The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Treatment Success of Combined Intervention with Exercise, Foot Orthoses, and Patellar Taping in Individuals with Patellofemoral Pain Syndrome: Development of Clinical Prediction Rules

Document Type : RESEARCH PAPER

Authors
Mehri Shakerinasab 1
Mohammad Jafar Shaterzadeh Yazdi 2
Nahid Pirayeh 2
Neda Orakifar 2
1 Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Department of Physiotherapy, School of Rehabilitation Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
10.22038/abjs.2025.89727.4066
Abstract
Objectives: The effective management of patellofemoral pain syndrome (PFPS) remains a significant clinical challenge. While various interventions demonstrate short-term efficacy, long-term outcomes are often suboptimal, potentially due to insufficient understanding of the patient characteristics that predict treatment success. This study aimed to identify clinical predictors of successful outcomes following a six-week combined intervention, consisting of exercise therapy, patellar taping, and prefabricated orthoses, in individuals with PFPS.
Methods: Fifty patients (30 females, 20 males; mean age, 29.4 years) diagnosed with PFPS were assessed for demographic, pain-related, biomechanical, and functional variables. Treatment success was defined as a ≥2-point reduction in the Visual Analog Scale (VAS) score for pain during daily activities and a ≥8-point increase in the Anterior Knee Pain Scale (AKPS) score postintervention.
Results: Logistic regression analysis identified several significant predictors of treatment success. A higher body mass index (BMI) and greater maximum pain intensity at baseline were associated with a lower probability of a successful outcome (OR = 0.427, p = 0.043; OR = 0.317, p = 0.027, respectively). Conversely, higher baseline Anterior Knee Pain Scale (AKPS) scores (indicating better function), as well as greater isometric hip internal rotator strength, hip extensor strength, hip abductor strength, and hip external rotator strength, were positively associated with treatment success (ORs ranging from 2.583 to 3.858, all p < 0.05). Furthermore, hamstring shortness negatively impacted treatment outcomes (OR = 0.497, p = 0.034).
Conclusion: The study findings suggest that a combination of anthropometric measures, pain and functional status, hip muscle strength, and hamstring length can serve as valuable clinical predictors for identifying individuals with PFPS who are more likely to benefit from a combined physiotherapy approach. These identified predictors may assist clinicians in tailoring treatment strategies and improving long-term outcomes for this challenging patient population.
Level of evidence: III
Keywords
Knee pain
Physical exam
Prediction factor
Treatment
Subjects
1.    Sahrmann S, Azevedo DC, Van Dillen L. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Ther. 2017; 21(6):391-399. doi: 10.1016/j.bjpt.2017.08.001.
2.    An M, Dusing SC, Harbourne RT, Sheridan SM, Consortium S-P. What really works in intervention? Using fidelity measures to support optimal outcomes. Phys Ther. 2020;100(5):757-765. doi: 10.1093/ptj/pzaa006.
3.    Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak hip muscles: a systematic review. Aust J Physiother. 2009;55(1):9-15. doi:10.1016/s0004-9514(09)70055-8.
4.    Willy RW, Hoglund LT, Barton CJ, et al. Patellofemoral Pain. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.
5.    Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. 2000;84(4):983-1007, viii. doi:10.1016/s0025-7125(05)70270-4.
6.    Rathleff CR, Olesen JL, Roos EM, Rasmussen S, Rathleff MS. Half of 12-15-year-olds with knee pain still have pain after one year. Dan Med J. 2013;60(11):A4725.
7.    Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Is knee pain during adolescence a self-limiting condition? Prognosis of patellofemoral pain and other types of knee pain. Am J Sports Med. 2016;44(5):1165-1171. doi:10.1177/0363546515622456.
8.    Smith BE, Moffatt F, Hendrick P. The experience of living with patellofemoral pain-loss, confusion and fear-avoidance: a UK qualitative study. BMJ Open. 2018;8(1):e018624. doi: 10.1136/bmjopen-2017-018624.
9.    Lankhorst N, van Middelkoop M, Crossley K, et al. Factors that predict a poor outcome 5–8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2016;50(14):881-886. doi:10.1136/bjsports-2015-094664.
10.  Collins NJ, Oei EH, de Kanter JL, Vicenzino B, Crossley KM. Prevalence of radiographic and MRI features of patellofemoral osteoarthritis in young and middle-aged adults with persistent patellofemoral pain. Arthritis Care Res (Hoboken). 2019;71(8):1068-1073. doi:10.1002/acr.23726.
