Patellofemoral Pain: Current evidence and ideas for the future

The Effect of Foot Manipulations on Patellofemoral Pain Syndrome


The knee is one of the most commonly injured sites of the lower extremities with Patellofemoral Pain Syndrome (PFPS) being one of the most common problems. The incidence rate has been reported to be 22/1000 per year (1). The incidence in the female population was 33/1000 per year and 15/1000 per year for the male population. Females are reported to have 2.23 times more chance of developing PFPS than their male counter parts (1). The incidence risk was reported to be 9.66/100 in female athletes (2).

Gender was not a significant predictor of prevalence of PFPS, but females were 25% more likely to have a history of PFPS compared to males (1). The prevalence reported in the cohort was 13.5%, with prevalence numbers in the female and male population was 15.3% and 12.3% respectively (1). Myer (2) reported a point prevalence of 16.3/100 female athletes and 1.09 per 1000 athletic exposures.

The following criteria was put forward to diagnose PFPS: Retropatellar pain during at least two of the following activities, ascending/descending stairs, hopping/jogging, prolonged sitting, kneeling, and squatting, negative findings on examination of knee ligaments, menisci, bursa, plica, and pain on palpation of the patellar facets or femoral condyles (1). A systematic review by Cook (3) concludes that the research done until now is of such poor quality that no conclusion can be drawn to the best test for PFPS.

Various risk factors have been proposed for the development of PFPS: Onset timing of Vastus Medialis, flexibility of the Quadriceps muscle, a reduction in jump height, increase in medial patellar mobility (4). Individuals with PFPS have showed decreased soft tissue mobility of the gastrocnemius and soleus (4,5). A meta analysis of pooled results from several studies found weak knee extension measured by peak torque to be a risk factor for PFPS (6). Overuse and an increase in physical activity have commonly been reported as risk factors, as well as anthropometric variables, Q-angle, and kinematic variables, but the evidence is not conclusive (6). Boling (7) reported decreased knee flexion during landing and increased hip internal rotation to be risk factors. Myer (2) reported increased valgus knee position during a landing task in patients with PFPS.

The etiology of the condition has been proposed to be a loss of tissue homeostasis due to increased load on the joint (8), and small alterations in the functioning of the lower extremity can lead to increased stress on the patellofemoral joint (9).

Historically traditional therapeutic interventions have focused on either local treatments to the knee like patellar mobilizations, taping, soft tissue mobilization of the structures surrounding the knee or strengthening the hip muscles to avoid internal rotation of the hip, manipulation of the SI joint and/or lumbar spine (10–12). Even though there is fair evidence for the use of manual therapy on the knee and/or full kinetic chain for patients with PFPS (12), until now no one has investigated the effect of foot manipulations on PFPS.

Research Question

What is the difference between manipulations of the foot (I) and exercise therapy (C) in reducing pain (O) in young adults with Patellofemoral Pain Syndrome (PFPS) (P).


Individuals with a limited ankle dorsiflexion range of motion (ROM) often display less sagittal plane motion at the knee and trunk (13–15), and show a greater medial knee displacement, and increased knee valgus (16–18). Patients who showed medial knee displacement during an overhead squat had a 20% decrease in passive ankle dorsiflexion (19). There is also a link between sagittal plane ankle motion and frontal plane knee motion (16). Individuals with a limited ankle dorsiflexion also showed decreased activity of the Vastus group (16).

It has been hypothesized that an increased frontal plane motion at the knee may play a role in the development of PFPS due to increased loading of the patellofemoral joint (20). Patients with PFPS show altered patellofemoral joint kinematics as a result of excessive internal rotation of the femur (21,22). Cronström (23) identified decreased ankle range of motion as a modifiable factor for knee abduction.

Individuals with increased ankle dorsiflexion in a weight-bearing lunge showed increased knee flexion and ankle dorsiflexion displacement and peak knee flexion during single leg and overhead squats, but not during a drop landing task (24). Increased sagittal plane motion in all lower extremity joints is believed to absorb and dissipate landing forces (13).

Limited ankle dorsiflexion has been hypothesized to encourage subtalar joint eversion and thus tibial internal rotation, which again will encourage femoral internal rotation and knee valgus (25). Barton (26) showed the link between greater rearfoot eversion, tibial internal rotation, and hip adduction in patients with PFPS and the control group. On the other hand, Burns (27) showed that individuals with pes cavus have a decreased weight bearing ankle dorsiflexion range of motion compared to individuals with a pes planus or normal foot type.

Dill (24) argues that most research done on ankle dorsiflexion ROM and PFPS has been performed with a non-weight bearing measurement while functional movements are mostly performed in weight bearing. To achieve a full ROM in a functional task such as a lunge or squat in a weight bearing position individuals should have a full range of motion in the foot as well as the ankle joint. In accordance with the findings of Devita (13), this would further absorb and dissipate landing forces and would decrease the frontal plane motion seen in patients with PFPS (16–18).

It could be hypothesized that increasing foot mobility, and thus improving total range of motion of the ankle foot complex could lead to greater activation of the Vastus group and possibly the gluteus group by allowing the tibia to go into medial rotation together with the femur, putting the gluteus in a position of pre-stretch, and by increasing dorsal flexion of the ankle, one could increase the activity of the quadriceps.

By allowing the tibia to move freely into internal rotation, by allowing controlled pronation, one could possibly decrease the share forces at the patellofemoral joint. The relative motions of the tibia and femur would decrease, as well as the Q-angle of the hip. The lateral forces acting on the patella would decrease due to the improved line of pull from the quadriceps as the tibial tuberosity moves in line with the femur. This is in line with the biomechanical model proposed by Powers (10).

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21. Powers CM, Ward SR, Fredericson M, Guillet M, Shellock FG. Patellofemoral Kinematics During Weight-Bearing and Non–Weight-Bearing Knee Extension in Persons With Lateral Subluxation of the Patella: A Preliminary Study. J Orthop Sport Phys Ther. 2003;33:677–85.

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24. Dill KE, Begalle RL, Frank BS, Zinder SM, Padua DA. Altered knee and ankle kinematics during squatting in those with limited weight-bearing-lunge ankle-dorsiflexion range of motion. J Athl Train. 2014;49(6):723–32.

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26. Barton CJ, Levinger P, Crossley KM, Webster KE, Menz HB. The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome. Clin Biomech. 2012;27:702–5.

27. Burns J, Crosbie J. Weight bearing ankle dorsiflexion range of motion in idiopathic pes cavus compared to normal and pes planus feet. Foot. 2005;15(2):91–4.

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