho H, Järvinen M. Computerized recording of visits to an outpatients sports clinic. Am J Sports Med 1987; 15: 79–85PubMedCrossRefGoogle Scholar
  26. 26.
    Kujala UM, Kvist M, Österman K. Knee injuries in athletes: review of exertion injuries and retrospective study of outpatient sports clinical material. Sports Med 1986; 3: 447–60PubMedCrossRefGoogle Scholar
  27. 27.
    Newman P, Thomson J, Barnes J, et al. A clinic for athletic injuries. Proc R Soc Med 1969; 62: 939–41PubMedGoogle Scholar
  28. 28.
    Orava S. Exertion injuries due to sports and physical exercise: a clinical and statistical study of nontraumatic overuse injuries of the musculoskeletal system of athletes and keep-fit athletes [thesis]. Oulo: University of Oulo, 1980Google Scholar
  29. 29.
    Bentley G, Dowd G. Current concepts of etiology and treatment of chondromalacia patellae. Clin Orthop Rel Res 1984; 189: 209–28Google Scholar
  30. 30.
    Kujala UM, Österman K, Kvist M, et al. Factors predisposing to patellar chondropathy and patellar apecitis in athletes. Int Orthop 1986; 10: 195–200PubMedCrossRefGoogle Scholar
  31. 31.
    Klingman RE, Liaos S, Hardin K. The effect of subtalar joint posting on patellar glide position in subjects with excessive rearfoot pronation. J Orthop Sports Phys Ther 1997; 25 (3): 185–91PubMedGoogle Scholar
  32. 32.
    Galanty HL, Matthews C, Hergenroeder AC. Anterior knee pain in adolescents. Clin J Sports Med 1994; 4: 176–81CrossRefGoogle Scholar
  33. 33.
    Kannus P, Niittymäki S. Which factors predict outcome in the nonoperative treatment of patellofemoral pain syndrome? A prospective follow-up study. Med Sci Sports Exerc 1994; 26: 289–96PubMedGoogle Scholar
  34. 34.
    Karlsson J, Thomeé R, Swärd L. Eleven year follow-up of patellofemoral pain syndrome. Clin J Sports Med 1996; 6: 22–6CrossRefGoogle Scholar
  35. 35.
    Messier SP, Davis SE, Curl WW, et al. Etiologic factors associated with patellofemoral pain in runners. Med Sci Sports Exerc 1991; 23: 1008–15PubMedGoogle Scholar
  36. 36.
    Schutzer SF, Ramsby GR, Fulkerson JP. The evaluation of patellofemoral pain using computerised tomography: a preliminary study. Clin Orthop 1984; 204: 186–293Google Scholar
  37. 37.
    Schutzer SF, Ramsby GR, Fulkerson JP. Computed tomographic classification of patello-femoral pain patients. Orthop Clin North Am 1986; 17: 235–48PubMedGoogle Scholar
  38. 38.
    Merchant AC, Mercer RL, Jacobsen RH, et al. Roentgenographic analysis of patellofemoral congruence. J Bone Joint Surg Am 1974; 56 (7): 1391–6PubMedGoogle Scholar
  39. 39.
    Stanford W, Phelan J, Kathol MH, et al. Patellofemoral joint motion: evaluation by ultrafast computed tomography. Skeletal Radiol 1988; 17: 487–92PubMedCrossRefGoogle Scholar
  40. 40.
    Insall JN, Aglietti P, Tria AJ. Patellar pain and incongruence II: clinical application. Clin Orthop 1983; 176: 225–32PubMedGoogle Scholar
  41. 41.
    Dupuy DE, Hangen DH, Zachazewski JE, et al. Kinematic CT of the patellofemoral joint. Am J Roentgenol 1997; 169 (1): 211–5Google Scholar
  42. 42.
    Dillon PZ, Updyke WF, Allen WC. Gait analysis with reference to chondromalacia patellae. J Orthop Sports Phys Ther 1983; 5: 127–31PubMedGoogle Scholar
  43. 43.
    Powers CM, Perry J, Hsu A, et al. Are patellofemoral pain and quadriceps femoris muscle torque associated with locomotor function? Phys Ther 1997; 77 (10): 1063–75PubMedGoogle Scholar
  44. 44.
