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Michael Tunning, DC, ATC, and Robert Vining, DC
My patient has recurrent knee pain—How can I prevent future episodes?
J Amer Chiropr Assoc 2011 April;48(3):15-18
|Abstract: This article integrates recent research into a clinical approach to a patient’s knee pain to provide the basis for a treatment plan.|
A young woman comes to your practice with a complaint of anterior knee pain.
The Condition History
The Physical Examination
So, where do you begin with this patient?
Can you use this study to help your patient?
A closer look at critical appraisal
Army Physical Training Instructors (PTIs) were taught to personally oversee the standardized sequence of 8 exercises (4 stretches and 4 active contraction exercises). They were provided with written instructions prior to participating in the study. The exercises occurred in subsets of 4 at both the warm-ups and warm-downs of every formal physical training session. The number of repetitions increased during the 14 week timeframe. The control group(s) performed standard exercises consisting of slow running, abdominal curls, pushups and general upper-and lower-body stretching of the same duration. Both groups spent the same amount of time in their respective training programs.
Recruits were classified as developing anterior knee pain if they reported to the army medical center and were subsequently diagnosed with AKP by physicians with specific training. Diagnosis was based on criteria including: “1) anterior or retropatellar knee pain arising from at least two of the following: prolonged sitting, stair climbing, squatting, running, kneeling, and hopping/jumping; 2) insidious onset of symptoms unrelated to a traumatic incident; and 3) presence of pain on palpation of the patellar facets, on step down from a 25-cm step, or during a double-legged squat.” Recruits were not diagnosed with AKP if they exhibited “intra-articular pathologic conditions; ligament laxity or tenderness; tenderness over the patellar tendon, iliotibial band, or pes anserinus tendons; patellar apprehension sign; Osgood-Schlatter or Sinding-Larsen-Johanssen syndrome” (chronic traction injury at the proximal patellar tendon),” “evidence of a knee-joint effusion or hip or lumbar referred pain; a history of patellar dislocation; or other surgery or structural damage to the knee.”
Results: The investigators calculated a 75 percent risk reduction for developing AKP over the 14-week training program in the exercise intervention group. Recruits who developed AKP in the intervention group were more likely to experience a successful outcome after diagnosis.
Conclusion: Based on the strength of their results, the authors concluded that this exercise program “significantly reduced the incidence of AKP.” They recommended this program for adoption by the British army.
Strengths: The study was conducted in a military recruit training setting where two relatively equal groups were engaged in the same physical activities for 14 weeks. This eliminates several factors that potentially skew results. The participants in both groups were supervised daily in the correct performance of their exercises, which helped to ensure consistency and proper technique.
Limitations: Control-group recruits were not blinded and in 33 percent of diagnosed cases, the physician reported knowledge of the intervention group. This limitation can be significant. The authors acknowledged that this can result in “an overestimation of effect by up to 17 percent.”3 Because cases of AKP were counted only after diagnosis, which required recruits to present to the army medical clinic, it is unknown how many recruits developed AKP, but failed to report. Therefore, it is plausible that the actual risk reduction (reported at 75 percent) is smaller. Males outnumbered females by more than 2:1, and even though the authors reported no sex difference relative to AKP incidence, the reported risk reduction is based on the entire population (mostly male). Finally, the cause or predisposition for AKP was not explored; meaning the effectiveness of preventing specific AKP conditions in patients with known predisposing factors is unknown.
Despite the limitations of this study, the exercise program demonstrated a preventive effect on the development of AKP. The authors stated that careful supervision is probably critical to the success of this program, and cite an unsuccessful study performing similar, less-supervised exercises.4 You will have to consider the feasibility of incorporating supervision into your recommendations.
Are the findings applicable to your patient?
You may wish to find out more about the diagnosis of AKP. A quick search on Pub-Med using the terms “patellofemoral,”“syndrome,” and “classification,” may lead you to an article by Witvrouw that offers an evaluation and classification system for AKP.2 While Witvrouw’s article may not directly help you decide whether to recommend the preventive exercise program, it can provide you with a standard and thorough method of assessing and classifying patients.
What is your decision?
Michael Tunning, DC, ATC, is an instructor in the Diagnosis and Radiology Department at Palmer College of Chiropractic, Davenport Iowa.
Robert Vining, DC, is an assistant professor and senior research clinician at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.
1. Coppack R, Etherington J, Wills A. The effects of exercise for the prevention of overuse anterior knee pain. Am J Sports Med 2011;6 ePub.
2. Witvrouw E, Werner S, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G. Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc 2005;13:122-130.
3. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408-412.
4. Bushoj C, Larsen K, Albrecht-Beste E, Nielsen MB, Loye F, Homich P. Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits. Am J Sports Med. 2008;36:663-670.
5. Aaltonen S, Karjalainen H, Heinonen A, Parkkari J, Kujala UM. Prevention of sports injuries: systematic review of randomized controlled trials. Arch Int Med 2007;167:1585-1592.