Methods

RCT
Computer generated randomisation

High quality: Delphi score 6

Participants

AKP/PFPS, median duration >12 months (<3 to >12)
Patients referred from orthopaedic/rheumatology consultants/GPs
81 patients, 56% male
Age 26.0 ± 7.4 (15‐40)

1) n=20
2) n=20
3) n=19
4) n=22

Interventions

Duration 3 months, 6 sessions
1) education, exercise, tape
2) education, exercise
3) education, tape
4) education

Education: background of PFPS
Exercise: 3 months 6 sessions and training at home: eccentric/isotonic strengthening exercises: bicycle warm‐up, wall squats gradually lengthened up to 3 min., sit to stand, proprioceptive balance, exercise gluteus muscles, progressive step down,
Tape: first three sessions, thereafter optional

Outcomes

VAS pain: baseline, 3 months, 12 months
1) 75.6 ±32.6, 35.9 ±28.7, 35.1±45.1
2) 77.1 ±44.4, 30.0 ±39.9, 37.8 ±43.4
3) 83.9 ±39.8, 57.8 ±38.7, 77.3 ±62.8
4) 77.0 ±41.8, 41.8 ±40.6, 51.9 ±53.8
WOMAC: baseline, 3 months, 12 months
1) 25.2 ±12.5, 11.5 ±10.5, 14.8 ±18.0
2) 23.7 ±12.9, 10.0 ±11.8, 15.6 ±16.2
3) 33.4 ±16.8, 20.9 ±15.5, 27.6 ±22.7
4) 28.7 ±15.4, 13.8 ±15.8, 22.0 ±21.3
Patient satisfaction expressed as N discharged: 3 months
1) 19=95% 2) 20=100% 3) 8=42% 4) 13=59%
Patient recovery expressed as N still troubled: 12 months
1) 6=60% 2) 7=58% 3) 9=75% 4) 13=87%
Patient recovery expressed as N continuing therapy: 12 months
1) 2=10% 2) 2=10% 3) 3=16% 4) 5=23%

Notes

Drop‐outs:
1) 3 months: 4 patients
12 months: 10 patients
2) 3 months: 4 patients
12 months: 8 patients
3) 3 months: 1 patient
12 months: 7 patients
4) 3 months: 1 patient
12 months: 7 patients

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT
Quasi random, matching for age, physical findings and disability

Low quality: Delphi score 3

Participants

PFPS, mild or moderate
Recreational athletes
29 patients, 66% male
Age (15‐24)

1) n=13
2) n=16

Interventions

Duration 6‐8 weeks,
Stretching*, ice application after exercise
1) Pogo stick bounces (isometric exercise + endurance training), incremental increase from 250 bounces twice daily up to 10 minutes
2) Conservative isometric exercises: straight leg raises with increasing weights, bicycling

Outcomes

Baseline, 6‐8 weeks:
N >50% improved on 11‐point pain scale:
1) 9 (82%)
2) 13 (93%)

Notes

1) 2 withdrawals: 1 female increased pain, 1 male vacation interruptions,
2) 2 female withdrawals, no description

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT
Randomisation method not specified

Low quality: Delphi score 4

Participants

PFPS, all unilateral, duration: 10 ± 8 months
Outpatient clinic of university medical faculty physical medicine and rehabilitation

60 patients, 20% male
Age: 37 ± 10 (17‐50)

1) n=30
2) n=30

Interventions

Conventional exercise program: 4 weeks 5 days/week supervised, total duration not stated. Biofeedback 4 weeks, 3 times per week.
Stretching*, proprioception training, endurance training with bicycle
1) conventional open and closed kinetic chain exercise with electromyographic feedback
2) conventional open and closed kinetic chain exercise (n=30)

Outcomes

VAS pain: baseline, 1, 2, 3 months
1) 7.5 ±1.6, 4.3 ±1.4, 2.2 ±1.8, 1.2 ±0.6
2) 7.3 ±1.5, 3.7 ±1.7, 2.0 ±1.2, 0.7 ±1.1
FIQ: baseline, 1, 2, 3 months
1) 8.3 ±1.8, 12.0 ±1.7, 13.4 ±2.0, 15.1 ±1.4
2) 7.9 ±1.8, 12.8 ±2.0, 14.3 ±1.5, 15.2 ±1.2

Notes

No drop outs

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT
Randomisation method not specified

