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Objective: Define a best practice guide for managing people with patellofemoral pain (PFP)., Methods: A mixed-methods convergent segregated synthesis of meta-analysed data with a thematic analysis of semistructured interviews and focus groups. Agreement between subproject results informed the strength of clinical recommendation for interventions eligible for best practice recommendation., Data Sources: Medline, Web of Science, Scopus, reference lists and citation tracking; semistructured interviews of people with PFP; and semistructured interviews and focus groups with clinical experts., Eligibility Criteria: High-quality (PEDro scale >7) randomised controlled trials (RCTs) were retained for efficacy estimation using meta-analysis. People with PFP were required to have experienced an episode of care in the past 6 months and clinical experts were required to have>5 years of clinical experience alongside direct involvement in research., Results: Data from 65 high-quality RCTs involving 3796 participants informed 11 meta-analyses of interventions. Interviews with 12 people with PFP led to 3 themes and interviews with 19 clinical experts led to 4 themes. These were further explored in three clinical expert focus groups. Best practice for PFP should first involve understanding a patient's background risk factors, their reasons for seeking care, greatest symptoms, and physical impairments, to inform treatment selection. Synthesis led to six distinct interventions being recommended. Knee-targeted±hip-targeted exercise therapy underpinned by education should be delivered, with additional supporting interventions such as prefabricated foot orthoses, manual therapy, movement/running retraining, or taping decided on and tailored to a patient's needs and preferences., Conclusion: A best practice guide based on a synthesis of three data streams recommends that exercise therapy and education be delivered as the primary intervention for people with PFP. Prescription of other supporting interventions should be aligned with the individual patient's particular presentation following a thorough assessment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

OBJECTIVE: To determine the effects of nonsurgical treatments on pain and function in people with patellofemoral pain (PFP). DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched MEDLINE, Web of Science, and Scopus databases from their inception until May 2022 for interventional randomized controlled trials (RCTs) in people with PFP. STUDY SELECTION CRITERIA: We included RCTs that were scored ≥7 on the PEDro scale. DATA SYNTHESIS: We extracted homogenous pain and function data at short- (≤3 months), medium- (>3 to ≤12 months) and long-term (>12 months) follow-up. Interventions demonstrated primary efficacy if outcomes were superior to sham, placebo, or wait-and-see control. Interventions demonstrated secondary efficacy if outcomes were superior to an intervention with primary efficacy. RESULTS: We included 65 RCTs. Four interventions demonstrated short-term primary efficacy : knee-targeted exercise therapy for pain (standardized mean difference [SMD], 1.16; 95% CI: 0.66, 1.66) and function (SMD, 1.19; 95% CI: 0.51, 1.88), combined interventions for pain (SMD, 0.79; 95% CI: 0.26, 1.29) and function (SMD, 0.98; 95% CI: 0.47, 1.49), foot orthoses for global rating of change (OR = 4.31; 95% CI: 1.48, 12.56), and lower-quadrant manual therapy for function (SMD, 2.30; 95% CI: 1.60, 3.00). Two interventions demonstrated short-term secondary efficacy compared to knee-targeted exercise therapy: hip-and-knee-targeted exercise therapy for pain (SMD, 1.02; 95% CI: 0.58, 1.46) and function (SMD, 1.03; 95% CI: 0.61, 1.45), and knee-targeted exercise therapy and perineural dextrose injection for pain (SMD, 1.34; 95% CI: 0.72, 1.95) and function (SMD, 1.21; 95% CI: 0.60, 1.82). CONCLUSIONS: Six interventions had positive effects at 3 months for people with PFP, with no intervention adequately tested beyond this time point. J Orthop Sports Phys Ther 2022;52(11):750-768. Epub: 8 September 2022. doi:10.2519/jospt.2022.11359 .

Background: Patellofemoral pain (PFP) is common and has a poor long-term prognosis. There is a lack of clarity about the clinical reasoning of recognised inter-disciplinary experts in the published literature., Objectives: To help identify best practice by exploring the clinical reasoning of a range of inter-disciplinary experts that regularly diagnose and treat PFP., Design: Qualitative study with semi-structured interviews., Method: Recruitment resulted in a convenience sample for semi-structured interview, which were recorded and transcribed verbatim. Data were analysed until theoretical saturation, as determined by multiple investigators., Findings: Interviews with 19 clinical experts (15 men, 4 women; mean experience 18.6 years ± 8.6) from four broad professions yielded four themes. Firstly, the assessment and diagnosis process should include a thorough history and examination to rule in PFP. Secondly, information provision should aim to increase patients' understanding, aid in controlling symptoms, and facilitate behaviour change. Thirdly, active rehabilitation, which was a salient theme and included advocacy of combined hip and knee exercise that is adapted to the individual. Finally, treatment adjuncts, which can be used selectively to modify symptoms, may include running retraining, taping, or foot orthoses., Conclusions: PFP should be diagnosed clinically, and tailored treatment programmes should be prescribed for people with PFP. Exercise was considered the most effective treatment and underlying psychological factors should be addressed to improve prognosis., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Patellofemoral pain (PFP) is common and long-term treatment outcomes are unsatisfactory. Qualitative exploration of diagnosis and management from the perspective of people with PFP is lacking., Objectives: To inform care and improve intervention delivery by exploring the experience of people with PFP regarding diagnosis and management., Design: Qualitative study with semi-structured interviews., Method: Online recruiting yielded a convenience sample of participants with PFP for semi-structured interview. Interviews were recorded, transcribed verbatim, and analysed using thematic analysis until theoretical saturation by multiple investigators to determine themes and