    Antich TJ, Randall C, Westbrook RA, et al. Evaluation of knee extensor mechanism disorders: clinical presentation of 112 patients. J Orthop Sports Phys Ther 1986; 8: 248–54PubMedGoogle Scholar
  45. 45.
    Thomeé R, Renström P, Karlsson J, et al. Patellofemoral pain syndrome in young women: II. Muscle function in patients and healthy controls. Scand JMed Sci Sports 1995; 5: 245–51CrossRefGoogle Scholar
  46. 46.
    Bennett JG, Stauber WT. Evaluation and treatment of anterior knee pain using eccentric exercise. Med Sci Sports Excerc 1986; 18 (5): 526–30Google Scholar
  47. 47.
    Campbell DE, GlennW. Rehabilitation of knee flexor and knee extensor muscle strength in patients with meniscectomies, ligamentous repairs, and chondromalacia. Phys Ther 1982; 62: 10–5PubMedGoogle Scholar
  48. 48.
    Dvir Z, Halperin N. Patellofemoral pain syndrome: a preliminary model for analysis and interpretation of isokinetic and pain parameters. Clin Biomech 1992; 7: 240–6CrossRefGoogle Scholar
  49. 49.
    Hoke B, Howell D, Stack M. The relationship between isokinetic testing and dynamic patellofemoral compression. J Orthop Sports Phys Ther 1983; 4: 150–3PubMedGoogle Scholar
  50. 50.
    MacIntyre D, Robertson G. Quadriceps muscle activity in women runners with and without patellofemoral pain syndrome. Arch Phys Med Rehabil 1992; 73: 10–4PubMedGoogle Scholar
  51. 51.
    Werner S. An evaluation of knee extensor and knee flexor torques and EMGs in patients with patello-femoral pain syndrome in comparison with matched controls. Knee Surg SportsTraumatol Arthrosc 1995; 3 (2): 89–94CrossRefGoogle Scholar
  52. 52.
    Doxey GE, Eisenman P. The influence of patellofemoral pain on electromyographic activity during submaximal isometric contractions. J Orthop Sports Phys Ther 1984; 9: 211–6Google Scholar
  53. 53.
    Möller BN, Krebs B, Tideman-Dal C, et al. Isometric contractions in the patellofemoral pain syndrome: an electromyographic study. Arch Orthop Traum Surg 1986; 105: 24–7CrossRefGoogle Scholar
  54. 54.
    Cerny K. Vastus medialis oblique/vastus lateralis muscle activity ratios for selected exercises in persons with and without patellofemoral pain syndrome. Phys Ther 1995; 75 (8): 672–83PubMedGoogle Scholar
  55. 55.
    Souza DR, Gross MT. Comparison of vastusmedialis obliquus: vastus lateralis muscle integrated electromyographic ratios between healthy subjects and patients with patellofemoral pain. Phys Ther 1991; 71: 310–20PubMedGoogle Scholar
  56. 56.
    Voight ML, Wieder DL. Comparative reflex response time of vastus medialis obliquus and vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction. Am J Sports Med 1991; 19: 131–7PubMedCrossRefGoogle Scholar
  57. 57.
    Boucher J, King M, Lefebvre R, et al. Quadriceps femoris muscle activity in patellofemoral pain syndrome. Am J Sports Med 1992; 20: 527–32PubMedCrossRefGoogle Scholar
  58. 58.
    Witvrouw E, Sneyers C, Lysens R, et al. Reflex response times of vastus medialis oblique and vastus lateralis in normal subjects and in subjects with patellofemoral pain syndrome. J Orthop Sports Phys Ther 1996; 24 (3): 160–5PubMedGoogle Scholar
  59. 59.
    Powers CM, Landel R, Perry J. Timing and intensity of vastus muscle activity during functional activities in subjects with and without patellofemoral pain. PhysTher 1996; 76 (9): 946–55Google Scholar
  60. 60.
    Morrish GM, Woledge RC. A comparison of the activation of muscles moving the patella in normal subjects and in patients with chronic patellofemoral problems. Scand J Rehabil Med 1997; 29 (1): 43–8PubMedGoogle Scholar
  61. 61.
