Patellofemoral Score Research Articles

Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial

Objective To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome.Design Open label randomised controlled...

Achieving Deep Flexion After Primary Total Knee Arthroplasty

Total knee arthroplasty patients often have difficulty performing activities involving flexion beyond 130°. The NexGen LPS Flex (Zimmer Inc, Warsaw, Ind) mobile bearing implant accommodates up to 155° of flexion. Two hundred eighteen total knee arthroplasties were performed using this implant on 125 patients over a 2-year period with a minimum of 5 years follow-up. All data were collected prospectively. Forty-four percent of preoperative cases had full flexion (ie, 140° active flexion and ability to kneel with thigh/calf contact for 1 minute). Five-year data showed an average flexion of 140° ± 11.5° and flexion greater than 140° in 103 knees (68%). There were no differences in patellofemoral pain levels, complications, or Knee Society scores despite our patients having, on average, an increase in flexion and function.

The effects of vacuumic bracing system on the patellofemoral articulation in patients with patellofemoral pain syndrome

Patellar bracing is a component of treatment of patellofemoral joint (PFJ) problems. A new vacuumic brace was designed by the researchers that act based on an external vacuuming suction. Ten patients were undertaken for the CT scan study at both 0 degrees and 30 degrees knee flexion immediately pre- and post-bracing. Also they examined clinically pre, post and 1 week after using the brace. Measurements of patellofemoral joint space width (PFJSW) and patellofemoral joint area (PFJA) showed that the application of the vacuumic brace is able to create a significant patellofemoral joint distraction at both knee angles. A significant reduction in visual analog scale (VAS) and increase in kujala patellofemoral score (KPS) was found in subjects after using the brace for 1 week. In conclusion, the results conveyed that application of the vacuumic brace is able to create a joint distraction and useful changes in VAS and KPS parameters.

Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts

Existing clinical studies have not proven which graft is to be preferred in anterior cruciate ligament (ACL) reconstruction. In recent years, bone-patellar tendon-bone and hamstring tendons have been the most frequently used graft types. Muscle strength deficit is one of the consequences after ACL reconstruction. The aim of this study was to evaluate possible differences in hamstring and quadriceps muscle strength and knee function 5 years after ACL reconstruction between the BPTB and the STG groups. The study group consisted of 288 patients (132 women, 156 men) with a unilateral ACL rupture who had received a BPTB (175 patients) or STG (113 patients) ACL reconstruction. Lower extremity concentric isokinetic peak extension and flexion torques were assessed at the angular velocities of 60 degrees /s and 180 degrees /s. The International Knee Documentation Committee (IKDC), the Tegner activity level, the Lysholm knee and the Kujala patellofemoral scores were also collected. Isokinetic quadriceps peak torque (percentage of the contralateral side) was 3.9% higher in the STG group than in the BPTB group at the velocity of 60 degrees /s and 3.2% higher at the velocity of 180 degrees /s and the isokinetic hamstring peak torque 2% higher in the BPTB group than in the STG group at the velocity of 60 degrees /s and 2.5% higher at the velocity of 180 degrees /s. In both groups the subjects had weaker quadriceps and hamstring muscle strength in the injured extremity compared with the uninjured one. In the single-leg hop test (according to the IKDC recommendations) there was a statistically significant difference (P = 0.040) between the groups. In the STG group, 68% of the patients had the single-leg hop ratio (injured vs. uninjured extremity) > or =90%, 31% of the patients 75-89% and 1% of the patients <75%, while in the BPTB group the corresponding percentages were 72, 21 and 7%. However, no statistically significant differences in clinical outcome were found between the groups as determined by the IKDC, Tegner activity level, Lysholm knee and Kujala patellofemoral scores.

