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700 Ann Rheum Dis 2000;59:700704

Physiotherapy for anterior knee pain: a randomised controlled trial

D I Clark, N Downing, J Mitchell, L Coulson, E P Syzpryt, M Doherty

Department of Orthopaedics, City Hospital Nottingham D I Clark N Downing Department of Physiotherapy, City Hospital Nottingham J Mitchell Trent Institute for Health Services Research, The Medical School Queens Medical Centre, Nottingham L Coulson Queens Medical Centre, Nottingham E P Syzpryt Academic Rheumatology, Clinical Sciences Building, City Hospital Nottingham M Doherty
Correspondence to: Dr David Ian Clark, 60 Holme Road, West Bridgford, Nottingham NG2 5AD, UK Email: [email protected] Accepted for publication

Abstract ObjectiveTo determine the eYcacy of the individual components of physiotherapy in subjects with anterior knee pain. MethodsAn observer blind, prospective, factorial design randomised controlled trial. 81 young adults with anterior knee pain were randomly allocated to one of four treatment groups: (1) exercise, taping, and education; (2) exercise and education; (3) taping and education; and (4) education alone. Each group received six physiotherapist-led treatments over three months. Follow up took place at three months using the following outcome measures: patient satisfaction (discharge/ refer for further treatment); a visual analogue pain score; the WOMAC lower limb function score; the Hospital Anxiety and Depression scale (HAD); and quadriceps strength. At 12 months the WOMAC and HAD were assessed by postal questionnaire. ResultsAll groups showed signicant improvements in WOMAC, visual analogue, and HAD scores; these improvements did not vary signicantly between the four groups or between exercising/ non-exercising and taped/non-taped patients at three and 12 months. However, patients who exercised were signicantly more likely to be discharged at three months than non-exercising patients ( 2, p<0.001). Taping was not signicantly associated with discharge. Signicantly greater improvements in WOMAC, visual analogue, and the anxiety score (but not the depression score) were seen in patients who were discharged than in those who were referred. ConclusionsThe proprioceptive muscle stretching and strengthening aspects of physiotherapy have a benecial eVect at three months suYcient to permit discharge from physiotherapy. These benets are maintained at one year. Taping does not inuence the outcome.
(Ann Rheum Dis 2000;59:700704)

progressive muscle stretching and strengthening,24 68 and patella taping.3 4 810 Two large Medline review articles of anterior knee pain11 12 conclude that there are few controlled clinical trials to identify which elements of conservative treatment are eVective. This trial was designed to test the null hypothesis that there was no diVerence in the eYcacy of the key componentsnamely, proprioceptive muscle stretching and strengthening exercises, and the use of tape (tape applied to skin to alter patella tracking). Subjects and methods Ethical approval was obtained from the local research ethics committee and the patients general practitioners informed of their inclusion in the study. Between September 1995 and February 1998 we recruited to the trial 81 patients (36 female) aged 1640 years with a history of anterior knee pain of more than three months. Patients were referred from orthopaedic and rheumatology consultants and from general practitioners. Patients were excluded if they gave a history of true locking, patella dislocation, arthritis, any knee radiograph abnormality, ligament laxity (medial and lateral collateral ligament or anterior draw test), malignancy, infection, or previous knee physiotherapy. Suitable patients gave written consent and were assessed by one of the rst two authors by history, locomotor examination, WOMAC score,13 and the Hospital Anxiety and Depression scale (HAD).14 The patients height, weight, and quadriceps strength were measured. Isometric quadriceps strength was measured using a modied Tornvall chair taking the highest of three readings. A strain gauge measured quadriceps power from 90 degrees exion to full extension.15
RANDOMISATION

Anterior knee pain or patellofemoral pain syndrome is a commonly recognised symptom complex characterised by pain in the vicinity of the patella in young adults worsened by sitting and climbing stairs.1 2 Anterior knee pain is a common reason for referral to physiotherapy.3 DiVerent aspects of non-operative management have been emphasised, such as patient education,4 5 modication of activity,2 3 5 6

The patients were then randomly allocated by the physiotherapist to one of four groups using an individualised computer generated randomisation programme. The four treatment groups were (1) exercise, taping, and education; (2) taping and education; (3) exercise and education; and (4) education alone. It was not felt ethical to have a group that received no treatment in an intervention study of this kind. Each group had six treatments over three months to control for therapist contact time.
INTERVENTIONS

Education All four groups received the same advice. This involved receiving the Arthritis Research

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Physiotherapy for anterior knee pain 701

184 Patients invited to join study

81 Randomised

Exercise + tape (n = 20)

Exercise (n = 20)

Tape (n = 19)

Education (n = 22)

3/12

n = 16

n = 16

n = 18

n = 21

12/12 n = 10

n = 12

n = 12

n = 15

Figure 1

Patient ow.

