Patellofemoral Pain Syndrome is the most common knee problem in active adults and minors.Dye believes that PFPs are an enigma in orthopedics because are the most difficult disease to treat in orthopedics. Historically, clinicians have used a variety of treatments, many of which have had little, if any, supporting evidence. Recently, more attention has been focused on evidence-based medicine, which Sackett defines as the use of clear, judicious, and conscientious application of the strongest current evidence in the treatment of a patient to determine a treatment. This does not mean that clinicians do not respect prior clinical experience and practice when making treatment decisions. Instead, the emphasis is on combining individual clinical expertise with the best external clinical evidence available from systematic research. Murray concluded that clinicians in sports injuries are treating patellofemoral pain in only 44% of patients based on personal experience. More clinicians used initial clinical research evidence in only 24% of patients. This result provides evidence that primary data are rarely used in the clinical management of this condition. Clinicians believe that patellofemoral pain arises from excessive pressure on the patellofemoral surface due to abnormal patellar trajectory. Factors contributing to abnormal patellar trajectory include weak quadriceps, quadriceps imbalance, and altered foot motion mechanics. According to clinical theory, the treatment of patellofemoral joint pain is to improve patellar trajectory to reduce abnormal patellofemoral joint stress. Many patients respond well to conservative treatment evidence also supports the effectiveness of exercise methods for patellofemoral pain.Kettunen recently compared the outcomes of patients with chronic patellofemoral pain between arthroscopic surgery + exercise and exercise alone, and they found that all of the patients, whether treated surgically or conservatively, had greatly improved function. The researchers described a number of conservative treatments. Medialis obliqua head alone or quadriceps exercises were chief among them. The theory behind medial muscle oblique head exercises alone is that the lateral portion of the muscle is stronger than the medial, tractioning the patellar trajectory to shift laterally. However the evidence questions the effectiveness of medial muscle oblique head exercises. Quadriceps exercises remain the gold standard of treatment for patellofemoral joint pain. Other treatments in conjunction with patellar taping, patellar braces, and knee braces further improve patellar trajectory. While many patients with pain relief used these techniques, they also performed quadriceps exercises. Also, the findings of these studies are very limiting, and the additional benefit, if any, is the role of the patellar strap or patellar support in quadriceps exercises. Others believe that the etiology of patellofemoral joint pain is an increase in the Q-angle leading to an increase in outward force this is a prerequisite factor for an outward patellar trajectory. This theory has not been confirmed in research and many studies have found no correlation between increased Q angle and patellofemoral joint pain. The reason for these findings may reflect the poor reliability and validity of this method. Another reason is that this examination is performed at rest. However, many patients have an increased Q angle under power states such as walking single leg accounted for, jumping, and running. To address the shortcomings of this static method, Power used a dynamic approach to Q-angle measurement. He concluded that increased external and internal rotation of the femur would have an effect on knee valgus and lateral patellofemoral joint pressures under weight bearing. Using dynamic MRI, preliminary evidence suggests that patellofemoral pain patients have increased patellar internal rotation in relative patellar stabilization when standing on one foot. These findings have a theoretical basis for cooperative exercise in patients with patellofemoral pain. Foot mechanics of the affected lower extremity also dynamically images the Q-angle.Tiberio suggests that excessive pronation of the talocrural joint leads to increased internal rotation of the tibia. Excessive tibial internal rotation requires an increase in femoral internal rotation during weight-bearing activities. researchers such as Lee reported a relationship between increased lateral patellofemoral joint pressures and excessive internal rotation of the femur. Based on these findings, the researchers evaluated hip exercises and ankle braces for the treatment of patellofemoral joint pain. Quadriceps exercises were the most common treatment. Although this method is considered the gold standard, many patients still have pain and dysfunction. These patients experience pain relief but not complete pain relief, reflecting the need for other evidence-supported treatments. Therefore, the purpose of this review is to provide the most up-to-date evidence for conservative treatment. We would like clinicians to base the treatment of patellofemoral joint pain on the information gained from this review. METHODS Electronic searches were conducted in PUBmed, CUNAHL, and other databases from January 2000 to December 2010 using the following keywords patellofemoral joint pain, anterior knee pain, quadriceps exercises, quadriceps strengthening, hip exercises, hip strength, support bands, braces, orthopaedic braces, and a total of 878 tablets of articles were obtained from the above text. For study selection, the authors chose evidence and evidence related to the current operation, using articles that were peer-reviewed published in the last 10 years and interventions greater than 4 weeks. Studies were not in English and there were no exclusions from cited literature or abstracts. Each researcher began by identifying potential literature through the abstract then entered the study by reading