RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

ANNEXURE II

1. Name of the Candidate and MOHAMMAD SUHAIL

Address (in block letters) DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
VIDYANAGAR
KULOOR,MANGALORE-575013

2. Name of the Institution DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY

3. Course of Study and Subject MASTER OF PHYSIOTHERAPY (MPT)

MUSCULO SKELETAL DISORDERS AND SPORTS

PHYSIOTHERAPY

4. Date of Admission to Course 26th JUNE 2008

5. Title of the Topic EFFECTS OF MANUAL THERAPY ON REDUCING

PAIN AND IMPROVING FUNCTIONS IN YOUNG
ADULTS WITH PATELLOFEMORAL PAIN
SYNDROME (PFPS).

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6. BRIEF RESUME OF THE INTENDED WORK:

6.1) INTRODUCTION AND NEED OF THE STUDY:

Knee pain is one of the most commonly reported musculoskeletal disorders with estimates
that it will effects 30-40% of population by age 651. Anterior knee pain is the most prevalent
disorder involving the knee, with its prevalence being as high as 7% at any one time in active
young adults2.

Among all the causes of anterior knee pain, Patellofemoral pain syndrome (PFPS) is the
most common diagnosis in outpatients presenting with knee pain. Studies have shown PFPS to be
the most common single diagnosis among runners and in sports medicine centers 3,4. Eleven percent
of musculoskeletal complaints in the office setting are caused by anterior knee pain (which most
commonly results from PFPS), and PFPS constitutes 16 to 25 percent of all injuries in runners1, 5,6.
Patellofemoral pain is common, particularly in active, young patient with patellofemoral
malalignment7-9, 10, 11.

The term “PFPS” is often used interchangeably with “anterior knee pain” or “runner’s
knee.”PFPS can be defined as anterior knee pain involving the patella and retinaculum that
excludes other intraarticular and peripatellar pathology12. In patellofemoral joint the patella acts as
a lever and also increases the moment arm of the patellofemoral joint, the quadriceps and patellar
tendons13. Many theories have been proposed to explain the etiology of patellofemoral pain. These
include biomechanical, muscular and overuse theories. In genral, the literature and clinical
experience suggest that the etiology of patellofemoral pain syndrome is multifactorial 14. Overuse,
trauma, and anatomic factors appear to be the main contributors.

Patellofemoral pain syndrome (PFPS) remains one of the most common and challenging
musculoskeletal entities encountered by physiotherapists and sports medicine practitioners15-17. The
lack of understanding of the etiology and pathology associated with patellofemoral pain and
dysfunction is reflected in the vast number of treatment options for PFPS. Nonoperative treatments
are usually used (especially in the first instance), and physiotherapy is a commonly used
conservative physical intervention.

Physiotherapy treatments often include vastus medialis obliquus (VMO) strengthening to

promote active medial stabilization of the patella within the femoral trochlea18 and/or patellar
realignment procedures (taping, bracing, stretching)19.20. While these treatments appear to be based
on sound theoretical rationale, the evidence for the efficacy of these interventions is not well
established21.

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Need of the study:

It has been demonstrated that physiotherapy intervention is effective in reducing pain and
improving activity in people with anterior knee pain22-24. These studies have included combinations
of patellofemoral taping, muscle stretching, strengthening and co-ordination exercises, along with
techniques aimed at decreasing tightness of the lateral structures such as patellofemoral
mobilisation and deep friction massage to the lateral soft tissues of the knee. It is not yet known;
however, which components may be individually responsible for the improvement. Manual
therapy techniques including mobilisation, stretching, and soft tissue massage are used in the
treatment of anterior knee pain with the aim of decreasing tightness of the lateral structures 25,
results in significantly greater improvement in active knee flexion and the ability to step up/down
a step in people with anterior knee pain 26, but the participants in these trials were relatively old and
it may be possible that there would be a better response to this intervention in younger patients, so
there is a need to assess the efficacy of manual therapy for Patellofemoral pain syndrome (PFPS)
in younger patient.

Research Question:

Is manual therapy is efficient in reducing pain, increasing knee flexion and enhancing activity in
young patient of Patellofemoral pain syndrome (PFPS) ?

Hypothesis:

Null Hypothesis:
Six session of manual therapy shows no significant improvement in pain, knee flexion and activity
in young patient of Patellofemoral pain syndrome (PFPS)?

Alternate Hypothesis:
Six session of manual therapy result in significant improvement in pain, knee flexion and activity
in young patient of Patellofemoral pain syndrome (PFPS)?

