Nonoperative Therapy for Patellofemoral Pain Syndrome

A Cochrane review [Abstract] 1 on foot orthoses for managing patellofemoral pain in adults included 2 studies with a total of 210 subjects. Foot orthoses when compared with flat insoles had better results at 6 weeks in knee pain (participants with global improvement: risk ratio 1.48, 95% CI 1.11 to 1.99), but not at one year follow-up. Participants in the orthoses group reported significantly more minor adverse effects (e.g. rubbing, blistering) compared with the flat insole group (risk ratio 1.87, 95% CI 1.21 to 2.91). Comparisons of orthoses plus physiotherapy versus physiotherapy alone found no statistically significant differences between the groups in knee pain or function, nor did the comparisons of foot orthoses versus physiotherapy. Although participants in the physiotherapy group had consistently better results for the functional index questionnaire, the clinical relevance of these results is uncertain.

A systematic review 2 including 5 RCTs with a total of 219 subjects was abstracted in DARE. The results of the five studies are reported separately.

• Orthotic study (orthotic insoles): The orthotic group had significantly greater pain reduction than control group at 8 weeks.
• Knee brace study: 80% of the non-treated group had complete resolution of pain compared to 43% of the knee-brace group and 74% of the group given a simple elastic sleeve. The mean pain score for the non-treatment group was significantly better than either of the two groups wearing elastic sleeves (p=0.04).
• Anti-inflammatory study: 55% of patients taking diflunisal and 63% taking naproxen had significant relief after 5 days.
• Glycosaminoglycan polysulfate studies (2): Intra-articular glycosaminoglycan polysulfate (2 injections) or physiological saline injections resulted in significantly better pain relief at 6 weeks than the non-injection group, but this difference had disappeared at 6 months. A full recovery was made by 63% of the conservative group, 77% of the glycosaminoglycane group and 81% of the saline group.

Comment: The quality of evidence is downgraded by study quality, by imprecise results (limited study size for each comparison), and by inconsistency (heterogeneity in interventions and outcomes).

References

• Hossain M, Alexander P, Burls A, Jobanputra P. Foot orthoses for patellofemoral pain in adults. Cochrane Database Syst Rev 2011;(1):CD008402 [PubMed]
• Arroll B, Ellis-Pegler E, Edwards A, Sutcliffe G. Patellofemoral pain syndrome. A critical review of the clinical trials on nonoperative therapy. Am J Sports Med 1997 Mar-Apr;25(2):207-12. [PubMed] [DARE]