the literature. Researchers discussed their search findings to identify relevant literature and through this basis a total of 22 pieces of literature were included. Data Extraction The following data was extracted from each article, number of cases, duration of intervention, method of intervention, and pain outcomes. The authors also confirmed the study design for each study. Data analysis, each study was conducted through the method prescribed by Ebell et al. They categorized the level of evidence into 3 levels, this method was used because of the intersection of the patients and the permission to use the level of evidence to conduct the study. According to Philadelphia guidelines for operational levels of clinical evidence. Pain with this PFPS-related injury was present in all of the identified studies. Therefore pain alteration was used as an essential element in assessing and comparing the results of the studies. From the limited data obtained from each article, VAS alterations were calculated by the best calculation method for common pain, and the effective number of cases for each study was also reported Effective numbers were interpreted by the following methods: less than 0.4, moderate 0.41-0.70, and very large 0.7. Outcomes Hip Strengthening Exercise Five studies focused on hip exercise for patellofemoral joint pain, only one study was at level 3 and the others all reached level 2 and provided sufficient evidence to calculate effective change. The results of all of the studies showed that patients who participated in hip muscle exercises experienced moderate reductions. Additionally, Tyler achieved very significant improvements in pain including hip extension and hip flexion exercises. Quadriceps Strengthening Exercises Ten studies met the above requirements, all at the level of 2. Findings from many of the studies showed at least moderate to upper improvements in pain if patients performed non-weight-bearing latter weight-bearing quadriceps exercises. Although Syme et al. found that the control group also received a 17% improvement in pain without receiving the intervention. There was a slight improvement in this difference. In contrast, Bakhtiary and Fatemi reported poor results in patients performing supine leg raises and single-leg standing squats. It is worth noting that these patients exercised insufficiently compared to other studies. Some researchers have combined quadriceps point stimulation, biofeedback, or co-worker hip abduction activities all of which have resulted in increased quadriceps activity.Loudon reported an average improvement in pain, which does not allow us to assess the degree of effectiveness. However they reported an improvement in pain of between 43%-59%. Patellar banding 3 studies focused on treatment with patellar banding. crossley is a level 1 level. These studies were randomized controlled comparisons of specific exercises and orthopedic patellar taping, and a placebo control group. Patients in the treatment group had significant pain reduction, although the placebo group had moderate pain improvement.Whittingham found that quadriceps exercises combined with patellar bands resulted in more than moderate improvement regardless. Patellar Brace and Knee Brace Both studies were at the level of 2. Lun found moderate improvement with either a patellar band or knee brace. In contrast, the following studies considered quadriceps exercises, they found limited results with home exercises and did not support performing combined knee brace combined home exercises. DISCUSSION Discussion Patellofemoral joint pain is the most common and challenging knee pathology. Unlike ACL injuries, which have a specific mechanism of injury and treatment, patients receive a wide variety of treatments. Overall, this review reviews the extant evidence showing that many treatments are beneficial for this group of patients. However quadriceps exercises remain the most important treatment and this study supports additional hip muscle exercises. The evidence suggests that other interventions such as the use of patellar straps, patellar braces, knee braces, and ankle braces are less effective compared to exercise. The following section explains these findings and provides clinical treatment. Hip Exercise Computer simulations and cadaveric models have shown that excessive hip adduction or hip internal rotation increases the stress on the lateral patellofemoral joint structures These activities increase the strength in this region. These findings led to subsequent studies examining hip function in patellofemoral pain.Souza and Power recently used conventional MRI to analyze femoral structures, muscle strength, and kinetics during running. Overall patients with patellofemoral pain showed a large internal tilt angle of the femur but no change in the anterior tilt angle of the femur. They concluded that reduced hip strength and large femoral internal tilt lead to increased lateral patellofemoral joint stress in computer simulations and cadaveric models. Stepwise regression showed that hip extension time, not femoral structure, was the only prerequisite for hip internal rotation. These findings focus on the importance of the hip muscles for controlling femoral motion and cooperation in the resultant move compounded in other studies with decreased hip strength and altered lower extremity kinetics. This review finds that hip muscle exercise benefits sufferers with patellofemoral ache. Moderate evidence supports hip abduction and external rotation exercises that may further work hip flexion and extension. Although all of the studies prescribed exercise duration showed a need to determine the duration of exercise, therefore, clinical emphasis should be placed on exercising an increased number of times, especially in those patients with high activity demands. The flaw of the articles in this review is the lack of focus on neuromuscular factors in the intensity and duration of exercise differences at the