journal of orthopaedic & sports physical therapy | volume 38 | number 11 | november 2008 | 691 [ CASE REPORT ] CARINA D. LOWRY, DPT��55��55_dh]jV5VC5XaZaVcYA5PT, PhD��55��55���Zaan5Yn���ZA5DPT�� Management of Patients With Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series merous, but no general consensus exists as to the most efficacious treatment ap- proach.18 Current evidence-based treatment approaches include tap- ing, strengthening of the hip mus- culature and quadriceps, manual therapy to the lower quarter, and fitting of foot orthoses.17,35,43,47 Treatment interventions for PFPS have previously targeted presumed altered pa- tellofemoral joint biomechanics. One intervention often incorporated into the management of patients with PFPS is pa- tellar taping.17 Multiple studies have shown patellar taping to decrease pain14,21 and, theoretically, to improve patellar track- ing by changing vastus medialis obliquus (VMO) timing13-16,20 with functional tasks. Overall pain has been shown to signifi- cantly decrease with taping and exercise compared to exercise alone.73 Other re- searchers have shown that there is no dif- ference in pain or patellar alignment with sham versus directional taping,9,74,75 due, in part, to the poor reliability of assessing patellar mechanics.71,74 Although the reli- ability of identifying the proper method of taping has been questioned,71,74 there is evidence of its effectiveness for pain relief, specifically with the functional tasks of stair stepping and squatting.14,21 Exercise is another approach in the treatment of PFPS, which historically has targeted the improvement of the recruit- Padults.2,5 atellofemoral pain syndrome (PFPS) is a relatively common disorder encountered in the clinical setting, affecting an estimated 7% to 40% of adolescents and active young The diagnosis of PFPS is typically made based on the presence of anterior or retropatellar knee pain associated with prolonged sitting or with weight-bearing activities that load the patellofemoral joint, such as squatting, kneeling, running, and s5hijYn5YZh^\cO A case series of consecutive patients referred to physical therapy with patel- lofemoral pain syndrome (PFPS). s5WVX���\gdjcYO Physical therapists often treat patients with PFPS, yet there is currently no consensus as to the most effective management strategies. The purpose of this case series is to describe the outcomes of patients referred to physical therapy with PFPS who were treated with a multimodal approach. s5XVhZ5YZhXg^ei^dcO Five patients were treated with a combination of thrust and nonthrust manipulation directed at the joints of the lower quarter, trunk and hip stabilization exercises, patel- lar taping, and foot orthotics. Outcome measures used to capture change in patient status included the Numeric Pain Rating Scale, the Kujala Anterior Knee Pain Scale, the Lower Extremity Functional Scale, and the Global Rating of Change. s5djiXdbZhO Five patients (median age, 15 years range, 14-50 years) with a median duration of knee pain for 8 months (range, 3-24 months) were included in this prospective case series. Four (80%) of the 5 patients demonstrated decreased pain and a clinically significant improvement in function. These gains in function were maintained at a 6-month follow-up. s5Y^hXjhh^dcO Although a cause-and-effect relationship cannot be inferred from a case series, the outcomes achieved by the patients are con- sistent with studies incorporating manual physical therapy, exercise, patellar taping, and orthotic prescription to the management of conditions of the lower extremity. Further randomized controlled trials should be performed to determine the effectiveness of this multimodal approach for the management of individuals with PFPS. s5aZkZa5d[5Zk^YZcXZO Therapy, level 4. J Orthop Sports Phys Ther 2008 38(11):691-702. doi:10.2519/jospt.2008.2690 s5���Zn5ldgYhO knee, manual therapy, spine, orthotics, taping, pain, patellofemoral joint diagnosis of PFPS from 40% to 65% (pos- itive likelihood ratio, 2.34).48 Once the diagnosis of PFPS has been established, the possibilities for interventions are nu- ascending and descending steps.48 Because there currently exists no gold standard for diagnosis of PFPS, inclusion of the step- down test may increase the likelihood of 1Physical Therapist, Saint Joseph Hospital, Nashua, NH Fellow, University of Illinois at Chicago Fellowship in Orthopedic Manual Physical Therapy, Chicago, IL. 2Associate Professor, Department of Physical Therapy, Franklin Pierce College, Concord, NH Affiliate Faculty, Manual Physical Therapy Fellowship Program, Regis University, Denver, CO Research Coordinator and Physical Therapist, Rehabilitation Services, Concord, NH. 3Physical Therapist, Drum Hill Physical and Sports Therapy, Chelmsford, MA. This project should be attributed to Franklin Pierce College, Concord, NH. This case series received approval from The Institutional Review Board at Franklin Pierce College, Concord, NH. Address correspondence to Dr Carina Lowry, Physical Therapy Department, Saint Joseph Hospital, 172 Kinsley St, Nashua, NH 03061. E-mail: carina.lowry@hotmail.com

