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Effectiveness of elastic resistance in rehabilitation of patients with patellofemoral pain syndrome: what is the evidence?
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PMID:  23016008     Owner:  NLM     Status:  PubMed-not-MEDLINE    
CONTEXT: Patellofemoral pain syndrome (PFPS) is associated with muscle imbalance at the knee and hip. Therapeutic exercise is effective at reducing pain associated with PFPS.
OBJECTIVE: To identify and analyze clinical trials of elastic resistance in patients with PFPS to determine its efficacy.
DATA SOURCES: PubMed, CINAHL, and PEDro databases were searched for terms relevant to PFPS rehabilitation in patients aged 12 to 40 years.
STUDY SELECTION: Only peer-reviewed clinical trials lasting at least 4 weeks and specifying the use of elastic resistance in their protocols were included.
DATA EXTRACTION: Eight eligible studies were analyzed for design, sample, intervention, outcomes, and clinical application.
RESULTS: The studies included in this review lacked high-quality design, often using exercise as a "quasi-control" condition. Most studies did not provide specific exercise prescription or progression. Although participants in each study reported significant improvements in pain, deficiencies in scientific design limit the conclusion.
CONCLUSION: Elastic resistance exercise may reduce pain and improve function and strength in patients with PFPS.
Phil Page
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Sports health     Volume:  3     ISSN:  1941-0921     ISO Abbreviation:  Sports Health     Publication Date:  2011 Mar 
Date Detail:
Created Date:  2012-09-27     Completed Date:  2012-09-28     Revised Date:  2013-05-30    
Medline Journal Info:
Nlm Unique ID:  101518422     Medline TA:  Sports Health     Country:  United States    
Other Details:
Languages:  eng     Pagination:  190-4     Citation Subset:  -    
Department of Kinesiology, Louisiana State University, Baton Rouge, Louisiana.
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Journal Information
Journal ID (nlm-ta): Sports Health
Journal ID (iso-abbrev): Sports Health
Journal ID (publisher-id): SPH
Journal ID (hwp): spsph
ISSN: 1941-7381
ISSN: 1941-0921
Publisher: SAGE Publications, Sage CA: Los Angeles, CA
Article Information
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© 2011 The Author(s)
epub-ppub publication date: Month: 3 Year: 2011
Print publication date: Month: 3 Year: 2011
Volume: 3 Issue: 2
First Page: 190 Last Page: 194
ID: 3445141
PubMed Id: 23016008
DOI: 10.1177/1941738111398595
Publisher Id: 10.1177_1941738111398595

Effectiveness of Elastic Resistance in Rehabilitation of Patients With Patellofemoral Pain Syndrome : What Is the Evidence?
Phil Page, PhD, PT, ATC, CSCS, FACSM*
Department of Kinesiology, Louisiana State University, Baton Rouge, Louisiana
*Address correspondence to Phil Page, Louisiana State University, Department of Kinesiology, Attn: Athletic Training, 112 Huey P. Long Fieldhouse, Baton Rouge, LA 70803 (e-mail:

Patellofemoral pain syndrome (PFPS) is characterized by retropatellar or peripatellar pain with walking, running, ascending or descending stairs, squatting, or prolonged sitting. The cause of PFPS remains unclear, although it is typically associated with muscle imbalances. Females are twice as likely as males to develop PFPS.4

Traditionally, PFPS was thought to result from weakness of the vastus medialis muscle, theoretically creating a more laterally tracking patella. The flexibility of the hamstrings, quadriceps, and gastroc/soleus complex has been associated with PFPS.18,24,26 Researchers have suggested that PFPS is related to muscular weakness at the hip, causing lateral patellar tracking caused by poor eccentric strength and control of hip abductors and external rotators.14,23 Females appear to be predisposed to proximal influences more so than males.19

Elastic resistance exercises are commonly prescribed for rehabilitation17 in osteoarthritis,16,22 total knee replacement,21 anterior cruciate ligament reconstruction,5 and as part of a multimodal approach to PFPS.2 Despite the widespread clinical application of elastic resistance exercise, few studies have investigated its efficacy in treating PFPS. The purpose of this systematic review is to analyze clinical trials of elastic resistance in PFPS.