sub-themes., Results: 12 participants were interviewed, with three themes identified; the value of diagnosis, the need for tailored (individualised) care, and the role of education. Participants viewed receiving a diagnosis as essential to guide management, yet one was rarely provided, causing uncertainty about pain mechanisms; "it's nice to be told what it is that's wrong". Interventions needed to be tailored to the individual as not all participants responded in the same way to treatment(s) or had the same needs; "everyone copes and reacts differently". Finally, participants viewed education as essential to empower them to understand and manage the condition; "if I'd have been given more information, I think I'd know how to deal with it more"., Conclusions: The overarching narrative from three themes was a desire for clearly communicated personalised care that meets individual needs. People with PFP desire a diagnosis to explain their pain, tailored interventions, and appropriate education to optimise their experience and outcomes., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Local neuromuscular deficits have been reported in people with patellofemoral pain. We synthesised the neuromuscular characteristics associated with patellofemoral pain to help identify interventional targets and potential mechanisms., Methods: Five databases were searched for local neuromuscular characteristics in case-control studies. Electromyography, flexibility, muscle performance and cross-sectional area data were derived from functional or isolated task investigations and synthesised accordingly. An evidence gap map was constructed., Findings: Sixty-seven studies were included. In functional tasks, electromyographic investigations showed moderate evidence of small effect for vastus medialis onset-delays relative to vastus lateralis (0.44 [0.03, 0.85]) during stepping/stair negotiation tasks, and higher biceps femoris mean excitation amplitudes (0.55 [0.06, 1.04]) in single-leg triple-hop test. In isolated tasks, we found moderate evidence of medium effect for lower Hoffman-reflex amplitude of vastus medialis (-1.12 [-1.56, -0.67]). Muscle performance investigations showed; strong evidence with medium and small effects for lower extensors concentric (-0.61 [-0.81, -0.40]) and eccentric (-0.56 [-0.79, -0.33]) strength, and moderate evidence of medium effect of lower isometric (-0.64 [-0.87, -0.41]) strength, moderate evidence with small effect for rate of force development to 30% (-0.55[-0.89, -0.21]), 60% (-0.57[-0.90, -0.25]) and medium effect to 90% (-0.76[-1.43, -0.10]) of maximum voluntary contraction, and small effect for lower flexors concentric strength (-0.46 [-0.74, -0.19]) and extensors total work (-0.48 [-0.90, -0.07]). Flexibility investigations showed tighter hamstrings (-0.57 [-0.99, -0.14])., Interpretation: Differences within quadriceps and hamstrings motor-control, hamstrings tightness, and quadriceps and hamstrings weakness are associated with patellofemoral pain, and can be used to guide investigations of treatment effects., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: Investigate the validity and reliability of markerless, smart phone collected, two-dimensional (2D) video, analysed using the 'Hudl technique' application, compared to three-dimensional (3D) kinematics during running, in participants with patellofemoral pain (PFP)., Design: Validity/reliability study., Setting: Biomechanics laboratory., Participants: Males/females with PFP (n = 21, 10 males, 11 females, age 32.1 months [±12.9])., Main Outcome Measures: Manually synchronised 2D and 3D measurement of peak hip adduction (HADD) and peak knee flexion (KFLEX) during running., Results: 2D and 3D measures of peak KFLEX (p = 0.02, d = 1.13), but not peak HADD (p = 0.25, d = -0.27), differed significantly. Poor validity was identified for 2D measurement of peak HADD (ICC 0.06, 95% CI -0.35, 0.47) and peak KFLEX ICC 0.42, 95% CI (-0.10, 0.75). Moderate intra-rater reliability was identified for both variables (ICC 0.61-65), alongside moderate inter-rater reliability for peak KFLEX (ICC 0.71) and poor inter-rater reliability for peak HADD (ICC 0.31)., Conclusions: Measurement of peak HADD and KFLEX in runners with PFP using markerless, smart phone collected 2D video, analysed using the Hudl technique Application is invalid, with poor to moderate reliability. Investigation of alternate 2D video approaches to increase precision is warranted. At present, 2D video analysis of running using Hudl Technique cannot be advocated., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest in relation to this study., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Patellofemoral pain (PFP) is a prevalent condition commencing at various points throughout life. We aimed to provide an evidence synthesis concerning predictive variables for PFP, to aid development of preventative interventions., Methods: We searched Medline, Web of Science and SCOPUS until February 2017 for prospective studies investigating at least one potential risk factor for future PFP. Two independent reviewers appraised methodological quality using the Newcastle-Ottawa Scale. We conducted meta-analysis where appropriate, with standardised mean differences (SMD) and risk ratios calculated for continuous and nominal scaled data., Results: This review included 18 studies involving 4818 participants, of whom 483 developed PFP (heterogeneous incidence 10%). Three distinct subgroups (military recruits, adolescents and recreational runners) were identified. Strong to moderate evidence indicated that age, height, weight, body mass index (BMI), body fat and Q angle were not risk factors for future PFP. Moderate evidence indicated that quadriceps weakness was a risk factor for future PFP in the military, especially when normalised by BMI (SMD -0.69, CI -1.02, -0.35). Moderate evidence indicated that hip weakness was not a risk factor for future PFP (multiple pooled SMDs, range -0.09 to -0.20), but in adolescents, moderate evidence indicated that increased hip abduction strength was a risk factor for future PFP (SMD 0.71, CI 0.39, 1.04)., Conclusions: This review identified multiple variables that did not predict future PFP, but quadriceps weakness in military recruits and higher hip strength in adolescents were risk factors for PFP. Identifying modifiable risk factors is an urgent priority to improve prevention and treatment outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)