To investigate the incidence of subsequent lumbar spine, hip, and ankle-foot injuries after a diagnosis of patellofemoral pain.
Design
Retrospective cohort study.
Setting
Military Health System.
Participants
Individuals (n = 92,319) ages 17–60 diagnosed with patellofemoral pain between 2010–2011.
Interventions
Therapeutic exercise.
Main Outcome Measures
Frequency of adjacent joint injuries in the 2-year period after initial patellofemoral pain injury, and hazard ratios (HR) with 95% confidence interval (CI) and Kaplan–Meier survival curves for risk of adjacent joint injury based on receiving therapeutic exercise for the initial injury.
Results
After initial patellofemoral pain diagnosis, 42,983 (46.6%) individuals sought care for an adjacent joint injury. Of these, 19,587 (21.2%) were subsequently diagnosed with a lumbar injury, 2837 (3.1%) a hip injury, and 10,166 (11.0%) an ankle-foot injury. One in five (19.5%; n = 17,966) received therapeutic exercise which reduced the risk of having a subsequent lumbar (HR = 0.78, 95% CI 0.76–0.81), hip (HR = 0.93, 95% CI 0.87–0.98) or ankle-foot (HR = 0.86, 95% CI 0.83–0.90) injury.
Conclusion
The results suggest that a high number of individuals with patellofemoral pain will sustain an adjacent joint injury within 2 years although causal relationships cannot be determined. Receiving therapeutic exercise for the initial knee injury reduced the risk of sustaining an adjacent joint injury. This study helps provide normative data for subsequent injury rates in this population and guide development of future studies designed to understand causal factors.
CrossleyKMStefanikJJSelfeJ, et al. 2016Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. Br J Sports Med2016; 50: 839–843.
2.
GlavianoNRBaellowASalibaS. Physical activity levels in individuals with and without patellofemoral pain. Phys Ther Sport2017; 27: 12–16.
3.
NealBSLackSDLankhorstNE, et al.Risk factors for patellofemoral pain: a systematic review and meta-analysis. Br J Sports Med2019; 53: 270–281.
4.
CrossleyKMvan MiddelkoopMCallaghanMJ, et al. 2016Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 2: recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med2016; 50: 844–852.
5.
BolingMCPaduaDAMarshallSW, et al.A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the joint undertaking to monitor and prevent ACL injury (JUMP-ACL) cohort. Am J Sports Med2009; 37: 2108–2116.
6.
WillyRWBrorssonAPowellHC, et al.Elevated knee joint kinetics and reduced ankle kinetics are present during jogging and hopping after achilles tendon ruptures. Am J Sports Med2017; 45: 1124–1133.
7.
PowellHCSilbernagelKGBrorssonA, et al.Individuals post achilles tendon rupture exhibit asymmetrical knee and ankle kinetics and loading rates during a drop countermovement jump. J Orthop Sports Phys Ther2018; 48: 34–43.
8.
SouzaRBDraperCEFredericsonM, et al.Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis. J Orthop Sports Phys Ther2010; 40: 277–285.
9.
WillsonJDDavisIS. Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands. Clin Biomech2008; 23: 203–211.
10.
SteinbergNDarGDunlopM, et al.The relationship of hip muscle performance to leg, ankle and foot injuries: a systematic review. Phys Sportsmed2017; 45: 49–63.
11.
ChuterVHJanse de JongeXAK. Proximal and distal contributions to lower extremity injury: a review of the literature. Gait Posture2012; 36: 7–15.
12.
PatersonKLKaszaJHunterDJ, et al.The relationship between foot and ankle symptoms and risk of developing knee osteoarthritis: data from the osteoarthritis initiative. Osteoarthritis Cartilage2017; 25: 639–646.
13.
BackmanLJDanielsonP. Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players: a 1-year prospective study. Am J Sports Med2011; 39: 2626–2633.
14.
SammitoSHadzicVKarakolisT, et al. Risk factors for musculoskeletal injuries in the military: a qualitative systematic review of the literature from the past two decades and a new prioritizing injury model. Mil Med Res2021; 8: 66.
15.
CollinsNJBierma-ZeinstraSMACrossleyKM, et al.Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med2013; 47: 227–233.
16.
JonesCMGriffithsPCMellalieuSD. Training load and fatigue marker associations with injury and illness: a systematic review of longitudinal studies. Sports Med2017; 47: 943–974.
17.
WillyRWHoglundLTBartonCJ, et al.Patellofemoral pain: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American physical therapy association. J Orthop Sports Phys Ther2019; 49: CPG1–CPG95.
18.
YoungJLSnodgrassSJClelandJA, et al.Usual medical care for patellofemoral pain does not usually involve much care: 2-year follow-up in the military health system. J Orthop Sports Phys Ther2021: 1–25.
19.
GeorgeSZFritzJMSilfiesSP, et al. Interventions for the management of acute and chronic low back pain: revision 2021: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the academy of orthopaedic physical therapy of the American physical therapy association. J Orthop Sports Phys Ther2021; 51: CPG1–CPG60.
20.
CashinAGBoothJMcAuleyJH, et al.Making exercise count: considerations for the role of exercise in back pain treatment. Musculoskeletal Care2021: 1–12.
21.
MartinRLChimentiRCuddefordT, et al.Achilles pain, stiffness, and muscle power deficits: midportion achilles tendinopathy revision 2018: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American physical therapy association. J Orthop Sports Phys Ther2018; 48: A1–A38.