Campaign leaet Knee pain in young adults and sessions on (a) an explanation of the nature of anterior knee pain, the anatomy of the patellofemoral joint, and possible causes of anterior knee pain; (b) footwear and appropriate sporting activities; (c) pain controlling drugs; (d) stress relaxation techniques, ice and massage; (e) diet and weight advice; and (f) prognosis and self help. On each visit the patient was examined and reassessed. Gait, eccentric muscle control, ability to squat, one leg stance, quadriceps function, iliotibial band gastrocnemius rectus femoris, and hamstring tightness and patella tracking were all assessed.
Table 1 Baseline characteristics. Results are shown as No (%) unless stated otherwise
1 Exercise + tape (n=20) Age (years) Mean (SD) Min, max Sex Male Female Employed No Yes Pain duration <3 Months 36 Months 612 Months >12 Months Knee pain Right Left Bilateral Analgesia No Yes BMI* (mean (SD)) BMI grouped Underweight Healthy Overweight Obese 4 (20) 7 (35) 8 (40) 1 (5) 1 (5) 11 (55) 5 (25) 3 (15) 2 (11) 10 (53) 5 (26) 2 (11) 2 (9) 9 (41) 8 (36) 3 (14) 26.0 (7.4) 15, 37 10 (50) 10 (50) 3 (15) 17 (85) 1 (5) 0 5 (25) 14 (70) 6 (30) 7 (35) 7 (35) 11 (55) 9 (45) 24.8 (5.7) 2 Exercise (n=20) 29.5 (6.2) 18, 38 12 (60) 8 (40) 6 (30) 14 (70) 1 (5) 1 (5) 4 (20) 14 (70) 6 (30) 7 (35) 7 (35) 11 (55) 9 (45) 24.9 (4.2) 3 Tape (n=19) 29.3 (6.8) 17, 40 10 (53) 9 (47) 5 (26) 14 (74) 1 (5) 2 (11) 1 (5) 15 (79) 5 (26) 3 (16) 11 (58) 11 (58) 8 (42) 25.0 (3.9) 4 Education (n=22) 27.1 (7.2) 16, 39 0.9 13 (59) 9 (41) 0.70 6 (27) 16 (73) 0.56 0 3 (14) 2 (9) 17 (77) 7 (32) 5 (23) 10 (45) 0.44 16 (73) 5 (23) 25.2 (4.2) 0.84 (BMI <25/BMI >25) Signicance (p value) 0.31

Stretching and strengthening knee exercises The exercise group had six sessions of reassessment, education, and knee exercises to improve progressively the motor skill of the lower limb extensors and to stretch tight structures. Patients were taught hamstring, iliotibial band, quadriceps, and gastrocnemius stretches to hold for 10 seconds and repeat 10 times. All visits began with three minutes warm up on a static exercise bicycle. Patients were taught to squat on the wall, with hips, knees, and feet in alignment until their hips were at 90 degrees. Patients were instructed to hold this position for 10 seconds and repeat the exercise 10 times. This exercise was lengthened over the six sessions until the patient was able to hold the position for three minutes. Other functional isotonic exercises included sit to stand, proprioceptive balance work using a trampet, and specic exercises for gluteus medius and maximus. Progressive step down exercises were performed. All exercises resulted in strong eccentric contraction of lower limb extensors. Patients were instructed to repeat the exercises every day and a diary sheet was supplied to help compliance. Taping The taping group had six sessions of assessment, education, and taping. Tape was applied from the lateral border of the patella pulling medially and upwards over the medial femoral condyle. Taping in this way should reduce pain on the squat test and wall/step down test. If this did not eliminate the pain then the taping was repeated in knee exion. Tape was given to the patient and applied each day over attendances 13 inclusive during all activities. During the fourth and fth visits taping was only applied during painful activities. On the sixth session the tape was removed. The exercise and taping group included all of the above.
OUTCOME MEASUREMENTS

