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Patellofemoral pain affects 23%–29% of adolescent and the general population, with one in two reporting persistent symptoms 5–8 years later.1 Patellofemoral pain is considered a multifactorial condition with underlying biomechanical, neuromuscular and/or psychological contributors.2 3 Foot orthoses and hip exercises are recommended for the management of patellofemoral pain.4 Clinically, the quandary is to determine (1) which individual’s presenting characteristic(s) may help guide which treatment to prioritise and (2) which treatment is best in the early stages of management, irrespective of presenting characteristics.
Evidence suggests that greater foot mobil ity (defined as a change of 11 mm or more in midfoot width when moving from non-weight bearing to weight bearing) is associated with better outcomes following foot orthoses.5 Crucially, methodological considerations in previous literature, such as lack of a comparator treatment, compromise their clinical applicability.5 The aims of this trial were to test (1) whether greater foot mobility (measured as midfoot width mobility) is associated with better outcomes with foot orthoses treatment, compared with hip exercises and (2) whether hip exercises are superior to foot orthoses, irrespective of midfoot width mobility.
A two-arm parallel, randomised superiority clinical trial was conducted in Australia and Denmark. Participants (18–40 years) were included who reported an insidious onset of knee pain (≥6 weeks duration); ≥3/10 numerical pain rating, that was aggravated by activities (eg, stairs, squatting, running). Participants were stratified by midfoot width mobility (high ≥11 mm change in midfoot width) and site, randomised to foot orthoses or hip exercises and blinded to objectives and stratification. Success was defined a priori as much better or better on a patient-perceived 7-point scale at 12 weeks.
Of 218 stratified and randomised participants, 192 completed 12-week follow-up. This study found no difference in success rates between foot orthoses versus hip exercises in those with high (6/21 vs 9/20; 29% vs 45%, respectively) or low (42/79 vs 37/72; 53% vs 51%) midfoot width mobility. There was no association between midfoot width mobility and treatment outcome (interaction effect p=0.19). This study found no difference in success rate between foot orthoses versus hip exercises (48/100 vs 46/92; 48% vs 50%). There was no evidence of any differences between groups with respect to 22 secondary outcome measures.
Midfoot width mobility should not be used to help clinicians decide which patient with patellofemoral pain might benefit most from foot orthoses. Clinicians and patients may consider either foot orthoses or hip exercises in managing patellofemoral pain.
Twitter @Mark_MatthewsNZ, @Bill_Vicenzino
Contributors MM contributed to the study conception and design, recruitment of participants, management of study proceedings, data collection and drafting and revision of the manuscript. APC, TM, RN and KMC contributed to the study conception and design, and drafting and revision of the manuscript. MSR contributed to the study design, recruitment of participants, management of study proceedings, data collection and reviewed the manuscript. JK contributed to the statistical analysis and reviewed the manuscript. BTV contributed to the study conception and design, recruitment of participants, data management and the drafting and revision of the manuscript. BTV and MM act as guarantors to affirm that this manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding National Health and Medical Research Council (Ref: 631717).
Competing interests BTV reports grants from Commonwealth of Australia National Health and Medical Research Council (Ref: 631717) and from Vionics International for this research. MM is supported by an Australian Postgraduate Award. BTV and TM are voluntary (non-compensated) members by invitation on the Vasyli Think Tank.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.