Low quality: Delphi score 3

Participants

PFPS/chondromalacia, 50% bilateral
Duration of complaints 40.7 months
72 patients, 65% male
Age: 34 (11‐65)

1) n=36
2) n=36

Interventions

Duration 6 weeks, weekly visits to check correct performance all groups, stretching retinaculum before taping
1) pain free eccentric and isometric exercise with taping (squats, steps with gradually increasing speed, height of step and weights (hand/rucksack))
2) concentric isometric exercise (quadriceps setting, straight leg raises and knee extensions)

Outcomes

VAS pain baseline, 6 weeks:
1) 6.07, 2.86
2) 5.81, 2.64
Function grade 6 weeks:
1) improved=18, no change=4, variable=6
2) improved=15, no change=7, variable=10
Clarke's test positive baseline, 6 weeks:
1) 20 (28%), 8 (14%)
2) 28 (39%), 11 (17%)
Individual's opinion of success 6 weeks:
1) 25 (89%)
2) 24 (75%)

Notes

1) 8 withdrawals
2) 4 withdrawals

Descriptions:
1: too far to attend
2: another injury
2: work commitments/travel
7: unknown

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT
Randomisation method not specified

Low quality: Delphi score 1

Participants

Chondropathy, type Wyberg I or II (not III), with or without dysplasia of the patella

40 patients per group were included, analysed were following numbers:
1) n=28
2) n=40
3) n=26

Interventions

Duration 4 weeks,
All groups ice application
1) at home electro stimulation of quadriceps with memory card for compliance, 4 hours a day
2) pain free isokinetic training at 30°/s and 300°/s, 3 times a week 25‐30 minutes
3) proprioceptive static exercise,
stretching* all structures, 3 times a week 30‐45 minutes

Outcomes

Arpège function scale: baseline, 4 weeks
1) 11.1 ±3.9, 14.4 ±2.69
2) 12.8 ±3.1, 15.5 ±2.6
3) 10.8 ±3.7, 15.1 ±2.3

Notes

Drop out reasons:
10 incomplete
4 non compliance with instructions
12 stopped because of ineffectiveness of treatment.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

RCT
Random number table, application not specified

Low quality: Delphi score 3

Participants

PFPS, 54% bilateral, 15% of patients limitations in activities
referred from GPs and orthopaedic surgeons
112 patients, 40% male,
Age: 22.2 ± 8.2 (12‐35)

1) n=42
2) n=34
3) n=36

Interventions

Duration 4 weeks,
All groups ice application after exercise, stretching
1) conservative home exercise: straight leg raises with progressive weights, knee extensions, education on background PFPS
2) similar program monitored by physiotherapist, education background PFPS, supervision 3 times weekly
3) exercises with patellar taping and biofeedback progressive exercises: stride standing, standing with foot supination, step downs, plié squats, wall squats, optional adductor strengthening
supervision 3 times weekly, home exercise

Outcomes

VAS 3 days average of worst pain: baseline, 1, 3, 6, 12 months
1) 4.58 ±2.51, 2.96 ±2.28,2.62 ±2.95, 3.11 ±3.45, 2.01 ±3.18
2) 4.68 ±2.48, 3.60 ±2.31, 2.40 ±2.53, 2.20 ±2.58, 2.21 ±2.83
3) 4.39 ±2.39, 1.99 ±2.06, 2.93 ±2.49, 1.65 ±1.77, 1.80 ±2.83
FIQ (0 worst, 16 best score)
number of patients with score 0‐4, 5‐8, 9‐12, 13‐16:
1) baseline: 0,7,15,12
1 month: 0,1,10,13
12 months: 0,3,4,12
2) baseline: 3,10,7,10
1 month: 1,5,12,8
12 months: 0,0,2,11
3) baseline: 0,6,10,14
1 month: 0,3,8,17
12 months: 0,2,4,14
PFS (0 worst ‐100 best):
baseline, 1, 3, 6, 12 months
1) 54 ±15, 64 ±19, 65±18, 73 ±19, 75 ±17
2) 54 ±13, 58 ±16, 65 ±15, 71 ±16, 82 ±11
3) 51 ±12, 68 ±16, 68 ±16, 73 ±19, 81 ±17
Perceived change in condition at 1 month:
none/worse, some improvement, significant improvement
1) 6, 14, 9,
2) 10, 13, 6
3) 2, 6, 17
Seconds of step test until pain: baseline, 1, 3, 6, 12 months
1) 106 ±110, 169 ±126, 188 ±121, 224 ±117, 211 ±123
2) 120 ±105, 154 ±117, 235 ±105, 231 ±115, 260 ±94
3) 131 ±106, 206 ±106, 235 ±95, 236 ±108, 265 ±90