Training Program and Additional Electric Muscle Stimulation for Patellofemoral Pain Syndrome: A Pilot Study

Bily W, Trimmel L, Mödlin M, Kaider A, Kern H. Training program and additional electric muscle stimulation for patellofemoral pain syndrome: a pilot study. Objectives To evaluate the beneficial effect of training in patients with patellofemoral pain syndrome (PFPS) and influence of additional electric muscle stimulation (EMS) of the knee extensor muscles. Design A randomized clinical trial. Setting Supervised physiotherapy (PT) training and home-based EMS. Participants Patients (N=38; 14 men, 24 women) with bilateral PFPS. Interventions One group (PT) received supervised PT training for 12 weeks. The other received PT and EMS. The stimulation protocol was applied to the knee extensors for 20 minutes, 2 times daily, 5 times a week for 12 weeks at 40Hz, with a pulse duration of .26ms, at 5 seconds on and 10 seconds off. Maximal tolerable stimulation intensity was up to 80mA. Main Outcome Measures Patellofemoral pain assessment with visual analog scale during activities of daily life, Kujala patellofemoral score, and isometric strength measurement before and after 12 weeks treatment as well as after 1 year. Results Thirty-six patients completed the 12-week follow-up. There was a statistically significant reduction of pain in both groups (PT group, P=.003; PT and EMS group, P<.001) and significant improvement of the Kujala score in both groups (PT group, P<.001; PT and EMS group, P<.001) after 12 weeks of treatment with improvement of function and reduction of pain at the 1-year follow-up. The difference between the 2 treatment groups was statistically not significant. We could not measure any significant change in isometric knee extensor strength in either group. Conclusions A supervised PT program can reduce pain and improve function in patients with PFPS. We did not detect a significant additional effect of EMS with the protocol described previously.

Multifragment fracture of the patellar apex: basket plate osteosynthesis compared with partial patellectomy

The purpose of the present study was to evaluate and compare the long-term results of operative treatment of a multifragment fracture of the inferior patellar pole by basket plate osteosynthesis and partial patellectomy. We retrospectively studied two groups of patients who had operative treatment of a multifragment fracture of the inferior patellar pole between 1988 and 2004. Seventy-one patients who had osteosynthesis by basket plate (Group 1) and 49 patients who had partial patellectomy (Group 2) were followed for an average of 5.3 years. The final evaluation was based on the modified Cincinnati Knee rating system test. The results were excellent or good in 90.1% patients of Group 1, and 73.5% patients of Group 2. Significant differences between the groups were noted with regard to knee pain, swallowing, level activity, compression pain, range of motion, muscular atrophy, muscular strength, and final patellofemoral score which confirms statistical analysis. The stability of the osteosynthesis by basket plate allows osseous consolidation of the fracture and permits immediate mobilization and early weight bearing. Osteosynthesis by basket plate can provide better clinical results.

Risk Factors for Pes Anserinus Tendinitis/Bursitis Syndrome

Pes anserinus tendinitis/bursitis (PATB) is a frequent cause of knee pain. Its predisposing factors are still controversial. Assess the effect of a set of demographic, clinical, somatometric, and biomechanical factors on the risk for PATB. A case control design was used to evaluate the association between clinically diagnosed PATB and the presence of diabetes; knee osteoarthritis (and its radiographic severity); obesity; knee collateral, and anteroposterior instability; and knee or hindfoot malalignment. Twenty-two consecutive, incident PATB patients were included; all were females 62.1 +/- 11.5-year-old (limits 45-82). Thirty-eight sex- and age-matched (59.8 +/- 9.4-year-old; P = 0.41) subjects were used as controls; these had asymptomatic osteoporosis (20) and a series of rheumatic syndromes (18). There was no difference in prevalence of diabetes, knee osteoarthritis, obesity, knee instability, varus knee deformity, and hindfoot malalignment between cases and controls. Furthermore, no difference in overall, lateral, medial, and patellofemoral knee osteoarthritis radiographic severity mean score was found between study groups. The presence of valgus knee deformity alone (OR: 5.2; 95% CI: 1.1-25.5), or in combination with collateral instability (OR: 6.0; 95% CI: 1.4-26.0), was identified as associated with PATB. Valgus knee deformity, alone or in association with collateral instability, seems to be a risk factor for PATB. No association was found between PATB and some conditions previously reported as predisposing factors such as diabetes, knee osteoarthritis, and obesity. PATB should be kept in mind as a highly probable diagnosis in mature women with medial knee pain and valgus knee deformity.