knee and hip. Preliminary evidence suggests that medial femoral muscle exercise affects hip function, and future studies should examine neuromuscular factors as well as factors that vary in hip exercise. Quadriceps Exercise The presence of diminished quadriceps strength in patients with patellofemoral pain is thought to be responsible for abnormal patellofemoral joint trajectories and patellofemoral joint excursions. Other possible influencing factors may be reset or delayed activity of the medial femoral adductors present for the lateral muscles which can cause excessive lateral patellar trajectory. So far, some researchers have conflicting findings. Even with a functional deficit in the vastus medialis, current evidence does not support exhaustive exercise of the vastus medialis alone. However, the results of quadriceps weight-bearing and non-weight-bearing functional exercises for patellofemoral joint pain are the same. It is basically believed that performing quadriceps functional exercises will improve pain. However, clinicians prefer to perform weight-bearing exercises to mimic functional activity, and the use of non-weight-bearing exercises may be just as effective, especially in patients with significant quadriceps weakness. The key point is for patients to exercise without pain. Clinicians should understand the pressures on the patellofemoral joint when exercising in both nonweight-bearing and weight-bearing states. Patellofemoral joint pressures are minimal when exercising at 90-45 degrees nonweight-bearing and when exercising at 0-45 degrees weight-bearing. Finally, the use of electrical nerve stimulation or biofeedback is not as effective as quadriceps exercises alone. Patellar taping Patellar taping is another therapeutic measure that results in improved patellar trajectory, and many times clinicians require patients to exercise after patellar taping for its pain relief and increased VMO motion. This review supports the use of patellar taping in conjunction with functional exercise as at least a short-term treatment for patellofemoral joint pain. The reason that patellar taping will reduce symptoms is unclear, although the initial theory was to improve patellar force lines, and previous studies have shown that patellar taping is ineffective for maintaining force lines or during subsequent exercise. Therefore, the benefits of patellar taping for patients may come from neuromuscular control or autosensory input at the time of use. Patellar banding may improve pain in order for patients to perform pain-free quadriceps exercises. Using MRI to assess patellar dynamics, Derasari evaluated patients with patellofemoral pain who had abnormal patellofemoral joint position or rotation in the patellofemoral joint before and after the use of patellar taping. They found that patellar taping primarily causes the patella to move underneath the femoral condyle. Increasing the patellar contact surface in the scooter would reduce patellofemoral joint stress which could partially explain the role of the patellofemoral band. As with the patellar band. Clinicians use both a patellar band and a knee brace to prevent and correct patellar force lines in the scooter. power examined pain and patellar contact area in the enucleation and patellar trajectory. They reported pain reduction in all patients with the brace and MRI showed an increase in patellar contact area. It is thought that the patellar support can move the patellar contact within the femoral scooter without sliding and thus creating agitation. These findings explain why Lun had moderate pain relief with the brace alone. The manufacturer’s theory is that the pain is due to increased pressure on the patellofemoral joint during quadriceps exercises. The brace controls the knee in the extended position allowing the patient to move painlessly during weight-bearing activities by reducing the pressure generated by the quadriceps. The patient showed no patellofemoral agitation and the brace could be adjusted to mild knee straightening requiring increased quadriceps activity. The current findings show that knee braces are effective in reducing pain. As with the patellar band, the exact mechanism of enhancement is unclear. Possible mechanisms are redistribution of patellar pressure, increased proprioception, improved neuromuscular control, and allowing patients to perform pain-free quadriceps exercises. Additional studies are needed to further compare the comparative effects of the brace alone and pain-free exercise. Although ankle braces are routinely used clinically to aid in lower extremity dynamics. Few studies have examined ankle braces for the treatment of patellofemoral joint pain within the last 10 years. More, the exact mechanism is currently unclear. No studies in this review examined the altered kinetics of ankle braces before and after their use, which also leads to an inability to analyze their mechanism of action. However, Barton found a clear relationship between foot pronation and patellofemoral pain.Boling identified increased foot navicular subluxation as a risk factor for patellofemoral pain. This finding suggests that correcting excessive pronation is beneficial in this group of patients. In contrast, reported Other studies are needed to determine if pain relief with the use of foot supports is due to altered kinetics or motion. Additional evidence is needed to confirm that patients derive benefit from foot supports. These studies show that foot supports enhance the effects of exercise. Further Research The results of this review support the continued use of quadriceps exercises and hip strengthening exercises. Although there is no data conclusively confirming that hip exercises alone are limited compared to quadriceps exercises alone. The authors found some interventions to be effective for patellofemoral pain. This review emphasizes the effectiveness of hip exercises alone or other specific interventions for patellofemoral joint pain.