Notes

In particular patients with good results at 1 month dropped out

Number of patients 0, 1, 3, 6, 12 months:
1) 33 23 22 14 18
2) 31 26 20 15 13
3) 29 25 20 23 18

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

CCT
Geographical location dictated group assignment

Low quality: Delphi score 3

Participants

Chondromalacia, all unilateral,
Duration of complaint: 4.07 ± 2.52 (1‐8 months)
29 patients, 55% male
Age: 28.12 ± 9.96
1) n=9
2) n=11
3) n=9

Interventions

Duration 4 weeks
1) waiting list control, weekly telephone contact
2) static exercise, stretching hamstrings,
12 sessions in 4 weeks
3) isokinetic exercise, 12 sessions in 4 weeks

Outcomes

CRS, overall activity level: 4 weeks
1) 10.92
2) 14.82
3) 13.86

Notes

No drop‐outs

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

CCT
Treatment assigned by investigator with attempts to balance for functional rating and patellar dislocation

Low quality: Delphi score 1

Participants

PFPS,
Sports Medicine Center
33 patients included, characteristics stated of 23 patients: 39 % male
Age: 19 ± 6

1) n=11
duration symptoms
13.1 ± 12.2 months,
4 luxations

2) n=12
duration symptoms
31.9 ± 31.8 months,
3 luxations

Interventions

Duration 8 weeks
Week 1: stretching only, from week 2 exercise three days per week
1) joint isolation isokinetic exercise: velocity spectrum from 180º/s to 360º/s with 30º/s increments
2) closed kinetic chain exercise: squats, lateral and retro step‐ups with increasing dumbbell resistance, progression to stair‐master exercise

Outcomes

Retro step repetitions until intolerance of symptomatic leg
(including patients with luxations): baseline, 8, 52 weeks
1) 2.5 ±2.3, 4.3 ±1.7, 6.7 ±3.5
2) 3.2 ±2.4, 18.6 ±11.9, 27.3 ±12.5
Questionnaire (without patients with luxations):
baseline, 6 months, 1 year
1) excellent 0, 0, 0
good 2, 1, 2
fair 5, 5, 4
poor 0, 1, 1
2) excellent 0, 1, 6
good 1, 4, 1
fair 6, 4, 2
poor 2, 0, 0

Notes

1) 6 drop‐outs
2) 4 drop‐outs
due to <70% of training sessions attended

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

RCT
Odd‐even number treatment allocation

Low quality: Delphi score 3

Participants

PFPS, 27% bilateral, 75% pain with sports,
Duration: 43 ± 31.2 (6‐108) months
Referred by orthopaedic surgeons
40 female patients,
Age: 20.2 ± 3.2 (15‐28)

1) n=20
2) n=20

Interventions

Duration: 3 sessions to familiarise with training, 12 weeks training, 3 days per week during week 1 and 2, thereafter 2 days per week

1) isometric exercise
2) eccentric exercise

Outcomes

Number of patients participating in sports with/without pain: 0, 3, 12 months
1) 13/0, 3/9, 1/17
2) 17/0, 5/11, 1/17
Number of subjects experiencing pain: 0, 3, 12 months
1) Jogging 16 (80%),12 (60%), 6 (30%)
Heavy loading 17 (85%), 11(55%), 5 (25%)
At rest after activity 18 (90%), 7 (35%), 1 (5%)
2) Jogging 18 (90%), 9 (45%), 4 (20%)
Heavy loading 17 (85%), 12 (60%), 5 (25%)
At rest after activity 16 (80%), 6 (30%),1 (5%)

Notes

No drop‐outs reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT
Odd‐even number treatment allocation

Low quality: Delphi score 3

Participants

PFPS, all unilateral, duration: 12.5 ± 5 weeks (5‐19)
Referred from orthopaedic surgeons
100 patients, 60% male
Age: 30 ± 6 (24 ‐ 44)
1) n=50
2) n=50

Interventions

4 weeks duration, daily use of Protonics® device
1) Protonics® device: high volume submaximal concentric contractions of quadriceps and hamstrings
2) no treatment