Ipsilateral Patellofemoral Arthroplasty and Autogenous Osteochondral Femoral Condylar Transplantation

The aim of this study was to report the results of ipsilateral patellofemoral arthroplasty and autologous osteochondral transplantation for patellofemoral arthritis and focal full-thickness chondral defects of the femoral condyles. The size of the condylar cartilage defects ranged from as small as 10 × 9 mm to as big as 24 × 7 mm. The mean Knee Society function score improved from 49 to 93, and the clinical score improved from 47 to 95. The mean patellofemoral pain score improved from 12 to 49, and the patellofemoral function score increased from 16 to 42. There have been no radiographic signs of progressive tibiofemoral cartilage degeneration. Combining patellofemoral arthroplasty and autologous osteochondral transplantation is a reasonable short-term approach to this condition.

A New Patellofemoral Scoring System for Total Knee Arthroplasty

Patellofemoral complications after total knee arthroplasty (TKA) can result in substantial dissatisfaction with the procedure for some patients. In assessing outcomes of TKA, however, there is often a discrepancy between patellofemoral symptoms and the results obtained by conventional scoring and radiographic analysis. We asked whether a new scoring system and weightbearing radiographic view would more accurately represent patellofemoral kinematics and explain related complications. Sixty-nine patients (100 knees) who underwent posterior-stabilized TKA between 1994 and 1997 were included for clinical and radiographic evaluation. A new patella score was developed to rapidly determine complications, ranged from 0 to 100 points, and included ratings for subjective and objective aspects of TKA. A new weight-bearing axial radiographic view was devised by positioning the standing patient in a semisquatted position. Measurements for patella alignment (tilt and subluxation) were performed. Preoperative Knee Society knee and function scores were 43 +/- 5 points, and 39 +/- 15 points, respectively. Postoperatively, scores increased to 93 +/- 8 and 89 +/- 8 points, respectively. The patella score averaged 89 +/- 8 points and showed satisfactory interobserver variability. The new weightbearing radiographic view demonstrated sources of patellofemoral symptoms. We report a new scoring system and weightbearing view that are easy to use and more accurately represent patellofemoral kinematics than do conventional methods of analysis.

Trochlear osteotomy for patellar instability: satisfactory minimum 2-year results in patients with dysplasia of the trochlea

Trochlear dysplasia is a predisposing factor for recurrent patellar instability. We evaluated the results of an anterior lateral femoral condyle open wedge osteotomy for treating patellar instability. A total of 16 consecutive patients (19 knees) with symptoms of recurrent patellar instability and trochlear dysplasia identified using a true lateral radiograph of the knee underwent an anterior lateral femoral osteotomy. Outcomes were documented at 2 years minimum follow-up using the Lysholm scale, the patellofemoral score, WOMAC score and standard conventional radiographs. In 17 knees, patients reported good improvement in stability (no dislocations) and most patients had a marked improvement in pain and functional scores at follow-up (mean follow-up 51 months). No serious complications occurred. Anterior femoral osteotomy of the lateral condyle appears to be a satisfactory and safe method for treating patients with patellofemoral joint instability caused by trochlea dysplasia. In selected cases this procedure can be used to correct trochlea dysplasia. In our opinion, the key to a successful treatment of patellofemoral instability is to successfully distinguish the anatomic deficiencies and to correct the anatomical abnormality.