    Gilleard W, McConnell J, Parsons D. The effect of patellar taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 1998; 78 (1): 25–32PubMedGoogle Scholar
  62. 62.
    McConnell J. The management of chondromalacia patellae: a long term solution. Aust J Phys Ther 1986; 32: 215–23Google Scholar
  63. 63.
    Hehne HJ. Biomechanics of the patellofemoral joint and its clinical relevance. Clin Orthop 1990; 258: 73–85PubMedGoogle Scholar
  64. 64.
    Grabiner MD, Koh TJ, Miller GF. Fatigue rates of vastus medialis oblique and vastus lateralis during static and dynamic knee extension. J Orthop Res 1991; 9: 391–7PubMedCrossRefGoogle Scholar
  65. 65.
    Weinstabl R, Schaf W, Firas W. The extensor apparatus of the knee joint and its peripheral vasti: anatomic investigation and clinical relevance. Surg Radiol Anat 1989; 11: 17–22PubMedCrossRefGoogle Scholar
  66. 66.
    Speakman H, Weisberg J. The vastus medialis controversy. Phys Ther 1977; 63: 279–83Google Scholar
  67. 67.
    Mariani PP, Caruso I. An electromyographic investigation of subluxation of the patella. J Bone Joint Surg Br 1979; 61 (2): 169–71PubMedGoogle Scholar
  68. 68.
    Stratford P. Electromyography of the quadriceps femoris muscle in subjects with normal knees and acutely effused knees. Phys Ther 1981; 62: 279–83Google Scholar
  69. 69.
    Doucette SA, Child DD. The effect of open and closed chain exercise and knee joint position on lateral patellar compression syndrome. J Orthop Sports Phys Ther 1996; 23 (2): 104–10PubMedGoogle Scholar
  70. 70.
    Doucette SA, Goble EM. The effect of exercise on patellar tracking in lateral patellar compression syndrome. Am J Sports Med 1992; 20: 434–40PubMedCrossRefGoogle Scholar
  71. 71.
    Zappala FG, Taffel CB, Scuderi GR. Rehabilitation of the patellofemoral joint disorders. Orthop Clin North Am 1992; 23: 555–66PubMedGoogle Scholar
  72. 72.
    Palmitier R, An K-N, Scott S, et al. Kinetic chain exercise in knee rehabilitation. Sports Med 1991; 11 (6): 402–13PubMedCrossRefGoogle Scholar
  73. 73.
    Beynnon B, Johnson R, Fleming B, et al. The strain behaviour of the anterior cruciate ligament during squatting and active flexion-extension. Am J Sports Med 1997; 25 (6): 823–9PubMedCrossRefGoogle Scholar
  74. 74.
    Fitzgerald GK. Open versus closed kinetic chain exercise: issues in rehabilitation after anterior cruciate ligament reconstructive surgery. Phys Ther 1997; 77 (12): 1747–54PubMedGoogle Scholar
  75. 75.
    Thomeé R, Grimby G, Svantesson U, et al. Quadriceps muscle performance in sitting and standing in young women with patellofemoral pain syndrome and healthy controls. Scand J Med Sci Sports 1996; 6 (4): 233–41PubMedCrossRefGoogle Scholar
  76. 76.
    Secher NH, Rube N, Elers J. Strength of two- and one-legged extension in man. Acta Physiol Scand 1988; 134: 333–9PubMedCrossRefGoogle Scholar
  77. 77.
    Bynum BE, Barrack RL, Alexander AH. Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. Am J Sports Med 1995; 23: 401–6PubMedCrossRefGoogle Scholar
  78. 78.
    Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 1992; 15: 256–64PubMedGoogle Scholar
  79. 79.
    De Carlo M, Shelbourne D, McCarroll J, et al. Traditional versus accelerated rehabilitation following ACL reconstruction: a one-year follow-up. J Orthop Sports Phys Ther 1992; 6: 309–16Google Scholar
  80. 80.
    Shelbourne K, Klootwyk T, Wilckens J, et al. Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program. Am J Sports Med 1995; 5: 575–9CrossRefGoogle Scholar
  81. 81.