11.  Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42-51. doi:10.2519/jospt.2010.3337.
12.  Crossley K, Cowan S, Bennell K, McConnell J. Patellar taping: is clinical success supported by scientific evidence? Man Ther. 2000;5(3):142-150. doi:10.1054/math.2000.0354.
13.  Cowan SM, Bennell KL, Hodges PW. Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome. Clin J Sport Med. 2002;12(6):339-47. doi:10.1097/00042752-200211000-00004.
14.  Whittingham M, Palmer S, Macmillan F. Effects of taping on pain and function in patellofemoral pain syndrome: a randomized controlled trial. J Orthop Sports Phys Ther. 2004;34(9):504-10. doi:10.2519/jospt.2004.34.9.504.
15.  Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. BMJ. 2008;337:a1735. doi:10.1136/bmj.a1735.
16.  Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther. 1993;73(2):62-8; discussion 68-70. doi:10.1093/ptj/73.2.62.
17.  Eng JJ, Pierrynowski MR. The effect of soft foot orthotics on three-dimensional lower-limb kinematics during walking and running. Phys Ther. 1994;74(9):836-44. doi:10.1093/ptj/74.9.836.
18.  Johnston LB, Gross MT. Effects of foot orthoses on quality of life for individuals with patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2004;34(8):440-8. doi:10.2519/jospt.2004.34.8.440.
19.  Sutlive TG, Mitchell SD, Maxfield SN, et al. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: a preliminary investigation. Phys Ther. 2004;84(1):49-61. doi:10.1093/ptj/84.1.49.
20.  Mills K, Blanch P, Dev P, Martin M, Vicenzino B. A randomised control trial of short term efficacy of in-shoe foot orthoses compared with a wait and see policy for anterior knee pain and the role of foot mobility. Br J Sports Med. 2012;46(4):247-52. doi:10.1136/bjsports-2011-090204.
21.  Vicenzino B, Collins N, Crossley K, Beller E, Darnell R, McPoil T. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: a randomised clinical trial. BMC Musculoskelet Disord. 2008;9(1):27. doi:10.1186/1471-2474-9-27.
22.  Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM, Verhaar JA, Koes BW. Exercise therapy for patellofemoral pain syndrome. Cochrane Database Syst Rev. 2003;(4):CD003472. doi:10.1002/14651858.CD003472.
23.  Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weight-bearing exercises for patellofemoral pain. J Orthop Sports Phys Ther. 2007;37(4):155-60. doi:10.2519/jospt.2007.2433.
24.  Witvrouw E, Lysens R, Bellemans J, Peers K, Vanderstraeten G. Open versus closed kinetic chain exercises for patellofemoral pain. A prospective, randomized study. Am J Sports Med. 2000;28(5):687-94. doi:10.1177/03635465000280051201.
25.  Witvrouw E, Danneels L, Van Tiggelen D, Willems TM, Cambier D. Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med. 2004;32(5):1122-30. doi:10.1177/0363546503262187.
26.  Warden SJ, Hinman RS, Watson MA, Jr., Avin KG, Bialocerkowski AE, Crossley KM. Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis. Arthritis Rheum. 2008;59(1):73-83. doi:10.1002/art.23242.
27.  Davis IS, Powers C. Patellofemoral pain syndrome: proximal, distal, and local factors, an international retreat, April 30-May 2, 2009, Fells Point, Baltimore, MD. J Orthop Sports Phys Ther. 2010;40(3):A1-A48. doi:10.2519/jospt.2010.0302.
28.  Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther. 2006;86(1):122-31. doi:10.1093/ptj/86.1.122.
29.  Beneciuk JM, Bishop MD, George SZ. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther. 2009;89(2):114-24. doi:10.2522/ptj.20080239.
30.  Decary S, Fremont P, Pelletier B, et al. Validity of Combining History Elements and Physical Examination Tests to Diagnose Patellofemoral Pain. Arch Phys Med Rehabil. 2018;99(4):607-614 e1. doi:10.1016/j.apmr.2017.10.014.
31.  Collins NJ, Bierma-Zeinstra SM, Crossley KM, van Linschoten RL, Vicenzino B, van Middelkoop M. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2013;47(4):227-33. doi:10.1136/bjsports-2012-091696.
32.  Earl-Boehm JE, Bolgla LA, Emory C, Hamstra-Wright KL, Tarima S, Ferber R. Treatment Success of Hip and Core or Knee Strengthening for Patellofemoral Pain: Development of Clinical Prediction Rules. J Athl Train. 2018;53(6):545-552. doi:10.4085/1062-6050-510-16.