Randomized prospective study of ACL reconstruction with interference screw fixation in patellar tendon autografts versus femoral metal plate suspension and tibial post fixation in hamstring tendon autografts: 5-year clinical and radiological follow-up results

Patellar tendon graft has been the most frequently used material in anterior cruciate ligament (ACL) reconstruction, but the hamstring tendons have been increasingly used as well; however, which graft is to be preferred is not adequately supported by existing clinical studies. In this prospective randomized clinical trial, the study hypothesis was that the hamstring tendons are equally good graft material as the patellar tendon in ACL reconstruction. Ninety-nine patients with laxity due to a torn ACL underwent arthroscopically assisted reconstruction with graft randomization according to their birth year to either patellar tendon with metal interference screw fixation or double looped semitendinosus and gracilis tendons with fixation similar to the Endobutton technique using a titanium metal plate suspension proximally and screw-washer postdistally. Excluding preoperative Lysholm knee score, there were no significant differences between the two groups in the preoperative and operative data. A standard rehabilitation regimen was used for all the patients, including immediate postoperative mobilization without a knee brace, protected weight bearing for 2 weeks, and return to full activity at 6-12 months postoperatively. Forty patients in the patellar tendon group and 39 patients in the hamstring tendon group were available for clinical evaluation at median 5 years after surgery (ranges 3 years 11 months-6 years 7 months). The results revealed no statistically significant differences with respect to clinical and instrumented laxity testing, isokinetic muscle torque measurements, International Knee Documentation Committee ratings, Lysholm (knee score), Tegner (activity level) and Kujala patellofemoral knee scores. There was an enlargement of the drill tunnels, statistically more in the hamstring tendon group, but no increase from 2 to 5 years in either group. Narrowing of the joint spaces (IKDC measurement method) from 2 to 5 years postoperatively was seen in both the groups, however, without difference between the two groups.

Importance of Full Flexion After Total Knee Replacement in Muslims’ Daily Lifestyle

Previous studies show that total knee replacement (TKR) patients have difficulty performing certain tasks involving deep knee flexion which are part of activities of daily living (ADL). Muslims’ lifestyles heavily depend on the ability to fully flex the knee, and many daily activities, such as praying, social encounters (attending the Sheikh’s majlis), dining or even using the hole bathroom, are carried out on the ground. The LPS Flex implant has been designed to accommodate this by giving up to 165 degrees of flexion. One-thousand and thirty-two (1032) TKRs were performed on patients diagnosed with osteoarthritis using the LPS Flex mobile bearing implant over a five year period with a minimum of 1 year post-operative follow up. The results were then compared to a series obtained from the Zimmer Feedback database which is managed independently by the Audit and Research Office, Department of Orthopaedic and Trauma Surgery, University of Dundee, Dundee, Scotland, United Kingdom. 44% of pre-op cases had full flexion as per our set criteria. There were no apparent differences in patello-femoral pain levels, complications or Knee Society score despite the fact that our patients had, on average, an increase in maximum flexion along with an increase in functional ability. The knee score failed to assess this improved functionality of patients who had full flexion; a new diagnostic method is therefore needed. The results indicate that the implant allows patients to maintain a high degree of flexion and function post-operatively, with few complications.

Inferior Patellar Pole Avulsion Fractures: Osteosynthesis Compared with Pole Resection

The ideal treatment for avulsion fractures of the inferior pole of the patella has not yet been identified. The options include (1) internal fixation of the pole fragment and (2) resection of the avulsed fragment and repair of the patellar ligament to the patella. We are not aware of any previous study in which the results of internal fixation have been compared with those of pole resection. The purpose of the present study was to compare the long-term results of internal fixation (with use of a basket plate) with those of pole resection. We retrospectively studied two groups of patients who had had operative treatment of an avulsion fracture of the inferior patellar pole between 1990 and 1997. Fourteen patients had had internal fixation with a basket plate, and fourteen had had pole resection with patellar ligament repair. Eleven patients who had had internal fixation (Group A) and thirteen patients who had had pole resection (Group B) were followed for an average of 4.6 years. The final evaluation was based on the patellofemoral score, and the patellar height was measured radiographically. The average patellofemoral score (maximum, 100 points) was 94.1 points in Group A and 81.2 points in Group B. Significant differences between the groups were noted with regard to knee pain, level of activity, and range of motion. Normal patellar height was found in ten of eleven patients in Group A and in three of thirteen patients in Group B. Patella baja was significantly associated with a poor functional outcome. In patients who have sustained an avulsion fracture of the inferior patellar pole, the normal height of the patella can be maintained by preserving the patellar pole. In contrast with pole resection, which requires postoperative immobilization, internal fixation with a basket plate allows for immediate mobilization and early weight-bearing. The present study indicates that internal fixation with use of a basket plate can provide better clinical results.

