Table 4

Themes and subthemes identified from interview transcripts unrelated to current level 1 evidence

Theme (see online supplementary file)SubthemeIllustrative quotes
Over-arching principles to consider when treating PFP (see online supplementary file 2.1)
Keys to successAddressing pain and at what treatment stage“The most important aspect, probably reducing their pain, that's obviously what they've come for.”1 “First of all, you need to reduce their pain”5
The importance of patient education“Education is the key ingredient to any good therapy.”6 Patient-specific advice and education is critical”16
Empowering the patient through education“Educating the patient to make sure they understand what's causing their pain and how it's developed and what they can do to try and fix it.”1 “The most important thing I was able to do was educate the patient on what was wrong with them and what they needed to do to help themselves to get better”7
On the issue of patients actively engaging or being passive recipients of therapy“Some people are looking for the passive laying on of hands, the cure, and all that kind of stuff, and for Patellofemoral pain, that just isn't where it's at.”8 “Explain to the patient that there's a balance between intrinsic (active) and extrinsic (passive) therapy”1
Managing expectations“This condition is not cured, it is managed, and that's completely different.”10 “I think therapists spend too much time thinking they can cure this, probably instead of actually trying to educate the patient on how to manage it”13
Activity modificationControlling the amount of loading activities“I tell people to stop doing the activities that cause them pain until we can correct their movement patterns.”9 “Number one (is) reduction of primary aggravating factors. You're going to see a reduction in pain and symptoms just from doing that alone”15
The importance of individualising activity modification“I think it's a very negative thing to say, ‘oh, you've got to stop doing all of those things.”10 You can't ask a runner to stop running, you can only ask them to be reasonable about the mileage that they incur on a weekly basis”15
Addressing psychosocial factorsIdentifying psychosocial factors“There's always, probably, some underlying psychological or some psycho-social issues.”9 “The one thing that is here that needs to be thought about is, which patients aren't going to benefit from treatment….. there's a psychological element, and there are certain patients who will not benefit from physiotherapy”11
Addressing fear-avoidance behaviours“Sometimes patients are very fearful of even moving and unless this is addressed they just decondition and that makes the problem worse.”1 “Particularly in the younger girls I see, they have this fear of movement, this fear of loading up their knee, and so they actually offload so much that they get weaker and therefore more pain”5
Exercise prescription principles (see online supplementary file 2.2)
DoseDose considerations in relation to compliance and quality“The simpler you make it, the better it is, the more likelihood you have of someone being compliant.”1 “I give them no more than four exercises to do, that they can do any time, any place, anywhere….. you want it to become part of their daily routine”10
Other principlesOn balancing muscle strength and movement control“Power is nothing without control. And, to me, that's pretty much it. What we're doing, as physiotherapists, is very much about trying to improve control at some level with the patients, and if you can improve that control, that will have an impact on their pain”8
Exercise principles to optimise outcomesExercise needs to be done regularly, there's not much point in doing exercise once every now and again when you go and see the physio. Exercise, for the most, needs to be repeated for it to be of any benefit.”6 “(Exercises should) facilitate them getting back into functional activity. So, if their problem was going up and downstairs, exercises that help them to achieve that, or if they want to get back to running, exercises that help them to achieve their goals”7
Exercise specifics (see online supplementary file 2.3)
Foot and ankleExercises to control foot pronation“Those people (with excessive foot pronation) could benefit from being given foot muscle exercises to allow them to elevate their midfoot.”9 “I would much rather teach that foot to be stronger—and we don't have a lot of evidence for that yet, but … by strengthening the foot so it does it on its own and doesn't need a brace to hold it up, I think would be a much better way to approach a musculoskeletal injury like that ”16
CoreIncorporating core strengthening“There's no evidence for trunk strengthening and I would use trunk strengthening quite frequently.”7 “Trunk strengthening, I think it's important for postural control and dynamic control of movement”14
BiofeedbackIncorporating other forms of biofeedback to improve hip and knee control“Exercises in front of mirrors, is about trying to give the patient the feedback about their control mechanisms, which is about improving the pattern of activity.”8 “Video feedback is going to give you an ability for the patient to understand better what they're doing wrong”13
Stretching and addressing flexibilityOn the importance of stretching“Flexibility, range of motion, often look at that, maybe not as immediate priority but certainly longer-term, that can certainly help in terms of stretching.”1 “I think flexibility/range of motion is an adjunct”9