    Callaghan MJ, Oldham JA. The role of quadriceps exercise in the treatment of patellofemoral pain syndrome. Sports Med 1996; 21: 384–91PubMedCrossRefGoogle Scholar
  82. 82.
    Greenberger H, Paterno M. Relationship of knee extensor strength and hopping test performance in the assessment of lower extremity function. J Orthop Sports Phys Ther 1995; 5: 202–6Google Scholar
  83. 83.
    Wilk K, Romaniello W, Soscia S, et al. The relationship between subjective knee scores, isokinetic testing, and functional testing in the ACL-reconstructed knee. J Orthop Sports Phys Ther 1994; 2: 60–72Google Scholar
  84. 84.
    Augustsson J, Esko A, Thomeé R, et al. Weight training of the thigh muscles using closed vs open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Ther 1998; 27 (1): 3–8PubMedGoogle Scholar
  85. 85.
    Steinkamp LA, Dillingham MF, Markel MD, et al. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 1993; 21 (3): 438–44PubMedCrossRefGoogle Scholar
  86. 86.
    Tegner Y. Cruciate ligament injuries in the knee: evaluation and rehabilitation [thesis]. Linköping: Linköping University, 1985Google Scholar
  87. 87.
    Lindblom U, Németh G. Smärttyper med eftersatt differential diagnostik. Läkartidningen 1992; 89: 1392–9PubMedGoogle Scholar
  88. 88.
    Biedert RM, Stauffer E, Friedrich N. Occurrence of free nerve endings in the soft tissue of the knee joint: a histologic investigation. Am J Sports Med 1992; 20: 430–3PubMedCrossRefGoogle Scholar
  89. 89.
    Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med 1982; 10: 329–35PubMedCrossRefGoogle Scholar
  90. 90.
    Fulkerson JP, Tenant R, Jiving JS, et al. Histologic evidence of retinacular nerve injury. Clin Orthop Rel Res 1985; 197: 195–205Google Scholar
  91. 91.
    Goodfellow J, Hungerford DS, Woods C. Patello-femoral joint mechanics and pathology. 2: chondromalacia patellae. J Bone J Surg Br 1976; 58 (3): 291–9Google Scholar
  92. 92.
    Werner S, Eriksson E. Isokinetic quadriceps training in patients with patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1993; 1: 162–8PubMedCrossRefGoogle Scholar
  93. 93.
    Scott J, Huskisson EC. Graphic representation of pain. Pain 1976; 6: 175–84CrossRefGoogle Scholar
  94. 94.
    Dixon JS, Bird HA. Reproducibility along a 10 cm vertical visual analogue scale. Ann Rheum Dis 1981; 40: 887–9Google Scholar
  95. 95.
    Price DD, McGrath PA, Rafii A, et al. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain 1983; 17 (1): 45–56PubMedCrossRefGoogle Scholar
  96. 96.
    Seymour RA, Simpson JM, Charlton JE, et al. An evaluation of length and end-phrase of visual analogue scales in dental pain. Pain 1985; 21: 177–85PubMedCrossRefGoogle Scholar
  97. 97.
    Downie WW, Leatham PA, Rhind VM, et al. Studies with pain rating scales. Ann Rheum Dis 1978; 37: 378–81PubMedCrossRefGoogle Scholar
  98. 98.
    Joyce CRB, Zutshi DW, Hrubes V, et al. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol 1975; 8: 415–20PubMedCrossRefGoogle Scholar
  99. 99.
    Kremer E, Atkinson JH, Ignelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain 1981; 10 (2): 241–8PubMedCrossRefGoogle Scholar
  100. 100.
    Ohnhaus E, Adler R. Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale. Pain 1975; 1: 379–84PubMedCrossRefGoogle Scholar
  101. 101.
    Carlsson AM. Assessment of chronic pain. 1: aspects of the reliability and validity of the visual analog scale. Pain 1983; 16 (1): 87–101PubMedCrossRefGoogle Scholar
  102. 102.