A blinded independent observer undertook assessment on the sixth visit. The primary outcome measure was an assessment of patient satisfaction (satised = discharge, not satised = continue physiotherapy, or refer to consultant). Secondary outcome measures were a visual analogue pain score (two 0100 mm horizontal scales which indicated diYculty in climbing stairs and walking on the at, with no pain and extreme pain at each end; total score 200) and the WOMAC lower limb function score (Likert version). In addition, patients lled out the HAD score, and had the strength of their quadriceps measured. At a minimum of one year patients were then sent a further postal questionnaire, visual analogue pain score, the WOMAC score, and the HAD score. The physiotherapy and medical outpatient attendances were traced for Nottingham in those patients who failed to respond to two questionnaires and a phone call.
BLINDING

*BMI = body mass index.

The assessors before and after the intervention were unaware of the intervention given. The patients themselves were not completely

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702 Clark, Downing, Mitchell, et al Primary outcome measure at three months after baseline. Results are shown as No
1 Exercise + tape (n=20) Discharged Referred 19 (95) 1 (5) 2 Exercise (n=20) 20 (100) 0 3 Tape (n=19) 8 (42) 11 (58) 4 Education (n=22) 13 (59) 9 (41) All patients (n=81) 60 (74) 21 (26)

Table 2 (%)

Results
PATIENT FLOW

blinded because they were aware that of the four types of treatment one group would receive advice only.
STATISTICAL ANALYSIS

The study was based on a 2 2 factorial design. With a 90% power of detecting a 40% diVerence in discharge rates between muscle strengthening and taping at a signicance level of 5% a minimum of 14 patients would be required in each arm of the studythat is, a minimum of 14 4 = 56 patients. Patients who failed to attend were included in the analysis on an intention to treat basis. Data were analysed using SPSS, version 8.0. All the baseline signicance tests were 2 (categorical variables) except for age (one way analysis of variance (ANOVA) for continuous variables). We found no evidence of an interaction between exercise and taping and so our analysis focused on comparing all four groups and comparing taped with non-taped patients and exercising with non-exercising patients. 2 Tests were used for categorical outcomes and Students t tests, MannWhitney U test, and Kruskall-Wallis test for continuous outcomes.

Of the 184 patients invited to join the study, 81 were recruited (40 patients did not attend, 36 patients had a diVerent diagnosis, seven were already better, six refused consent, one had previous physiotherapy, three were too young/ old, two had had recent surgery, and eight had miscellaneous reasons) (g 1). 10 patients withdrew during the study and these were included in the analysis on an intention to treat basis. 49 patients returned the questionnaires at 12 months.
BASELINE CHARACTERISTICS OF THE PATIENTS

There were no signicant diVerences between the four groups in age, sex, employment status (students were included in the employed group), duration of knee pain, use of analgesia (simple or anti-inammatory types and regular or intermittent use were also similar between the groups), or body mass index (table 1). There were also no diVerences in baseline WOMAC score, visual analogue score, HAD scores, or quadriceps power (see table 3).
PRIMARY OUTCOME MEASURE: PATIENT SATISFACTION (TABLE 2)

Patients who had the proprioceptive stretching and strengthening exercise component of the physiotherapy were signicantly more likely to be discharged than non-proprioceptive exercising patients ( 2, p<0.001). Taping alone was not signicantly associated with discharge.