The importance of ITB stretching“I don't think you can stretch your ITB, and that's where the foam roller is much more effective in terms of releasing tension in ITB.”5 “I'm not a great fan of the Iliotibial band stretching ….. the Iliotibial band probably is a non-modifiable factor”8
Addressing hamstring flexibility“Hamstrings, I think people need 80° of hamstring range for normal everyday function.”4 “There's a high degree of association between short hamstrings and Patellofemoral pain”13
Addressing calf flexibility“Calf, I think you need 15° of dorsi-flexion minimum or else you'll get compensation at the knee and/or the foot.”4 “Calf stretching, if it's appropriate ….. sometimes just stretching the calf is sufficient to minimise the excessive pronations through the midfoot”10
Movement pattern and gait retraining (see online supplementary file 2.4)
Movement pattern and gait retrainingPotential effects of movement and pattern gait retraining“I try and do movement pattern retraining, with most patients.”7 “We do gait retraining with the majority of the patients that we see. Just strengthening alone is not going to change mechanics”16
The challenges of implementing gait retraining“Clinically, I don't have the time necessarily to spend with someone, implementing the types of programmes that they use in the studies, particularly the real time feedback.”5 “It's very easy to see. We've videotaped them, it doesn't take a lot of high-tech equipment”16
Adjunctive interventions (see online supplementary file 2.5)
Foot and ankle mobilisationAddressing foot and ankle mobility limitations“If motion is limited in the sagittal plane, this should be addressed through soft tissue or mobilisation. Otherwise more pronation is likely and this will cause medial collapse at the knee.”1 “I will mobilise the subtalar joint, to improve calcaneal inversion, to improve shock absorption”10
MassageMassage use and effects“Massage, probably along with some of the stretches, such as hamstring and hips, I'd probably go less towards, because I really struggle to see how they're adding value to the situation”13 “I think massage plays a big role and people underestimate the effectiveness of massage, just in terms of getting—I would say massage is far more effective than have somebody stretch their IT band or even do fascial lengthening, that's rolling. So, more times than not, we actually recommend one or two massage therapy visits, in combination with our home programme”15
UltrasoundUltrasound use and effects“I don't overly see where it adds to value within the patient management of these sort of patients.”13 “If somebody's doing ultrasound on a Patellofemoral joint, that's bad medicine”15
Gaps in evidence and priorities for future research (see online supplementary file 2.6)
Pain and pathologyUnderstanding risk factors and developing prevention programs“Prevention's probably the holy grail.”4 “We need to discriminate a lot more as to cause and effect, rather than just an association”13
The source of pain“Priority, try and understand what causes the pain and where does it come from … because if we understand that, then we can design better intervention and prevention strategies”12
Identifying those likely to become chronic“We need to better understand what it is that makes the condition become chronic”5
The potential relationship between PFP and PFJ OA“(We need to) work out the relationship between Patellofemoral pain and Patella Osteoarthritis”7
Treatment principlesApproaches to patient specific advice and activity modification“It would be great to have a sort of smorgasbord of patient-specific advice, so you can pick out the right bits”4
Subgroups and tailoring interventions“I think we need to try and develop research around identifying subgroups that are likely to benefit (from various interventions) That's probably where the biggest gap lies.” (1) “Our ability to target individual patients with an evidence-based approach, I think is an area which is most lacking … The priority has definitely got to be looking for predictors of outcomes for different treatments.” (6)
The effectiveness of longer term interventions (ie, >6 weeks) “Most of the interventions have been quite short, and I think that, in clinical practise, we tend to treat people for longer. And so I think that we need to evaluate whether a longer intervention will provide better results….. I think the six week intervention is too short.” (7)
Improving our understanding of the impact of psychosocial factors on PFP“Nobody's really looked at the psychosocial aspect of whether that predicts whether someone will get Patellofemoral pain”5
Specific interventionsThe relationship of the foot, footwear and orthoses to pathology“Footwear would be interesting, both from an efficacy and from a biomechanics point of view.”7 “I think we need to understand a little bit more about what's going on with the foot, up”16
The value of proximal strengthening“The gaps are clearly in hip strengthening. And I also said earlier, I think there are gaps in trunk strengthening.”7 “People are going to start moving in to the core and the trunk also”9
The value of gait retraining“There's good stuff that's looking at retraining movement patterns and retraining the way in which people move, to try and modify their pain. I think that's something that needs more support and needs more work”2
  • ITB, iliotibial band; PFP, Patellofemoral pain; PFJ, patellofemoral joint; OA, osteoarthritis.