6.2) REVIEW OF LITERATURE:

Van Saase JL et al. (1989)1 did a study on Epidemiology of osteoarthritis: Zoetermeer

survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other
populations and according to their findings knee pain is one of the most commonly reported
musculoskeletal disorders in all the populations.

Witvrouw E, et al. (2000) 2 in their study on Intrinsic risk factors for the development of
anterior knee pain in an athletic population found that anterior knee pain is the most prevalent
disorder involving the knee, with its prevalence being as high as 7%.

Smillie, I.S (1980)11 in his book “Diseases of the knee joint” wrote that patellofemoral
pain is common, particularly in active, young patient with patellofemoral malalignment and it is
reported to be seen in young adults having poor quadriceps flexibility.

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 A literature Review on Patellofemoral Pain Syndrome treatment was done by Mark S.
Juhn, (1999).14 According to him the etiology of patellofemoral pain include biomechanical,
muscular and overuse theories but in general, the etiology of patellofemoral pain syndrome is
multifactorial.

Palumbo PM. (1981)19 did a study to find the effectiveness of Dynamic patellar brace in
the management of patellofemoral pain and he concluded that this orthosis can be used with other
conservative intervention like taping, stretching to treat the patellofemoral pain syndrome.

A Systematic Review of Physical Interventions for Patellofemoral Pain Syndrome by

Crossley, Kay et al. (April 2001)21 concluded that the evidence to support the use of physical
interventions in the management of PFPS is limited. There appears to be a consistent improvement
in short-term pain and function due to physiotherapy treatment but further trials are warranted for
the other interventions.

Paul A van den Dolder et al. (2006) 26 did a study on older adults with anterior knee pain
to check whether manual therapy is effective in increase knee flexion and improve activity and he
concluded that manual therapy is effective in improving knee flexion and stair climbing in patients
with anterior knee pain. He also advocates doing the similar study in young adults for better
results.

Brukner P et al. (2002)28 in his book “Clinical Sports Medicine.” 2nd ed. 464-93 give a
complete examination of the knee, including a careful assessment of the patellofemoral joint in all
the aspect (inspection, palpation and range of motion).

“Clinical evaluation of patients with patellofemoral disorders” a book by Post WR

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(1999) has provided a thorough review of Patellofemoral Pain syndrome, from pathogenesis
(providing fresh insights and approaches for patient evaluation) through treatment alternatives
both surgical and non-surgical.

A self-administered pain severity scale for patellofemoral pain syndrome was developed
by Laprade J et al. (2002)31 which make the patient to do ten common activities that often provoke
anterior knee pain. These range from sedentary activities such as sitting and resting to vigorous
activities including running/sprinting and participating in sport. It has been shown to have
excellent test-retest reliability (rs = 0.95) and a high degree of concurrent validity when compared
with the Western Ontario MacMaster and Hughston scales.

Norkin C et al (1995)32 in his book “Measurement of Joint Motion: A Guide to

Goniometry.” Told about testing of knee flexion and extension in prone position, this alternative
testing position which allows for more stability than the supine position.

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 Gogia et al (1987)33 studied the reliability and validity of joint angle measurement using
a goniometer. Intertester reliability was high, with average correlation coefficients of 0.98(r) and
0.99(ICC). The correlation coefficients for validity also were high, ranging from 0.97 to 0.98(r)
and from0.98 to 0.99(ICC).The author concluded that goniometric measurements were both
reliable and valid.

A study done by Paul A van den Dolder et al (2006)26 on anterior pain syndrome patients
use 1 minute step test for measuring the activity level of the patient on the basis of number of
times a patient performance with affected leg on 15 cm step.

Cyriax J (1984)27 in his book “Textbook of Orthopaedic Medicine: Treatment by

Manipulation, Massage and Injection” tells about the effectiveness of transverse massage on the
lateral aspect of the knee in the case of anterior knee pain.

“Clinical Sports Medicine” (2nd ed.) a book by Brukner P et al. (2001)30 describe about
the tilt patellofemoral stretches use in case of anterior knee pain.

6.3) OBJECTIVES OF STUDY:

The aim of this trial is to assess the efficacy of manual therapy on Pain, Knee Flexion and
Activity in young adults for Patellofemoral Pain Syndrome.