Table 3 WOMAC, visual analogue (VA), Hospital Anxiety and Depression (HAD) scores, and quadriceps strength at baseline, three months, and 12 months (WOMAC out of 96, VA out of 200, HAD anxiety out of 21, HAD depression out of 21, quadriceps strength (kgF). Results are shown as No (%) unless stated otherwise
1 Exercise + tape (n=20) Baseline WOMAC (mean (SD)) VA score (mean (SD)) HAD anx Mean (SD) Normal Borderline Anxious HAD dep Mean (SD) Min, max Normal Borderline Depressed R quads (mean (SD)) L quads (mean (SD)) Three months WOMAC (mean (SD)) VA score (mean (SD)) HAD anx (mean (SD)) HAD dep (mean (SD)) R quads (mean (SD)) L quads (mean (SD)) Twelve months WOMAC (mean (SD)) VA score (mean (SD)) HAD anx (mean (SD) HAD dep (mean (SD)) 25.2 (12.5) 75.6 (32.6) 5.6 (2.9) 16 (80) 3 (15) 1 (5) 3.2 (2.8) 0, 9 17 (85) 3 (15) 0 186.8 (133.0) 169.4 (100.0) 11.5 (10.5) 35.9 (28.7) 3.3 (2.5) 1.8 (1.5) 280.4 (149.9) 266.9 (132.9) 14.8 (18.0) 35.1 (45.1) 4.6 (3.2) 2.0 (1.3) 2 Exercise (n=20) 23.7 (12.9) 77.1 (44.4) 6.5 (3.9) 14 (70) 3 (15) 3 (15) 3.1 (2.4) 0, 8 17 (85) 3 (15) 0 233.2 (148.5) 224.7 (130.9) 10.0 (11.8) 30.0 (39.9) 5.1 (4.7) 2.2 (2.4) 320.1 (193.6) 307.9 (162.4) 15.6 (16.2) 37.8 (43.4) 5.3 (5.2) 3.0 (3.3) 3 Tape (n=19) 33.4 (16.8) 83.9 (39.8) 6.7 (4.2) 13 (68) 4 (21) 2 (11) 4.0 (4.3) 0, 14 16 (84) 1 (5) 2 (11) 198.7 (144.7) 156.7 (106.1) 20.9 (15.5) 57.8 (38.7) 5.7 (4.3) 2.8 (3.4) 222.5 (143.1) 189.4 (122.4) 27.6 (22.7) 77.3 (62.8) 5.2 (2.8) 3.9 (4.0) 4 Education (n=22) 28.7 (15.4) 76.99 (41.8) 6.8 (2.3) 16 (73) 4 (18) 2 (9) 0.16 4.6 (2.9) 1, 13 19 (86) 2 (9) 1 (5) 190.6 (107.8) 205.6 (130.8) 13.8 (15.8) 41.8 (40.6) 5.5 (3.4) 3.0 (2.7)) 258.8 (159.6) 279.9 (155.1) 22.0 (21.3) 51.9 (53.8) 5.2 (3.3) 3.7 (3.6) 0.52 0.52 0.11 0.17 0.25 0.46 0.39 0.12 0.38 0.22 0.97 0.54 Signicance (p value) 0.23 0.94 0.43

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Physiotherapy for anterior knee pain Table 4 Mean diVerence between exercising/non-exercising patients and taped/non-taped patients
Exercising Change in WOMAC (SD) p Value* Mean diVerence (95% CI) Change in VA (SD) p Value* Mean diVerence (95% CI) Change in HAD anx (SD) p Value* Mean diVerence (95% CI) Change in HAD dep (SD) p Value* Mean diVerence (95% CI) Change in quadriceps strength (SD) p Value* 11.7 (12.4) Non-exercising 13.4 (14.2) Taped 11.8 (15.3) Non-taped

703

0.6 1.7 (4.7 to 8.1) 34.4 (41.6) 26.8 (43.8) 0.46 7.6 (28 to 12.9) 1.6 (2.3) 0.87 (3.2) 0.29 0.7 (2.17 to 0.6) 0.97 (1.9) 1.1 (1.7) 0.76 0.1 (0.7 to 1.0) 91.2 (95.4) 55.7 (113) 0.18

13.3 (11.5) 0.65 1.4 (5.0 to 7.9) 27.9 (47.5) 32.2 (38.3) 0.67 4.5 (16.0 to 25.0) 1.2 (3.2) 1.3 (2.5) 0.82 0.2 (1.2 to 1.5) 0.9 (3.2) 1.2 (1.3) 0.56 0.3 (0.6 to 1.1) 62.6 (108) 80.8 (104.9) 0.50

*Students t test. VA = visual analogue; HAD = Hospital Anxiety and Depression Scale.
SECONDARY OUTCOME MEASURES (TABLE 3) WOMAC and visual analogue scores At three months the WOMAC and visual analogue scores improved signicantly in all patients (Wilcoxon matched pairs signed ranks test, p<0.0001), but these improvements did not vary signicantly between the four groups or between exercising and non-exercising patients or taped and non-taped patients (table 4). Scores improved signicantly more among patients who were discharged than among patients who were referred (WOMAC p=0.03; visual analogue p=0.02). At one year all groups had improved signicantly (Wilcoxon matched pairs signed ranks test: WOMAC p=0.005; visual analogue p=0.007). One way ANOVA tests failed to show signicant diVerences in score or changes in score between the four groups (table 3). However, patients who performed exercises had signicantly lower pain scores than those who did not (Mann-Whitney U, p=0.03). Taping had no detectable eVect on score. WOMAC scores improved signicantly more among patients who were no longer troubled by knee pain than among those who were not troubled (independent samples t test: WOMAC p=0.02; visual analogue p=0.001).