33.  Lesher JD, Sutlive TG, Miller GA, Chine NJ, Garber MB, Wainner RS. Development of a clinical prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping. J Orthop Sports Phys Ther. 2006;36(11):854-66. doi:10.2519/jospt.2006.2208.
34.  Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determination. Br J Sports Med. 2010;44(12):862-6. doi:10.1136/bjsm.2008.052613.
35.  Barton CJ, Menz HB, Crossley KM. Clinical predictors of foot orthoses efficacy in individuals with patellofemoral pain. Med Sci Sports Exerc. 2011;43(9):1603-10. doi:10.1249/MSS.0b013e318211c45d.
36.  Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008;38(6):297-309; discussion 309-12. doi:10.2519/jospt.2008.2669.
37.  Esculier JF, Bouyer LJ, Dubois B, et al. Predictors of clinical success in runners with patellofemoral pain: Secondary analyses of a randomized clinical trial. J Sci Med Sport. 2018;21(8):777-782. doi:10.1016/j.jsams.2018.01.006.
38.  ElMelhat AM, Shalash KA, Chabara AEA, Azzam AH, Mohamed NA. Identifying female responders to proximal control exercises in patellofemoral pain syndrome: A clinical prediction rule. J Taibah Univ Med Sci. 2022;17(6):954-961. doi:10.1016/j.jtumed.2022.05.008.
39.  Shalash KA, Azzam AH, Mohamed NA, ElMelhat AM. Is there a subgroup of females with patellofemoral pain syndrome likely to benefit from proximal control exercises? Physiotherapy Quarterly. 2024;32(1):43-49.
40.  Crossley K, Bennell K, Green S, Cowan S, McConnell J. Physical therapy for patellofemoral pain: a randomized, double-blinded, placebo-controlled trial. Am J Sports Med. 2002;30(6):857-65. doi:10.1177/03635465020300061701.
41.  Crossley KM, Bennell KL, Cowan SM, Green S. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil. 2004;85(5):815-822. doi:10.1016/s0003-9993(03)00613-0.
42.  da Cunha RA, Costa LO, Hespanhol Junior LC, Pires RS, Kujala UM, Lopes AD. Translation, cross-cultural adaptation, and clinimetric testing of instruments used to assess patients with patellofemoral pain syndrome in the Brazilian population. J Orthop Sports Phys Ther. 2013;43(5):332-9. doi:10.2519/jospt.2013.4228.
43.  Negahban H, Pouretezad M, Yazdi MJS, et al. Persian translation and validation of the Kujala Patellofemoral Scale in patients with patellofemoral pain syndrome. Disabil Rehabil. 2012;34(26):2259-63. doi: 10.3109/09638288.2012.683480.
44.  Mc CJ. The management of chondromalacia patellae: a long term solution. Aust J Physiother. 1986;32(4):215-23. doi:10.1016/S0004-9514(14)60654-1.
45.  Clapis PA, Davis SM, Davis RO. Reliability of inclinometer and goniometric measurements of hip extension flexibility using the modified Thomas test. Physiother Theory Pract. 2008;24(2):135-41. doi:10.1080/09593980701378256.
46.  Reese NB, Bandy WD. Use of an inclinometer to measure flexibility of the iliotibial band using the Ober test and the modified Ober test: differences in magnitude and reliability of measurements. J Orthop Sports Phys Ther. 2003;33(6):326-30. doi:10.2519/jospt.2003.33.6.326.
47.  Magee DJ, eds. Orthopedic physical assessment. 6st ed. Philadelphia, PA: WB Saunders Company; 1997.
48.  Barton CJ, Bonanno D, Levinger P, Menz HB. Foot and ankle characteristics in patellofemoral pain syndrome: a case control and reliability study. J Orthop Sports Phys Ther. 2010;40(5):286-96. doi:10.2519/jospt.2010.3227.
49.  Mostafaee N, Pashaei-Marandi M, Negahban H, Pirayeh N, Saki Malehi A, Ebrahimzadeh MH. Examining the diagnostic accuracy of common physical examination and functional tests in the diagnosis of patellofemoral pain syndrome among patients with anterior knee pain. Physiother Theory Pract. 2024;40(4):843-855. doi:10.1080/09593985.2022.2158053.