MATERIALS AND METHODOLOGY:

7.
7.1) Study design:

7.2) Source of data:

7.2(I) Definition of Study Subjects:

Participants were recruited from patients referred to the Physiotherapy Departments of

Wenlock Hospital or Dr.M.V.Shetty Hospital, Mangalore, Karnataka for management of anterior
knee pain.

7.2(II) Inclusion and Exclusion Criteria:

Inclusion Criteria:

1. Patients were included in the trial if they were between the ages of 18 and 35years.
2. Complains of anterior knee pain.

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Exclusion Criteria:

1. Knee pain was caused by trauma in the preceding four weeks was reproduced with combined
extension/rotation and side flexion of the lumbar spine to the ipsilateral side or on hip quadrant
With overpressure.
2. Knee pain due to infection
3. Neoplastic disorder
4. Knee pain of acute inflammatory nature
5. If they had undergone knee surgery within the past six weeks
6. No palpable tenderness over the lateral patellofemoral joint27

7.2(III) Study Sampling Design, Method and Size:

Sample design:

Sample size:

More then 50

7.2(IV) Follow Up:

One time study, no follow up required.

7.2(V) Parameters used for comparison and statistical analysis used:

7.2(VI) Duration of study:

The study will be conducted over a duration of 12 months.

7.2(VII) Methodology:

Once the inclusion criterion is achieved, upon initial interview, patients were
screened for Patellofemoral Pain Syndrome to determine their eligibility for the study28,29. If
eligible, written consent will be taken and baseline measures of pain, range of motion, and activity
limitations will be taken. Each patient will receive six sessions of manual therapy consisting of
transverse frictions to the lateral retinaculum as described by Cyriax (1984)27 conducted both in
the fully extended and fully flexed position, tilt patellofemoral stretches as described by Brukner et
al (2001)30, and the application of a sustained medial glide during repeated flexion and extension
of the knee. Each session lasted for 15–20 minutes. No other intervention (such as advice or
exercise) will be given during the trial.

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 Post-intervention measures were taken two days after the completion of treatment to
decrease the chance that only the effect of the last treatment was measured. Participants were
shown their baseline responses to questionnaires immediately prior to filling them out again to
improve the reliability of responses.34 Finally, participants were asked to fill out their satisfaction
with treatment using the words ‘very satisfied’, ‘somewhat satisfied’, ‘somewhat dissatisfied’ or
‘very dissatisfied‘.

7.3) Does the study require any investigations to be conducted on patients or other human
or animal? If so, please describe briefly.

Patellofemoral Pain Severity Questionnaire31- For pain measurement.

Goniometer32, 33- For accessing active knee flexion and extension.

Step test34- Activity was measured using a step test

7.4) Has ethical clearance been obtained from your institution in case of 7.3?

YES

LIST OF REFERENCES:

1. Van Saase JL, Van Romunde LK, Cats A, Vandenbroucke JP, Valkenburg HA (1989)
Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a
Dutch population with that in 10 other populations. Annals of the Rheumatic Diseases 48: 271–
280.

2. Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G (2000) Intrinsic risk factors

for the development of anterior knee pain in an athletic population. A two-year prospective study.
American Journal of Sports Medicine 28: 480–489.

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A
retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95-101.

4. Baquie P, Brukner P. Injuries presenting to an Australian sports medicine centre: a 12-month

study. Clin J Sport Med 1997; 7:28-31.

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 5. Garrick JG. Anterior knee pain (chondromalacia patella). Physician Sportsmed 1989; 17:75-84.

6. Clement DB, Taunton JE, Smart GW, McNicol KL. A survey of overuse running injuries.
Physician Sportsmed 1981; 9:47-58.

8. 7. Ficat, P., Ficat, C., and Bailleux, A.: Syndrome d’hyperpression externe de la rotule. Rev. Chir.
Orthop. 61:39,1975.

8. Ficat, R. P., and Hungerford, D.S.: Disorders of the Patellofemoral Joint. Baltimore, Williams
and Wilkins, 1977.

9. Fulkerson, J.P.: Awareness of the retinaculum in evaluating Patellofemoral pain. Am.J. Sports
Med. 10(3):147, 1982.

10. Insall, J.:“Chondromalacia Patellae, “Patellar malalignment syndrome.Orthop.Clin.North

Am.10:117, 1979.