nicantly more in patients who were discharged than in patients who were referred (anxiety p=0.05), but depression scores did not (p=0.56). At 12 months the HAD anxiety (p=0.02) but not the HAD depression score (p=0.07) had improved signicantly in all patients. However, one way ANOVA tests showed no signicant diVerences between the four groups in change in HAD scores. Quadriceps strength (table 3) Quadriceps power in the aVected leg(s) improved signicantly in all patients (p<0.001) but by more in the exercising and education groups than in the group with tape alone (table 3). This result approached signicance (p=0.08).
ONE YEAR QUESTIONNAIRE (TABLE 5)

The number receiving further physiotherapy and the number still troubled by their knee pain were not signicantly diVerent between the four groups. However, patients who exercised were less likely to have severe knee pain than those patients who did not exercise ( 2, p=0.08). Discussion The patients who had proprioceptive muscle stretching and strengthening exercises were signicantly more likely to be satised and discharged at three months than those patients who had taping and education alone (p=0.001). At one year patients who performed exercises had signicantly better pain scores than those who did not and were less likely to be troubled by their knee pain. However, the results showed an equal improvement in visual analogue pain score and WOMAC lower limb functional score for all four treatment groups at three and 12 months. No diVerence could be shown in these outcome measures between the groups. This may indicate that the WOMAC score is not suYciently sensitive in this group of patients. This is the rst time that the WOMAC score, designed for assessment of hip or knee osteoarthritis, has been used to assess anterior knee pain without structural change. This group of young adults did not have high levels of baseline pain or disability and were not signicantly anxious or depressed. Nevertheless, we

Anxiety and depression score (table 3) At three months the HAD anxiety and depression scores improved signicantly in all patients (anxiety p=0.0005, depression p=0.0001), but these improvements did not vary signicantly between the four groups (table 3) or between exercising and nonexercising patients or taped and non-taped patients (table 4). Anxiety scores improved sigTable 5 One year questionnaire. Results are shown as No (%)

(a) Question Have you had a further course of physiotherapy for your knee pain? More physiotherapy Yes No Exercise + tape (n=20) 2 (10) 17 (85) Exercise (n=20) 2 (10) 18 (90) Tape (n=19) 3 (16) 16 (84) Education (n=22) 5 (23) 17 (77) Signicance* (p value)

0.63

(b) Question Are you still troubled by your knee pain? Exercise + tape (n=10) 6 (60) 4 (40) Exercise (n=12) 7 (58) 5 (42) Tape (n=12) 9 (75) 3 (25) Education (n=15) 13 (87) 2 (13) Signicance* (p value)

Still troubled Yes No *One way ANOVA.

0.33

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704 Clark, Downing, Mitchell, et al

did show a signicant reduction in the WOMAC scores in all the groups. No additional benet of the use of tape to correct patella glide, above that of patient education and therapist contact, suYcient to allow discharge has been shown. For the purposes of this trial taping was used in a standardised way to improve patella glide only. In a clinical setting taping can be applied to correct patella tilt, patella rotation, or for fat pad unloading. This trial does not consider these uses of taping. Taping can be used in isolation11 12 but is usually applied to reduce pain to enable proprioceptive exercises to take place, as in the McConnell regimen.4 In our patients we did see short term benet, allowing exercises to take place. However, we did not show any benet from this use of tape in WOMAC or visual analogue scores above that of therapist contact and education suYcient to allow discharge. Indeed our results suggested that quadriceps strengthening in the tape alone group was less than in all the other patients, possibly owing to muscle inhibition or persistent pain. The results have identied the importance of therapist contact and the value of education and simple advice: pain, function, wellbeing, and quadriceps strength improved suYciently in 60% of patients with this intervention alone for them to require no further treatment. This is the rst study to control for the eVect of therapist contact. The McConnell-type physiotherapy programme is widely used for treating anterior knee pain.3 Our ndings agree with uncontrolled trials claiming overall benets of the McConnell-type physiotherapy programme for anterior knee pain.4 9 What has not been considered before is which specic components of physiotherapy are eVectivethat is, taping, exercises, or the patient education and therapist contact. Our results do not support other small uncontrolled trials that taping is of additional value in reducing pain.16 17 Our results agree with a small comparative trial of 20 subjects which suggested that taping has no benet over standard physiotherapy alone.18 It is interesting to note that in knee osteoarthritis similar ndings of the benet of therapist contact and education have been shown.19 The benet of physical exercise above this has also been shown previously.20 It therefore seems that such treatment is helpful for knee pain, whether or not there is any structural change. There are several important caveats to our study. This is a single centre study with relatively small numbers. The physical interventions could not be blinded for the patient and a signicant number of patients left the study over the 12 months. The WOMAC score was administered by diVerent blinded investigators at baseline and three months, and by post at one year, possibly introducing an