Electric muscle stimulation of the quadriceps in the treatment of patellofemoral pain

Callaghan MJ, Oldham JA. Electric muscle stimulation of the quadriceps in the treatment of patellofemoral pain. Arch Phys Med Rehabil 2004;85:956–62. Objective To compare a commercially available electric muscle stimulation regimen with a novel form of stimulation for the rehabilitation of the quadriceps muscle, in patients with patellofemoral pain syndrome. Design Double-blinded randomized trial with a parallel control group and stratified randomization. Setting Home-based rehabilitation program assessed in research center. Participants Eighty patients (47 women, 33 men) with patellofemoral pain syndrome. Interventions One group (EMPI) received 1 uniform constant frequency component of 35Hz. The other (EXPER) group received an experimental form of stimulation that contained 5 simultaneously delivered frequency components of 125, 83, 50, 2.5, and 2Hz. Stimulation was applied to the quadriceps muscles of the affected leg for 1 hour daily for 6 weeks, a total of 42 treatments. Main outcome measures Lower-limb isometric and isokinetic torque, quadriceps fatigue, knee flexion, patellar pain, a step test, quadriceps cross-sectional area, and Kujala patellofemoral score for pain before and after treatment. Results Seventy-four patients (43 women, 31 men) completed the trial. Patients in both groups showed significant improvements in all outcomes ( P<.05). No significant differences existed between the 2 stimulators in any outcome ( P>.05) except for quadriceps cross-sectional area ( P=.023). Conclusions One form of stimulation was just as efficacious as the other in improving subjective and objective measures.

Relationship between knee range of motion and Kellgren-Lawrence radiographic scores in knee osteoarthritis.

To investigate the relationships between the joint range of motion and Kellgren-Lawrence radiographic scores of knee joint compartments in patients with knee osteoarthritis. Forty knees of 20 consecutive bilateral, primary knee osteoarthritis patients were examined in the study. Maximal flexion, extension, and internal and external rotation were assessed using a goniometer. Kellgren-Lawrence radiographic scores were determined for medial tibiofemoral, lateral tibiofemoral, and patellofemoral compartments of the knee joint on lateral, tangential, and standing anteroposterior radiographs. Statistically significant negative correlations were found between the range of motion and radiographic scores. Specifically, internal rotation was correlated with lateral compartment scores (r = -0.439, P < 0.01), and external rotation and flexion were correlated with medial compartment scores (r = -0.361, P < 0.05; r = -0.338, P < 0.05; respectively) [corrected]. Extension values were correlated with patellofemoral ( = -0.533, < 0.01), medial (r = -0.456, P < 0.01), and lateral (r = -0.327, P < 0.05) compartment scores. A clear relationship is present between joint range of motion and Kellgren-Lawrence radiographic scores in knee osteoarthritis patients. Examination of the joint range of motion can give information about the compartmental distribution of the disease and help the physician focus on the compartment or compartments involved when performing diagnostic and therapeutic procedures. Evaluation of the compartments of the knee joint in radiographs can be informative about the joint range of motion in knee osteoarthritis.

Functional outcome after tibial tubercle transfer for the painful patella alta.

Twenty-five patients with painful patella alta without symptomatic subluxation were identified in a prospective database. All patients had a distal tibial tubercle transfer and preoperative knee arthroscopy. The mean postoperative followup was 2.4 years. These patients were matched with healthy volunteers. Patellofemoral scores using the scoring systems of Kujala et al and Lysholm and Gillquist were collected prospectively. The Short Form-36 health survey and the Western Ontario and McMaster Universities Osteoarthritis Index were used postoperatively. Significant improvement in the patellofemoral scores was documented postoperatively; however, the healthy volunteers had significantly higher patellofemoral scores when compared with the patients who were treated surgically. For the three Short Form-36 survey parameters based on physical health (physical functioning, role physical, and bodily pain), there were no statistically significant differences between the patients and the United States age-matched norms; data are available in the Short Form-36 survey manual. Patients with Grade 2 chondromalacia (fissuring and fragmentation less than 1.25 cm) had significantly better scores in pain and function domains of the Western Ontario and McMaster Universities Osteoarthritis Index compared with patients with Grade 3 (fissuring and fragmentation greater than 1.25 cm) and Grade 4 (erosion down to bone) changes. Distal tibial tubercle transfer is a beneficial procedure for treating patients with painful patella alta.

