Efficacy of adding manual therapy to hip and knee exercises in patients with patellofemoral pain syndrome: a double-blinded randomized controlled clinical trial

Patellofemoral pain syndrome (PFPS) is the most common knee problem that affects the knee in adulthood. It is more common in females twice than in males. It has a multifactorial etiology. The effect of the combination of manual therapy and hip and knee exercises is unconfirmed till now. Therefore, the aim of this study is to investigate the effect of adding manual therapy to knee and hip exercises on pain intensity, self-reported and objective knee function, hip abductors, hip external rotators, and knee extensor strength in addition to calf, and hamstring flexibility in patients with PFPS. This was a double-blind study. Fifty-nine adult patients with PFPS matched with eligibility criteria were sequentially recruited from an outpatient clinic, and faculty students were enrolled in this study and randomized by a generated Excel sheet into two groups either control (30 patients) or manual therapy (29 patients) group. The control group received stretch and open and closed kinetic chain strength exercises, while the manual therapy group received the same exercises as the control plus patellar mobilization, iliotibial band release, and deep friction massage of lateral retinacula. This treatment was performed in the outpatient clinic for 12 sessions in 4 weeks. Fifty-three patients had only been analyzed at the end of treatment. The primary outcomes were knee pain intensity and self-reported knee function. The secondary outcomes were hip and knee muscle strength, calf and hamstring flexibility, and a step-down test. All outcomes were measured before and after 4 weeks of treatment immediately by a blind assessor. Comparing between and within groups were performed using the Multivariate analysis of variance (MANOVA) test. The mean age was 22.64 ± 3.71 years for control group, 21.92 ± 2.39 years for manual therapy group. Both treatment protocols showed significant reduction of pain (ascending (p < 0.001; CI: (14.85-39.44)), descending (p < 0.001; CI: (15.95-30.62)), squatting (p < 0.001; CI: (15.00-38.07)) and sitting (p < 0.001; CI: (13.49-37.87))) for control group, while (ascending (p < 0.001; CI: (20.37-39.07)), descending (p < 0.001; CI: (12.72-32.80)), squatting (p < 0.001; CI: (28.98-51.66)) and sitting (p < 0.001; CI: (16.72-42.24))) for manual therapy group, improvement in knee function (Kujala: (p < 0.001; CI: (-17.02-8.76))) for control group while (Kujala: (p < 0.001; CI: (-21.32-12.19))) for manual therapy group, hip and knee muscle strength and flexibility (p < 0.05). However, there were non-significant differences between groups in all dependent variables (p > 0.05). Manual therapy added to hip and knee exercises may have the same effect as hip and knee exercises without superiority to one of them. Manual therapy improved patients' clinical outcomes, including pain and function disability, with a higher percentage of change than exercises only.Clinical trial registration: www.clinicaltrials.gov (NCT05665452). Date: 27/12/2022.