11. Smillie, I.S.: Diseases of the knee joint. Edinburgh, Churchill-Livingston, 1980.

12. Reid DC. The myth, mystic and frustration of anterior knee pain [Editorial]. Clin J
Sport Med 1993;3:139-43.

13. Beynnon BD, Johnson RJ, Coughlin KM. Relevant biomechanics of the knee. In: DeLee JC,
Drez D, Miller MD, eds. Orthopaedic Sports Medicine:Principles and Practice. 2nd ed.
Philadelphia, Pa.: Saunders, 2003:1590.

14. Mark S. Juhn. Patellofemoral Pain Syndrome: A Review and Guidelines for Treatment
American Family PhysicianVol. 60/No. 7 (November 1, 1999).

15. Baquie P, Brukner P. Injuries presenting to an Australian sports medicine centre: a 12 month
study. Clin J Sports Med 1997; 7:28–31.

16. Devereaux M, Lachmann S. Patellofemoral arthralgia in athletes attending a sports injury

clinic. Br J Sports Med 1984; 18:18–21.

17. Kannus P, Aho H, Jarvinen M, et al. Computerised recording of visits to an outpatient sports
clinic. Am J Sports Med 1987; 15:79–85.

18. Lieb FJ, Perry J. Quadriceps function. An anatomical and mechanical study. J Bone Joint Surg
1968; 50A:1535–1548.

19. Palumbo PM. Dynamic patellar brace: a new orthosis in the management of patellofemoral

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pain. Am J Sports Med 1981; 9:45–49.

20. McConnell J. The management of chondromalacia patellae: a long term solution. Aust J
Physiother 1986; 32:215–223.

21. Crossley, Kay; Bennell, Kim; Green, Sally; McConnell, Jenny. A Systematic Review of
Physical Interventions for Patellofemoral Pain Syndrome Volume 11(2), April 2001, pp 103-110.

22.Crossley K, Bennell K, Green S, Cowan S, McConnell J (2002) Physical therapy for

patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. American Journal of
Sports Medicine 30: 857–86

23.Cowan S, Bennell K, Hodges P, Crossley K, McConnell J (2003) Simultaneous feed forward

recruitment of the vasti in untrained postural tasks can be restored by physical therapy. Journal of
Orthopaedic Research 21: 553–558.

24. Harrison E, Sheppard M, McQuarrie A (1999) A randomized controlled trial of physical

therapy treatment programs in patellofemoral pain syndrome. Physiotherapy Canada 51:
93–100

25. Cyriax J (1977) Textbook of Orthopaedic Medicine. London: Bailliere Tindall.

26. Paul A van den Dolder and David L Roberts. Six sessions of manual therapy increase knee
flexion and improve activity in people with anterior knee pain: a randomised controlled trial.
Australian Journal of Physiotherapy 2006 Vol. 52 261–264.

27. Cyriax J (1984) Textbook of Orthopaedic Medicine: Treatment by Manipulation, Massage and
Injection. London: Bailliere Tindal.

28. Brukner P, Khan K, McConnell J, Cook J. Anterior knee pain. In: Brukner P, Khan K. Clinical
Sports Medicine. 2nd ed. New York, N.Y.: McGraw Hill, 2002:464-93.

29. Post WR. Clinical evaluation of patients with patellofemoral disorders. Arthroscopy 1999;
15:841-51.

30. Brukner P, Khan K, McConnell J, Cook J (2001): Anterior knee pain. In Brukner P, Kahn K
(Eds): Clinical Sports Medicine (2nd ed.) Sydney: McGraw Hill, Ch 24.

31. Laprade J, Culham E (2002) A self-administered pain severity scale for patellofemoral pain
syndrome. Clinical Rehabilitation 16: 780–788.

32. Norkin C, D.Joyce White (1995) Measurement of Joint Motion: A Guide to Goniometry.

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Philadelphia: FA Davis.

33.Gogia,PP,et al: Reliability of goniometric measurements at the knee.Phys Ther 67:192,1987

34. Guyatt G, Berman L, Townsend M, Taylor D (1985) Should study subjects see their previous
responses? Journal of Chronic Diseases 38: 1003–1007.

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9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF GUIDE Appropriate And Feasible Study

Recommended

11. NAME AND DESIGNATION (in block DR.U.T IFTHIKAR ALI

letters)
11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE
(If any)

11.4 SIGNATURE

11.5 HEAD OF DEPARTMENT N.A

11.6 SIGNATURE --------------

12. 12.1 REMARKS OF THE CHAIRMAN TOPIC IS APPROPRIATE

AND PRINCIPAL AND HAS CLINICAL
IMPLICATIONS.
RECOMMENDED

12.2 SIGNATURE

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