692 | november 2008 | volume 38 | number 11 | journal of orthopaedic & sports physical therapy [ CASE REPORT ] ment of the quadriceps and VMO. It is unknown if the VMO can preferentially be recruited with exercise or if VMO at- rophy is an indication of total quadriceps atrophy.12,51 Additionally, recent studies have shown that there is weakness of the gluteus medius, gluteus maximus, and hip external rotators,34,58 and poor proprio- ceptive control3,60 in patients with PFPS. It is still debated whether the most effec- tive exercise for PFPS should be weight bearing or non-weight bearing. While a recent randomized controlled trial (RCT)28 showed significant decreases in pain and increases in functional outcomes with both multiple-joint weight-bearing and single-joint non���weight-bearing ex- ercises compared to a control group, the small sample size taken from a homog- enous population could have predisposed the study to type 2 error and loss of sta- tistical power. Boling et al6 found that a program of weight-bearing therapeutic exercise targeting the quadriceps, gluteus medius, and proprioceptive control of the lower extremity decreased pain and im- proved function in patients with PFPS. In contrast to previous studies focusing solely on the VMO, Boling and colleagues6 examined the recruitment of the gluteus medius in addition to the VMO to consid- er the lower extremity kinetic chain as a functional unit. Case reports have shown improvements with weight-bearing thera- peutic exercises for the lower extremity, lending further support to a regional- interdependence approach.47 Manual physical therapy is also often used by physical therapists in the man- agement of PFPS1 however, its use has received less attention in the literature than patellar taping and exercise. Patellar nonthrust manipulation, hip nonthrust manipulation, and lumbopelvic thrust ma- nipulation are examples of manual therapy interventions investigated in this popula- tion.10,21,35,62 In a recent RCT, transverse friction massage and sustained medial pa- tellar nonthrust manipulation were shown to be more effective in relieving pain with a functional step-down task than no treat- ment in a control group.65 Crossley et al,21 in a recent RCT, demonstrated that pa- tellar nonthrust manipulation combined with taping and exercise significantly re- lieved pain with stair descent. However, it has been reported that the direction of application of the patellar nonthrust manipulation may not be important, and patients who received thrust manipula- tion demonstrated greater pain pressure tolerance thresholds when compared to placebo.59 Although this study lacked sta- tistical power, the authors concluded pa- tellar manipulation might be considered a useful intervention for pain relief.59 Manual therapy interventions directed at regions proximal to the patellofemoral joint have also been found to decrease anterior knee pain.10 Hip nonthrust ma- nipulation was suggested as a useful in- tervention in a recent case report that described decreased pain and improved functional outcome measures after pro- longed manual stretching of the hip fol- lowed by therapeutic exercise.10 Suter and colleagues62 found ipsilateral sacro- iliac joint dysfunction with either posi- tive palpation tests or provocation tests in each patient with PFPS in their study. The authors of this RCT found that thrust manipulation techniques directed at the lumbopelvic spine decreased quadriceps muscle inhibition in a PFPS population.62 Other preliminary findings have dem- onstrated that patients with PFPS with asymmetrical hip rotation might respond rapidly and dramatically to lumbopelvic manipulation.35 Iverson and colleagues35 found that patients who exhibit asym- metrical hip internal rotation had an 80% probability of a successful outcome with lumbopelvic manipulation. These patients had at least a 50% or greater decrease in pain with a step-down test after a single treatment session.35 Further research is needed to validate these findings. Foot orthoses have been proposed to correct lower extremity malalignment and reduce patellofemoral stresses, there- by relieving patellofemoral pain. Litera- ture supports the use of foot orthoses for patients who excessively pronate or have excessive tibial rotation, and custom or- thotics have been found to significantly decrease pain and improve functional outcome scores in patients who exces- sively pronate and report anterior knee pain.26,37 Thus foot orthoses may be a viable treatment intervention in certain subgroups of patients with PFPS. Despite extensive research, there is still little consensus as to the most effec- tive treatment strategy for the manage- ment of patients with PFPS. Although recent studies have indicated that specific interventions may be beneficial, these in- terventions have been studied in isolation or have targeted a single joint. Few stud- ies have examined a more clinically based multimodal intervention directed toward the lower extremity as a functional unit. The purpose of this case series is to de- scribe the management and outcomes of 5 patients with PFPS treated with manual physical therapy, patellar taping, orthotics, and exercise, using a regional- interdependence approach. XVhZ5YZhXg^ei^dch [outpatientaclinic ive consecutive patients, re- ferred to single physical therapy with a diagnosis of PFPS or anterior knee pain were screened for the eligibility criteria in this case se- ries. All participants satisfied the in- clusion criteria: 14 to 50 years of age, anterior knee pain with squatting, kneel- ing or ascending or descending stairs, pain with an eccentric-loading step test, and sufficient ability to read and under- stand English to complete the outcome questionnaires. Exclusion criteria for this study included prior knee surgery, patient refusal of manipulation tech- niques, radicular pain, positive clinical tests or imaging consistent with menis- cal or ligamentous involvement, and a clinical exam consistent with nonmus- culoskeletal etiology of symptoms. Each subject agreed to participate and pro- vided informed consent. This study was approved by The Institutional Review Board at Franklin Pierce College. Patient privacy, patient consent, and compliance