Efficacy of Adding Patellar Mobilization to Hip and Knee Exercises in Patients With Patellofemoral Pain Syndrome

Study Overview
=================
Brief Summary
-----------------
Patellofemoral pain syndrome is a common source of anterior knee pain. The causes of PFPS may be multifactorial such as biomechanical disorders, muscle weakness which affect the dynamic stability of lower limb and alter patellar tracking in trochlear groove. Moreover, the syndrome associated with muscular tightness of iliotibial band, gastrocnemius, soleus, hamstring and quadriceps. Strengthening and stretching exercises are effective in improving patient's symptoms. However, they do not sufficient in correction of kinematic changes associated with PFPS. Patellar mobilization is effective in improving patient'symptoms in cases with PFPS. However, studies that conducted patellar mobilization were either low quality studies or no study combined patellar mobilization with hip and knee exercises. Therefore, APTA guidelines recommended for conducting high quality study to investigate the effect of adding patellar mobilization to exercise therapy to support the definite recommendation delivered to therapists.

Detailed Description
-----------------
this is interventional study in which patients will receive stretching and strengthening exercises in control group. in addition, experimental group will receive the same exercises of control group in addition to patellar mobilization, retinacula release and deep friction message.

Official Title
-----------------
Efficacy of Adding Patellar Mobilization to Hip and Knee Exercises in Patients With Patellofemoral Pain Syndrome

Conditions
-----------------
Patellofemoral Pain Syndrome

Intervention / Treatment
-----------------
* Procedure: Patellar mobilization, retinacula release, deep friction message, stretch and strength


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Age ranging between 18 and 35 years Tenderness of medial and lateral borders of patella Retropatellar pain Duration of symptoms of patellofemoral pain syndrome is greater than 4 weeks Positive patellar compression test Pain intensity is more than 3 at visual analogue scale Had a history of insidious onset Had anterior knee pain during 2 or more of provocative activities that include stair ascent or descent, kneeling, prolonged sitting, or squatting Exclusion Criteria: Previous patellar realignment surgery or patellar fracture Had a history of traumatic patellar dislocation Had a history of previous knee surgery Had any form of inflammatory arthritis that include osteoarthritis or rheumatoid arthritis Had a history of knee menisci, ligaments, bursae, or synovial plica syndrome dysfunction Taking corticosteroids or nonsteroidal anti-inflammatory medication Inability to attend treatment program to the end of sessions

Ages Eligible for Study
-----------------
Minimum Age: 18 Years
Maximum Age: 35 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group (1)<br>patients will receive stretch and strength exercises | Procedure: Patellar mobilization, retinacula release, deep friction message, stretch and strength<br>* All exercises will be performed for 30 to 45 minutes per session, 3 times per week for 4 weeks (12 sessions). Group (1): stretch exercises are performed for calf, hamstring, iliotibial band and quadriceps. strength exercises consist from open kinetic chain (hip abductors, hip external rotators and quadriceps) and closed kinetic chain exercises (mini wall squat exercise, forward step up exercise, lateral step up exercise and terminal knee extension exercise). Group (2): stretch exercises are performed for calf, hamstring, iliotibial band and quadriceps. strength exercises consist from open kinetic chain (hip abductors, hip external rotators and quadriceps) and closed kinetic chain exercises (mini wall squat exercise, forward step up exercise, lateral step up exercise and terminal knee extension exercise). manual therapy consists from iliotibial band release, deep friction message for lateral retinacula and medial patella mobilization.<br>|
| Experimental: Group (2)<br>patients will receive stretch, strength, patellar mobilization, retinacula release and deep friction message | Procedure: Patellar mobilization, retinacula release, deep friction message, stretch and strength<br>* All exercises will be performed for 30 to 45 minutes per session, 3 times per week for 4 weeks (12 sessions). Group (1): stretch exercises are performed for calf, hamstring, iliotibial band and quadriceps. strength exercises consist from open kinetic chain (hip abductors, hip external rotators and quadriceps) and closed kinetic chain exercises (mini wall squat exercise, forward step up exercise, lateral step up exercise and terminal knee extension exercise). Group (2): stretch exercises are performed for calf, hamstring, iliotibial band and quadriceps. strength exercises consist from open kinetic chain (hip abductors, hip external rotators and quadriceps) and closed kinetic chain exercises (mini wall squat exercise, forward step up exercise, lateral step up exercise and terminal knee extension exercise). manual therapy consists from iliotibial band release, deep friction message for lateral retinacula and medial patella mobilization.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in pain that felt during ascending, descending, squatting and prolonged sitting | Pain during ascending, descending, squatting and prolonged sitting will be assessed using visual analogue scale, it is a horizontal line from 0 to 10, where 0 no pain and 10 maximum pain. | It will be assessed one week before and after treatment | 
| Changes in functional disability | Functional disability will be assessed using Kujala questionnaire.The scale ranges from 0 to 100 score where 100 represents no functional limitation. | It will be assessed one week before and after treatment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in hip abductors strength | It will be assessed using handheld dynamometer | It will be assessed one week before and after treatment | 
| Changes in hip external rotators strength | It will be assessed using handheld dynamometer | It will be assessed one week before and after treatment | 
| changes in quadriceps strength | It will be assessed using handheld dynamometer | It will be assessed one week before and after treatment | 
| changes in functional performance | It will be assessed using step down test | It will be assessed one week before and after treatment | 
| changes in hamstring flexibility | It will be assessed using 90-90 test | It will be assessed one week before and after treatment | 
| changes in gastrocnemius flexibility | It will be assessed using ankle dorsiflexion range of motion | It will be assessed one week before and after treatment | 
| changes in knee valgus | It will be assessed using Q angle | It will be assessed one week before and after treatment | 
| changes in foot pronation | It will be assessed using navicular drop test | It will be assessed one week before and after treatment | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
patellofemoral pain syndrome, strength, stretch, mobilization, release, deep friction message, retinacula