Outcomes

VAS pain: baseline, 4 weeks
1) 6.50 ±1.07, 3.54 ±0.97
2) 6.54 ±0.97, 6.74 ±1.05
KPFS: baseline, 4 weeks
1) 41.72 ±4.21, 86.76 ±6.65
2) 41.42 ±3.87, 41.20 ±3.95

Notes

No drop‐outs reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

RCT
Randomisation by independent person in blocks of 4 persons, prestratified for gender and duration of symptoms (< or < 1 year)

High quality: Delphi score 6

Participants

PFPS,
Duration: 32 (4 ‐ 96)
Orthopaedic outpatient clinic
18 patients, 28% male
Age: 22 (16‐37)

1) n=7
2) n=8

Interventions

Duration 6 weeks: group 1 group 2 home exercise intensity not specified
1) McConnell regimen with individual exercise program. 12 sessions twice weekly and twice daily home training
2) Coumans bandage with standard home exercise schedule

Outcomes

11‐point pain scale walking stairs, mean (min‐max): baseline, 6 weeks
1) 6.3 (1‐10), 4.4 (1‐7)
2) 5.3 (0‐8), 4.1 (0‐9)
11‐point pain scale sitting with knees bent, mean (min‐max): baseline, 6 weeks
1) 6.3 (1‐10), 1.9 (0‐6)
2) 5.3 (0‐8), 4.3 (0‐10)
11‐point pain scale squatting, mean (min‐max): baseline, 6 weeks
1) 6.3 (1‐10), 5.1 (0‐10)
2) 5.3 (0‐8), 6.0 (0‐10)
KPFS: baseline, 6 weeks
1) 58.3 (28‐84), 84 (60‐96)
2) 64.6 (39‐84), 74.1 (43‐89)
Ranawat function score: baseline, 6 weeks
1) 74.4 (38‐97), 95 (81‐100)
2) 79.0 (58‐97), 85.3 (58‐100)
11‐point scale patient satisfaction with therapy: 6 weeks
1) 7.6 (6‐9)
2) 4.3 (0‐9)
11‐point scale patient satisfaction with recovery: 6 weeks
1) 6.1 (4‐9)
2) 3.4 (0‐8)

Notes

Drop‐outs
1) 1 patient did not show up, 1 patient found quadriceps contraction too painful
2) 1 patient could not tolerate Coumans bandage

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate

Methods

RCT
Randomisation using sealed envelopes

High quality: Delphi score 6

Participants

PFPS, 45% bilateral, duration: 15.1 (0.5 ‐ 28) months
Physical therapy department of hospital
60 patients
Age: 20.3 (14‐33),

1) n=30
2) n=30

Interventions

Duration: 5 weeks, three days per week
1) open kinetic chain exercise: maximal static quadriceps muscle contractions in full extension, straight leg raises in supine position, short arc terminal knee extensions, leg adductions in lateral decubitus position
2) closed kinetic chain exercise: seated leg presses, one‐third knee bends on one and both legs, stationary bicycling, rowing‐machine exercises, step‐up and step‐down, progressive jumping

Outcomes

VAS pain during daily activity: baseline, 5 weeks, 3 months
1) 5.4 ±2.2, 3.7 ±1.6, 3.9 ±1.5
2) 5.5 ±2.3, 4.0 ±1.6, 3.0 ±1.0
VAS pain during triple jump test: baseline, 5 weeks, 3 months
1) 2.5 ±7, 1.4 ±4, 0.9 ±2
2) 2.4 ±6, 1.3 ±4, 1.0 ±3
KPFS: baseline, 5 weeks, 3 months
1) 68 ±35, 83 ±37, 87 ±40
2) 68 ±34, 80 ±37, 84 ±39
N without symptoms during functional tests:
Unilateral squat: baseline, 5 weeks, 3 months
1) 6 (20%), 11 (37%), 16 (53%)
2) 6 (20%), 13 (43%), 17 (57%)
Step‐up: baseline, 5 weeks, 3 months
1) 11 (37%), 23 (77%), 22 (73%)
2) 8 (27%), 18 (60%), 22 (73%)
Step‐down: baseline, 5 weeks, 3 months
1) 8 (27%), 19 (63%), 23 (77%)
2) 5 (17%), 12 (40%), 20 (67%)

Notes

No drop‐outs

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Low risk

A ‐ Adequate