    Harms-Ringdahl K, Carlsson AM, Ekholm J, et al. Pain assessment with different intensity scales in response to loading of joint structures. Pain 1986; 27: 401–11PubMedCrossRefGoogle Scholar
  103. 103.
    Borg G. A category scale with ratio properties for inter modal and inter individual comparisons. In: Geisler HG, Petzold P, editors. Psychophysical judgement and the process of perception. Berlin: VEB Deutscher Verlag der Wissenschaften, 1982: 25–34Google Scholar
  104. 104.
    Chapman SL, Casey KL, Dubner R, et al. Pain measurement: an overview. Pain 1985; 22: 1–31PubMedCrossRefGoogle Scholar
  105. 105.
    Wright BD, Stone MH. Best test design: Rasch measurements. Chicago: Mesa Press, 1979Google Scholar
  106. 106.
    Thomeé R, Grimby G, Wright BD, et al. Rasch analysis of visual analog scale measurements before and after treatment of patients with patellofemoral pain syndrome. Scand J Rehabil Med 1995; 27: 145–51PubMedGoogle Scholar
  107. 107.
    Rutherford OM, Jones DA, Newham DJ. Clinical and experimental application of the percutaneous twitch superimposition technique for the study of the human muscle activation. J Neurol 1986; 49: 1288–91Google Scholar
  108. 108.
    Lindh MH, Johansson LG, Hedberg M, et al. Studies on maximal voluntary muscle contraction in patients with fibromyalgia. Arch Phys Med Rehabil 1995; 75: 1217–22CrossRefGoogle Scholar
  109. 109.
    Thomeé R. A comprehensive treatment approach for patellofemoral pain syndrome in young women. Phys Ther 1997; 77 (12): 1690–703PubMedGoogle Scholar
  110. 110.
    Carlsson AM, Werner S, Mattlar C-E, et al. Personality in patients with long term patello-femoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1993; 1 (3–4): 178–83PubMedCrossRefGoogle Scholar
  111. 111.
    Fordyce WE. Behavioral factors in pain. Neurosurg Clin 1991; 2: 749–59Google Scholar
  112. 112.
    Lindström IL. A successful intervention program for patients with subacute low back pain [thesis]. Göteborg: Göteborg University, 1994Google Scholar
  113. 113.
    Schwarz C, Blazina ME, Sisto DJ, et al. The results of operative treatment of osteochondritis dissecans of the patella. Am J Sports Med 1988; 16: 522–9PubMedCrossRefGoogle Scholar
  114. 114.
    Sontag S. Illness as metaphor. New York (NY): Vintage, 1977Google Scholar
  115. 115.
    Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther 1993; 73: 62–70PubMedGoogle Scholar
  116. 116.
    Fisher RL. Conservative treatment of patello-femoral pain. Orthop Clin North Am 1986; 17: 269–72PubMedGoogle Scholar
  117. 117.
    Lindberg U. The patellofemoral pain syndrome [thesis]. Linköping: Linköping University, 1986Google Scholar
  118. 118.
    Lysholm J, Nordin M, Ekstrand J, et al. The effect of a patella brace on the performance in knee extension strength test in patients with patellar pain. Am J Sports Med 1984; 12: 110–2PubMedCrossRefGoogle Scholar
  119. 119.
    Malek MM, Mangine RE. Patello-femoral pain syndrome: a comprehensive and conservative approach. J Orthop Sports Phys Ther 1981; 2: 108–16PubMedGoogle Scholar
  120. 120.
    Radin EL. A rational approach to the treatment of patello-femoral pain. Clin Orthop 1979; 144: 107–9PubMedGoogle Scholar
  121. 121.
    Shelton GL, Thigpen LK. Rehabilitation of patellofemoral dysfunction: a review of literature. J Orthop Sports Phys Ther 1991; 14: 243–9PubMedGoogle Scholar
  122. 122.
    Werner S, Eriksson E. Isokinetic quadriceps training in patients with patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1993; 1: 162–8PubMedCrossRefGoogle Scholar
  123. 123.
    Whitelaw GP, Rullo DJ, Markowitz HD, et al. A conservative approach to anterior knee pain. Clin Orthop 1989; 246: 234–7PubMedGoogle Scholar
  124. 124.