A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p &lt; 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p &lt; 0.01) and Lysholm scores (p &lt; 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p &lt; 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial.

Reconstruction of the anterior cruciate ligament: comparison of outside-in and all-inside techniques.

The aim of this prospective study was to compare two arthroscopic techniques for reconstructing the anterior cruciate ligament, the "outside-in" (two incisions) and the "all-inside" (one incision) techniques. The results...

Anteromedial tibial tubercle transfer in patients with chronic anterior knee pain and a subluxation-type patellar malalignment.

We performed a prospective analysis of 29 Fulkerson anteromedial tibial tubercle transfers in patients with chronic anterior knee pain. The average followup was 32 months (range, 25 to 44). Fourteen patients (Group 1) had subluxation-type malalignment (congruence angle > 20 degrees, tilt angle > 8 degrees) and were treated with an isolated anteromedial tibial tubercle transfer. Fifteen patients (Group 2) had combined subluxation and tilt malalignment (congruence angle > 20 degrees, tilt angle < 8 degrees) and underwent anteromedial tibial tubercle transfer combined with a lateral release. Pre- and postoperative evaluations included clinical and radiographic examinations, Lysholm and Kujala patellofemoral scores, and standing-alignment computed tomography scans in 15 degrees of flexion taken transversely at the midpatellar. In all but one patient a dramatic improvement in Lysholm and Kujala scores was noted. The congruence angle improved in all patients except one, with an average improvement of 16 degrees in Group 1 and of 14 degrees in Group 2. The tilt angle remained relatively unchanged (change, -0.5 degree) in Group 1, but it improved by 11 degrees in Group 2. We conclude that an isolated anteromedial tibial tubercle transfer can consistently improve patellar subluxation and, when combined with a lateral release, can improve patellar subluxation and tilt, resulting in improved functional scores for patients with chronic anterior knee pain.

Psychophysiological significance of temporal order in brain chaos

Bily W, Trimmel L, Mödlin M, Kaider A, Kern H. Training program and additional electric muscle stimulation for patellofemoral pain syndrome: a pilot study.To evaluate the beneficial effect of training in patients with patellofemoral pain syndrome (PFPS) and influence of additional electric muscle stimulation (EMS) of the knee extensor muscles.A randomized clinical trial.Supervised physiotherapy (PT) training and home-based EMS.Patients (N=38; 14 men, 24 women) with bilateral PFPS.One group (PT) received supervised PT training for 12 weeks. The other received PT and EMS. The stimulation protocol was applied to the knee extensors for 20 minutes, 2 times daily, 5 times a week for 12 weeks at 40Hz, with a pulse duration of .26ms, at 5 seconds on and 10 seconds off. Maximal tolerable stimulation intensity was up to 80mA.Patellofemoral pain assessment with visual analog scale during activities of daily life, Kujala patellofemoral score, and isometric strength measurement before and after 12 weeks treatment as well as after 1 year.Thirty-six patients completed the 12-week follow-up. There was a statistically significant reduction of pain in both groups (PT group, P=.003; PT and EMS group, P<.001) and significant improvement of the Kujala score in both groups (PT group, P<.001; PT and EMS group, P<.001) after 12 weeks of treatment with improvement of function and reduction of pain at the 1-year follow-up. The difference between the 2 treatment groups was statistically not significant. We could not measure any significant change in isometric knee extensor strength in either group.A supervised PT program can reduce pain and improve function in patients with PFPS. We did not detect a significant additional effect of EMS with the protocol described previously.