Efficacy of Nonsurgical Interventions for Anterior Knee Pain

Natalie J. Collins, Leanne M. Bisset, Kay M. Crossley, Bill Vicenzino

Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain. A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL and Pre-CINAHL, PEDro, PubMed, SportDiscus, Web of Science, BIOSIS Previews, and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models. Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Meta-analysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI 0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD -0.21, 95% CI -0.64, 0.21; 8-12 weeks: SMD -0.22, 95% CI -0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control). Findings suggest that, in implementing evidence-based practice for the nonsurgical management of anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required.