    Arroll B, Ellis-Pegler E, Edwards A, et al. Patellofemoral pain syndrome: a critical review of the clinical trials on nonoperative therapy. Am J Sports Med 1997; 20: 207–12CrossRefGoogle Scholar
  125. 125.
    Wise HH, Fiebert JM, Kates JL. EMG biofeedback treatment for patellofemoral pain syndrome. J Orthop Sports Phys Ther 1984; 6: 95–103PubMedGoogle Scholar
  126. 126.
    Yates C, Grana WA. Patellofemoral pain: a prospective study. Orthopaedics 1986; 9: 663–7Google Scholar
  127. 127.
    Evans TK, Paulos LE. Complications of patello-femoral surgery. Orthop Clin North Am 1992; 23: 697–710PubMedGoogle Scholar
  128. 128.
    Karlsson J, Lansinger O, Swärd L. Bad results after anterior advancement of the tibial tuberosity for patellofemoral pain syndrome. Arch Orthop Trauma Surg 1992; 111: 99–104CrossRefGoogle Scholar
  129. 129.
    Sandow MJ, Goodfellow JW. The natural history of anterior knee pain in adolescents. J Bone Joint SurgBr 1985; 67 (1): 36–8Google Scholar
  130. 130.
    Jensen DB, Albrektsen SB. The natural history of chondromalacia patellae: a 12 year follow-up. Acta Orthop Belg 1990; 56: 503–6PubMedGoogle Scholar
  131. 131.
    O’Neill DB, Micheili LJ, Warner JP. Patellofemoral stress: a prospective analysis of exercise treatment in adolescents and adults. Am J Sports Med 1992; 20: 151–6PubMedCrossRefGoogle Scholar
  132. 132.
    McMullen W, Roncarati A, Koval P. Static and isokinetic treatments of chondromalacia patella: a comparative investigation. J Orthop Sports Phys Ther 1990; 12: 256–66PubMedGoogle Scholar
  133. 133.
    Stiene HA, Brosky, T, Reinking M, et al. A comparison of closed kinetic chain and isokinetic joint isolation exercise in patients with patellofemoral dysfunction. J Orthop Sports Phys Ther 1996; 24 (3): 136–41PubMedGoogle Scholar
  134. 134.
    Beckman M, Craig R, Lehman RC. Rehabilitation of the patellofemoral dysfunction in the athlete. Clin Sports Med 1989; 8: 841–60PubMedGoogle Scholar
  135. 135.
    Brunet ME, Stewart GW. Patellofemoral rehabilitation. Clin Sports Med 1989; 8: 319–29PubMedGoogle Scholar
  136. 136.
    Gray D. Physical therapy techniques for conservative treatment of patellar pain and instability. Adapt Techn Sports Med 1994; 2: 263–72Google Scholar
  137. 137.
    Curtiss PH. Changes produced in the synovial membrane and synovial fluid by disease. J Bone Joint Surg Am 1964; 46: 873–88PubMedGoogle Scholar
  138. 138.
    Kannus P, Jozsa L, Renström P, et al. The effects of training, immobilization and remobilization onmusculoskeletal tissue. 1: training and immobilization. Scand J Med Sci Sports 1992; 2: 100–18CrossRefGoogle Scholar
  139. 139.
    Paukkonen K, Selkäinaho K, Jurvelin J, et al. Cells and nuclei of articular cartilage chondrocytes in young rabbits enlarged after nonstrenuous exercise. J Anat 1985; 142: 13–20PubMedGoogle Scholar
  140. 140.
    Radin EL. The physiology and degeneration of joints. Semin Arthritis Rheum 1973; 2: 245–57CrossRefGoogle Scholar
  141. 141.
    Fitzgerald GK, McClure PW. Reliability of measurements obtained with four tests for patellofemoral alignment. Phys Ther 1995; 75: 84–92PubMedGoogle Scholar
  142. 142.
    Werner S, Knutsson E, Eriksson E. The effect of taping the patella on concentric and eccentric torque and emg of knee extensor and knee flexor muscles in patients with patello-femoral pain syndrome. Knee Surg Sports Traumatol Arthrosc 1993; 1: 169–77PubMedCrossRefGoogle Scholar
  143. 143.
