Drugs used to treat the symptoms of patellofemoral syndrome have little evidence base

Heintjes EM, Berger M, Bierma-Zeinstra SMA, Bernsen RMD, Verhaar JAN, Koes BW

Published Online:

October 8, 2008

Patellofemoral pain syndrome is common among adolescents and young adults. The most common symptom is pain surrounding the kneecap when sitting with bent knees for prolonged periods of time or when performing activities like ascending or descending stairs, squatting or athletic activities. This review of pharmacological interventions showed that non-steroidal anti-inflammatory drugs (NSAIDs) may reduce pain in the short term, but overall pain did not improve after three months. There is conflicting evidence on the effect of glycosaminoglycan polysulphate. The anabolic steroid nandrolone may be effective, but associated risks demand extreme caution if used for patellofemoral pain syndrome, particularly in athletes.

Abstract (click to read)

Background:

Patellofemoral pain syndrome (PFPS) is common among adolescents and young adults. It is characterised by pain behind or around the patella and crepitations, provoked by ascending or descending stairs, squatting, prolonged sitting with flexed knees, running and cycling. The symptoms impede function in daily activities or sports. Pharmacological treatments focus on reducing pain symptoms (non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids), or restoring the assumed underlying pathology (compounds containing glucosamine to stimulate cartilage metabolism, anabolic steroids to increase bone density of the patella and build up supporting muscles). In studies, drugs are usually applied in addition to exercises aimed at building up supporting musculature.

Objectives:

This review aims to summarise the evidence of effectiveness of pharmacotherapy in reducing anterior knee pain and improving knee function in people with PFPS.

Search strategy:

We searched the Cochrane Bone, Joint and Muscle Trauma Group and Cochrane Rehabilitation and Related Therapies Field trials registers, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), PEDro (up to January 2004) , MEDLINE (1966 to January 2004), EMBASE (1988 to January 2004), and CINAHL (1982 to January 2004).

Selection criteria:

Controlled trials (randomised or not) comparing pharmacotherapy with placebo, different types of pharmacotherapy, or pharmacotherapy to other therapies for people with PFPS.

Data collection and analysis:

The literature search yielded 780 publications. Eight trials were included, of which three were of high quality. Data were analysed qualitatively using best evidence synthesis, because meta-analysis was impeded by differences in route of administration of drugs, care programs and outcome measures.

Main results:

Four trials (163 participants) studied the effect of NSAIDs. Aspirin compared to placebo in a high quality trial produced no significant differences in clinical symptoms and signs. Naproxen produced significant short term pain reduction when compared to placebo, but not when compared to diflunisal. Laser therapy to stimulate blood flow in tender areas led to more satisfied participants than tenoxicam, though not significantly.

Two high quality RCTs (84 participants) studied the effect of glycosaminoglycan polysulphate (GAGPS). Twelve intramuscular injections in six weeks led to significantly more participants with a good overall therapeutic effect after one year, and to significantly better pain reduction during one of two activities. Five weekly intra-articular injections of GAGPS and lidocaine were compared with intra-articular injections of saline and lidocaine or no injections, all with concurrent quadriceps training. Injected participants showed better function after six weeks, though only the difference between GAGPS injected participants and non-injected participants was significant. The differences had disappeared after one year.

One trial (43 participants) found that intramuscular injections of the anabolic steroid nandrolone phenylpropionate significantly improved both pain and function compared to placebo injections.

Authors' conclusions:

There is only limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS. The evidence for the effect of glycosaminoglycan polysulphate is conflicting and merits further investigation. The anabolic steroid nandrolone may be effective, but is too controversial for treatment of PFPS.

This record should be cited as:

Heintjes EM, Berger M, Bierma-Zeinstra SMA, Bernsen RMD, Verhaar JAN, Koes BW. Pharmacotherapy for patellofemoral pain syndrome. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003470. DOI: 10.1002/14651858.CD003470.pub2

Assessed as up to date:

April 30, 2004

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Primary Review Group:

Bone, Joint and Muscle Trauma Group

Health topics:

Orthopaedics & trauma > Overuse injuries

Rheumatology > Overuse injuries

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Drugs used to treat the symptoms of patellofemoral syndrome have little evidence base

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