Effectiveness of manual therapy on pain and self-reported function in individuals with patellofemoral pain: systematic review and meta-analysis

Key points

1. 01Patellar manual therapy reduced pain versus sham or control with a pooled SMD of -0.61 (95% CI -0.87 to -0.36, P<.001) at 2 to 6 weeks
2. 02Self-reported function also improved (pooled SMD 0.68, 95% CI 0.38 to 0.98, P<.001) but the change did not reach the minimal clinically important difference in most studies
3. 033 of 5 studies comparing patellar MT to sham reported pain changes that exceeded the MCID for VAS or NRS
4. 04Adding lumbopelvic manipulation to a knee MT program showed no additional benefit over knee MT alone in the studies reviewed
5. 05No long-term data beyond 6 weeks was available except one study showing no between-group difference at 1 year

How it was conducted

Design

Systematic review with meta-analysis of randomized controlled trials

Databases searched

PubMed, OVID, CENTRAL, CINAHL; search through August 2017

Studies included

9 RCTs (6 contributed to meta-analysis)

Population

Adults with a clinical diagnosis of patellofemoral pain, no other knee pathology

Primary outcomes

Pain (VAS or NRS) and self-reported function (AKPS or PSFS)

Risk of bias tool

Cochrane Risk of Bias tool; 5 of 9 studies rated low risk

What they found

• Patellar MT vs. sham/control - self-reported function: pooled SMD 0.68 (95% CI 0.38 to 0.98, P<.001); I2 = 0%
• Patellar MT vs. sham/control - pain: pooled SMD -0.61 (95% CI -0.87 to -0.36, P<.001); I2 = 0%
• Combined exercise + patellar MT vs. alternative treatment - pain: pooled SMD -0.03 (95% CI -0.52 to 0.46, P=.902); I2 = 0%
• Crossley et al (2002): MT group pain reduction -4.0 cm VAS vs. -2.0 cm control (P<.05); AKPS improvement 18 vs. 9 points (P<.05) at 6 weeks
• Collins et al (2009): MT group pain reduction -29.2 mm VAS vs. -8.6 mm sham at 6 weeks; difference -20.6 (95% CI -32.15 to -9.05)
• Hains & Hains (2010): local knee MT reduced pain by -3.57 cm VAS (60%) vs. remote hip MT -1.90 cm (28%) over 4 weeks
• Motealleh et al (2016): lumbopelvic manipulation vs. sham - pain difference -2.6 NRS points (95% CI -3.5 to -1.8, P<.001) immediately post-treatment; step-down test difference 2.4 (95% CI 0.8 to 3.9, P=.004); one-legged hop test P=.125
• Behrangrad & Kamali: ischemic compression at VMO outperformed lumbopelvic manipulation on pain and AKPS at 1 week, 1 month, and 3 months (all P<.001)

Limitations

• All 9 studies reported outcomes only at 6 weeks or less, except one 1-year follow-up; long-term effects remain unknown
• Blinding of treating clinicians was not feasible in 8 of 9 studies, introducing performance bias
• MT techniques, dosage, and comparison groups varied substantially across studies, limiting pooled interpretation
• Two studies (Osmond-Stakes et al and Rowlands and Brantingham) had high overall risk of bias, requiring cautious interpretation of pooled effects

Why it matters

For patients

Manual therapy to the knee area may meaningfully reduce pain in the short term, but whether it leads to lasting functional gains is unclear and should be part of a broader rehabilitation program including strengthening.

For clinicians

Patellar mobilization and soft-tissue techniques have moderate evidence for short-term pain relief and can be integrated into multimodal PFP management; lumbopelvic manipulation shows no consistent added benefit and cannot be routinely recommended.

For readers

This meta-analysis provides the best available synthesis for MT in PFP but is limited by small, heterogeneous trials with short follow-up, and stronger RCTs with longer follow-up are needed.