    Kowall MG, Kolk G, Nuber G, et al. Patellar taping in the treatment of patellofemoral pain: a prospective randomized study. Am J Sports Med 1996; 24 (1): 61–6PubMedCrossRefGoogle Scholar
  144. 144.
    Larsen B, Andreasen E, Urfer A, et al. Patellar taping: a radiographic examination of the medial glide technique. Am J Sports Med 1995; 23 (4): 465–71PubMedCrossRefGoogle Scholar
  145. 145.
    Fulkerson, JP, Schutzer SF. After failure of conservative treatment for painful patello-femoral malalignment: lateral release or realignment? Orthop Clin North Am 1986; 17: 283–8PubMedGoogle Scholar
  146. 146.
    Fabbriciani C, Panni AS, Delcogliano A. Role of arthroscopic lateral release in the treatment of patello-femoral disorders. Arthroscopy 1992; 8: 531–6PubMedCrossRefGoogle Scholar
  147. 147.
    Hayes WC, Huberti HH, Lewallen DG, et al. Patellofemoral contact pressures and the effects of surgical reconstructive procedures. In: Ewing JW, editor. Articular cartilage and knee joint function: basic science and arthroscopy. New York (NY): Raven Press, 1990: 57–77Google Scholar
  148. 148.
    Insall J, Bullogh PG, Burstein AH. Proximal ‘tube’ realignment of the patella for chondromalacia patellae. Clin Orthop 1979; 144: 63–9PubMedGoogle Scholar
  149. 149.
    Scuderi G, Cuomo F, Scott WN. Lateral release and proximal realignment for patellar subluxation and dislocation: a long-term follow-up. J Bone Joint Surg Am 1988; 70 (6): 856–61PubMedGoogle Scholar
  150. 150.
    Fielding JW, Liebler WA, Tambakis A. The effect of a tibial-tubercle transplant in children on the growth of the upper tibial epiphysis. J Bone Joint Surg Am 1960; 42: 1426–34Google Scholar
  151. 151.
    Cox JS. Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment. Am J Sports Med 1982; 10: 303–10PubMedCrossRefGoogle Scholar
  152. 152.
    Ferguson Jr AB, Brown TD, Fu FH, et al. Relief of patellofemoral contact stress by anterior displacement of the tibial tubercle. J Bone Joint Surg Am 1979; 61 (2): 159–66PubMedGoogle Scholar
  153. 153.
    Maquet P. Mechanics and osteoarthritis of the patello-femoral joint. Clin Orthop 1979; 144: 70–3PubMedGoogle Scholar
  154. 154.
    Engebretsen L, Svenningsen S, Benum P. Advancement of the tibial tuberosity for patellar pain: a 5-year follow-up. Acta Orthop Scand 1989; 60: 20–2PubMedCrossRefGoogle Scholar
  155. 155.
    Radin EL, Pan HQ. Long term follow-up study on the Maquet procedure with special reference to the causes of failure. Clin Orthop 1993; 290: 253–8PubMedGoogle Scholar
  156. 156.
    Fulkerson JP. Anteromedialization of the tibial tuberosity for patello-femoral malalignment. Clin Orthop 1983; 177: 176–81PubMedGoogle Scholar
  157. 157.
    Ficat RP, Ficat C, Gedeon P, et al. Spongialization: a new treatment for diseased patellae. Clin Orthop 1979; 144; 74–83PubMedGoogle Scholar
  158. 158.
    Papagelopoulos PJ, Sim FH. Patellofemoral pain syndrome: diagnosis and management. Orthopaedics 1997; 20: 148–57Google Scholar

Copyright information

© Adis International Limited 1999

Authors and Affiliations

  • Roland Thomeé
    • 1
    Email author
  • Jesper Augustsson
    • 1
  • Jon Karlsson
    • 2
  1. 1.Muscle Laboratory, Department of Rehabilitation MedicineSahlgrenska University HospitalGöteborgSweden
  2. 2.Department of OrthopaedicsSahlgrenska University HospitalGöteborgSweden

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