element of bias. Despite these limitations we have shown the value of patient education and therapist contact alone. The addition of proprioceptive muscle strengthening and stretching exercises improves the response signicantly above this, suYcient for patients to be discharged. We therefore recommend that patients in the community with anterior knee pain should be considered for a course of physiotherapy which focuses on patient education and activity modication, with the addition of proprioceptive exercises and stretches. It is suggested that future studies might look at the value of simple advice sheets and patient education compared with physiotherapy and look at the longer term follow up of these patients.
1 Heng RC, Haw CS. Patello-femoral pain syndrome. Current Orthopaedics 1996;10:25666. 2 Tria AJ, Palumbo RC, Alicia JA. Conservative care for patellofemoral pain. Orthop Clin North Am 1992;23:545 54. 3 Hilyard A. Recent advances in the management of patellofemoral pain: the McConnell programme. Physiotherapy 1990;76:55965. 4 McConnell J. The management of chondromalacia patellae: a long-term solution. The Australian Journal of Physiotherapy 1986;32:21523. 5 Reid DC. The myth, mystic and frustration of anterior knee pain [editorial]. Clin J Sports Med 1993;3:13943. 6 Kujala UM. Patellofemoral problems in sports medicine. Ann Chir Gynaecol 1991;80:21923. 7 Garrick JG. Anterior knee pain (chondromalacia patella). Physician and Sportsmedicine 1989;17:7584. 8 Fulkerson JP, Shea KP. Current concepts review: disorders of patellofemoral alignment. J Bone Joint Surg Am 1990;72:14249. 9 Gerrard B. The patello-femoral pain syndrome: a clinical trial of the McConnell programme. The Australian Journal of Physiotherapy 1989;35:7180. 10 Gilleard W, McConnell J, Parsons D. The eVect of patella taping on the onset of vastus medialis obliquus and vastus lateralis muscle activity in persons with patellofemoral pain. Phys Ther 1998;78:2532. 11 Cutbill JW, Ladly KO, Bray RC, Thorne P, Verhoef M. Anterior knee pain: a review. Clin J Sports Med 1997;7:405. 12 Arroll B, Ellis-Pegier E, Edwards A, SutcliVe G. Patellofemoral pain syndrome. A critical review of the clinical trials on non operative therapy. Am J Sports Med 1997;25: 20712. 13 Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt L. Validation study of WOMAC: a health status instrument for measuring clinically-important patientrelevant outcomes following total hip or knee arthroplasty in osteoarthritis. J Rheumatol 1988;15:183340. 14 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:36170. 15 Tornville G. Assessment of physical capabilities with special reference to the evaluation of maximum voluntary isometric muscle strength. Acta Physiol Scand 1963;58(suppl 201):1102. 16 Bockrath K, Wooden C, Worrall T, Ingersall CD, Farr J. EVects of patella taping on patella position and perceived pain. Med Sci Sports Exerc 1993;25:98992. 17 Herrington L, Payton CJ. EVects of corrective taping of the patella on patients with patellofemoral pain. Physiotherapy 1997;83:56674. 18 Kowall MG, Kolk G, Nuber GW, Cassisi JE, Stern SH. Patella taping in the treatment of patellofemoral pain. A prospective randomised study. Am J Sports Med 1996;24: 616. 19 Mazzuca SA, Brandt KD, Katz BP, Chambers M, Byrd D, Hanna M. EVects of self-care education on the health status of inner city patients with osteoarthritis of the knee. Arthritis Rheum 1997;40:146674. 20 OReilly SC, Muir KR, Doherty M. EVectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis 1999; 58:1519.

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Physiotherapy for anterior knee pain: a randomised controlled trial

D I Clark, N Downing, J Mitchell, et al. Ann Rheum Dis 2000 59: 700-704

doi: 10.1136/ard.59.9.700

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