22.
EnsekiKHarris-HayesMWhiteDM, et al.Nonarthritic hip joint pain: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American physical therapy association. J Orthop Sports Phys Ther2014; 44: A1–A32.
23.
MartinRLDavenportTEFraserJJ, et al. Ankle stability and movement coordination impairments: lateral ankle ligament sprains revision 2021: clinical practice guidelines linked to the International Classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American physical therapy association. J Orthop Sports Phys Ther2021; 51: CPG1–CPG80.
24.
YoungJLSnodgrassSJClelandJA, et al. Timing of physical therapy for individuals with patellofemoral pain and the influence on healthcare use, costs and recurrence rates: an observational study. BMC Health Serv Res2021; 21: 751.
25.
BenchimolEISmeethLGuttmannA, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med2015; 12: e1001885.
26.
RhonDIClewleyDYoungJL, et al. Leveraging healthcare utilization to explore outcomes from musculoskeletal disorders: methodology for defining relevant variables from a health services data repository. BMC Med Inform Decis Mak2018; 18: 10.
27.
MolloyJMPendergrassTLLeeIE, et al.Musculoskeletal injuries and United States Army readiness part I: overview of injuries and their strategic impact. Mil Med. 2020; 185: e1461–e1471.
GlavianoNRKewMHartJM, et al.Demographic and epidemiological trends in patellofemoral pain. Int J Sports Phys Ther2015; 10: 281–290.
30.
PowersCM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther2010; 40: 42–51.
31.
SeayJFShingTWilburnK, et al.Lower-extremity injury increases risk of first-time low back pain in the US army. Med Sci Sports Exerc2018; 50: 987–994.
32.
RhonDIGreenleeTADickensJF, et al.Are we able to determine differences in outcomes between male and female servicemembers undergoing hip arthroscopy? A systematic review. Orthop J Sports Med2021; 9: 23259671211053034.
33.
MølgaardCRathleffMSSimonsenO. Patellofemoral pain syndrome and its association with hip, ankle, and foot function in 16- to 18-year-old high school students: a single-blind case-control study. J Am Podiatr Med Assoc2011; 101: 215–222.
34.
HillOTBulathsinhalaLScofieldDE, et al. Risk factors for soft tissue knee injuries in active duty U.S. Army soldiers, 2000–2005. Mil Med2013; 178: 676–682.
35.
NealBSGriffithsIBDowlingGJ, et al.Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis. J Foot Ankle Res2014; 7: 55.
36.
DowlingGJMurleyGSMunteanuSE, et al.Dynamic foot function as a risk factor for lower limb overuse injury: a systematic review. J Foot Ankle Res2014; 7: 53.
37.
KusnezovNWattsNBelmontPJJr, et al.Incidence and risk factors for chronic anterior knee pain. J Knee Surg2016; 29: 248–253.
38.
RhonDIRoyTCOhRC, et al.Sex and mental health disorder differences among military service members with patellofemoral syndrome. J Am Board Fam Med2021; 34: 328–337.
39.
BolingMPaduaDMarshallS, et al.Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports2010; 20: 725–730.
40.
MosengTTveterATHolmI, et al.Patients with musculoskeletal conditions do less vigorous physical activity and have poorer physical fitness than population controls: a cross-sectional study. Physiotherapy2014; 100: 319–324.
41.
DorotkaRJimenez-BojEKyptaA, et al.The patellofemoral pain syndrome in recruits undergoing military training: a prospective 2-year follow-up study. Mil Med2003; 168: 337–340.
42.
DyeSF. The pathophysiology of patellofemoral pain. a tissue homeostasis perspective. Clin Orthop Relat Res2005; 436: 100–120.
43.
AndersenKAGrimshawPNKelsoRM, et al.Musculoskeletal lower limb injury risk in army populations. Sports Med Open2016; 2: 22.
44.
SuekiDGClelandJAWainnerRS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther2013; 21: 90–102.
45.
LowryCDClelandJADykeK. Management of patients with patellofemoral pain syndrome using a multimodal approach: a case series. J Orthop Sports Phys Ther2008; 38: 691–702.
46.
VaughnDW. Isolated knee pain: a case report highlighting regional interdependence. J Orthop Sports Phys Ther2008; 38: 616–623.
47.
WelshCHanneyWJPodschunL, et al.Rehabilitation of a female dancer with patellofemoral pain syndrome: applying concepts of regional interdependence in practice. N Am J Sports Phys Ther2010; 5: 85–97.
48.
FukudaTYMeloWPZaffalonBM, et al.Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome: a randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys Ther2012; 42: 823–830.
49.
WitvrouwEDanneelsLVan TiggelenD, et al.Open versus closed kinetic chain exercises in patellofemoral pain: a 5-year prospective randomized study. Am J Sports Med2004; 32: 1122–1130.
50.
DribanJBLoGHEatonCB, et al.Knee pain and a prior injury are associated with increased risk of a new knee injury: data from the osteoarthritis initiative. J Rheumatol2015; 42: 1463–1469.
51.
FultonJWrightKKellyM, et al.Injury risk is altered by previous injury: a systematic review of the literature and presentation of causative neuromuscular factors. Int J Sports Phys Ther2014; 9: 583–595.
52.
VerrelstRDe ClercqDWillemsTM, et al.Contralateral risk factors associated with exertional medial tibial pain in women. Med Sci Sports Exerc2014; 46: 1546–1553.