50.  Watson CJ, Leddy HM, Dynjan TD, Parham JL. Reliability of the lateral pull test and tilt test to assess patellar alignment in subjects with symptomatic knees: student raters. J Orthop Sports Phys Ther. 2001;31(7):368-74. doi:10.2519/jospt.2001.31.7.368.
51.  Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. J Athl Train. 2015;50(4):366-77. doi:10.4085/1062-6050-49.3.70.
52.  Bolgla LA, Malone TR, Umberger BR, Uhl TL. Hip strength and hip and knee kinematics during stair descent in females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2008;38(1):12-8. doi: 10.2519/jospt.2008.2462.
53.  Piva SR, Goodnite EA, Childs JD. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2005;35(12):793-801. doi:10.2519/jospt.2005.35.12.793.
54.  Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2007;37(5):232-8. doi:10.2519/jospt.2007.2439.
55.  Earl JE, Hoch AZ. A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. Am J Sports Med. 2011;39(1):154-63. doi:10.1177/0363546510379967.
56.  McGill SM, Childs A, Liebenson C. Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehabil. 1999;80(8):941-4. doi: 10.1016/s0003-9993(99)90087-4.
57.  Glynn P, Weisbach C, eds. Clinical prediction rules: a physical therapy reference manual. Jones & Bartlett Learning; 2011.
58.  Guyatt G, Rennie D, Satya-Murti S. Users' guides to the medical literature: a manual for evidence-based clinical practice. JAMA-Journal of the American Medical Association-International Edition. 2002;287(11):1463.
59.  Abd Elrahman AC, Azzam AH, Mohamed NA. Identifying female responders to proximal control exercises in patellofemoral pain syndrome: A clinical prediction rule. J Taibah Univ Med Sci. 2022;17(6):954e961. doi:10.1016/j.jtumed.2022.05.008.
60.  Lankhorst NE, van Middelkoop M, van Trier YD, et al. Can we predict which patients with patellofemoral pain are more likely to benefit from exercise therapy? A secondary exploratory analysis of a randomized controlled trial. J Orthop Sports Phys Ther. 2015;45(3):183-189. doi:10.2519/jospt.2015.5583.
61.  Shakerinasab M, Pirayeh N, Shaterzadeh MJ, Orakifar N. Associates of Physical Function and Pain with Lower Muscle Strength and Trunk Muscle Endurance in Subjects with        Patellofemoral Pain Syndrome. The Archives of Bone and Joint Surgery. 2025.doi:10.22038/ABJS.2025.84895.3873.
62.  White LC, Dolphin P, Dixon J. Hamstring length in patellofemoral pain syndrome. Physiotherapy. 2009;95(1):24-8. doi:10.1016/j.physio.2008.05.009.
63.  Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22:2264-2274. doi:10.1007/s00167-013-2759-6.
64.  Ezzati K, Soleymanha M, Asadi K, Ettehad H, Khansha R. Comparison of the Quadriceps Muscle Thickness and Function between Patients with Patellofemoral Pain Syndrome and Healthy Subjects using Ultrasonography: An Observational Study. Arch Bone Jt Surg. 2024;12(12):859. doi:10.22038/ABJS.2024.80937.3692.
65.  Alammari A, Spence N, Narayan A, Karnad SD, Ottayil ZC. Effect of hip abductors and lateral rotators’ muscle strengthening on pain and functional outcome in adult patients with patellofemoral pain: A systematic review and meta-analysis. J Back Musculoskelet Rehabil. 2023;36(1):35-60. doi:10.3233/bmr-220017.
66.  Van Cant J, Pineux C, Pitance L, Feipel V. Hip muscle strength and endurance in females with patellofemoral pain: a systematic review with meta-analysis. Int J Sports Phys Ther. 2014;9(5):564-82.
67.  Shakerinasab M, Mostamand J, Jamshidi N. The comparison of hip abductors with hip external rotator muscles fatigue on static standing balance in subjects with and without patellofemoral pain syndrome. Physical Treatments-Specific Physical Therapy Journal. 2014;4(1):47-54.
68.  Oliveira LVd, Saad MC, Felício LR, Grossi DB. Muscle strength analysis of hip and knee stabilizers in individuals with Patellofemoral Pain Syndrome. Fisioterapia e Pesquisa. 2014;21:327-332. doi:10.590/1809-2950/11903021042014.
 
 
 
 
The Archives of Bone and Joint Surgery
Volume 14, Issue 10
October 2026
Pages 662-672

  • Receive Date 20 July 2025
  • Revise Date 18 November 2025
  • Accept Date 12 August 2025