Data Sources and Extraction

An online search of 3 databases (PubMed, CINAHL, and PEDro) was performed in August 2010 for studies published since 1970. Search terms included patellofemoral, rehabilitation, exercise, knee pain, Thera-hand, and elastic in a variety of combinations. Studies of knee osteoarthritis, Osgood-Schlatter disease, patella tendonitis/tendinosis, patella dislocation, plica, and meniscus were excluded. Clinical trials greater than 4 weeks in length were scanned for the use of elastic resistance in the protocol. The study design, sample, intervention, outcomes, and clinical implications were reviewed (Table 1). In addition, PEDro scores (, where available, were determined (Table 2).


Eight clinical studies met the criteria for this review.

Study Design

Seven studies were randomized prospective studies; 1 was retrospective.7 Only 1 study13 used a nonexercising control group. Most studies used a “quasi-control” design: The exercise group was the control limiting the conclusions (Table 2). Two studies received PEDro scores of 7 (out of 10),11,15 generally limited by blinding of raters and subjects.


All but 1 study15 had 20 or more participants. Adequate power was found in 3 studies.3,11,20 The analyzed studies had similar inclusion and exclusion criteria. One study7 investigated patients with “lateral patellar compression syndrome,” with diagnostic criteria similar to PFPS. Most samples included both males and females, although all studies had a greater number of females, representative of the PFPS population.


All interventions lasted 4 to 12 weeks, with most lasting 8 weeks. Only 2 studies specified the intensity and volume of the elastic resistance exercise progression.3,20 Overall, well-defined protocols with elastic resistance exercises were lacking, limiting the replication or clinical application of the study and threatening external validity. Most studies combined multiple modes of exercise within groups, such as stretching, balance, and cardiovascular exercise, precluding analysis of exercise mode effectiveness. Elastic exercise was separately evaluated in 2 studies.15,20 Thomee20 found no difference between the elastic and isotonic groups. Nakagawa15 noted some additional benefit to adding specific elastic resistance exercises for the hip.

Two studies on healthy participants showed that elastic resistance exercises are as effective as isotonic resistance exercises for muscle activation and improving strength.1,6 Adding elastic resistance to terminal knee extension exercise significantly increases vastus medialis obliquis and vastus lateralis activity.25 Hopkins et al10 analyzed leg pulls with surface electromyogram, noting higher levels of vastus medialis activity.11


All studies reported significant reduction in pain regardless of the exercise intervention. Electrical stimulation, orthotics, patellar taping, biofeedback, and arthroscopic surgery had little to no additional benefit. Four studies assessed functional outcomes,3,9,11,13 reporting significant improvements over time without between-group differences. Three studies11,13,20 found significant improvements in strength, whereas 1 study did not.3 One study15 found improvements in quadriceps strength but not at the hip.


Elastic resistance exercise appears to be as effective as other modes of resistance for PFPS. Electromyogram studies have confirmed that elastic resistance is comparable to isotonic exercise.1,6

The overall lack of blinding and suitable control groups reduces the ability to detect differences based on elastic resistance alone. Unfortunately, none of the reviewed studies used isolated elastic resistance exercise as an independent variable in PFPS interventions.

The cause of PFPS is not well established; patients may exhibit different impairments (ie, hip weakness versus knee weakness). Stratification by impairment may help improve clinical decision making for therapeutic exercise prescription. A systematic review of females with PFPS showed hip weakness, indicating strong evidence for decreased strength in hip external rotation, abduction, and extension compared with controls.27 Eccentric hip abduction and adduction are weaker in females with PFPS, whereas rotation strength appears normal.12


In summary, exercise interventions including elastic resistance in patients with PFPS are effective at reducing pain and improving function and strength.


One or more of the authors has declared a potential conflict of interest: Dr Page is employed by the Hygenic Corporation, which manufactures Thera-Band elastic resistance.

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[TableWrap ID: table1-1941738111398595] Table 1. 

Clinical exercise trials for patellofemoral pain syndrome (PFPS) using elastic resistance.a

Study: Design and Sample Intervention /Elastic Exercises Outcomes Implications
Bily et al3
Randomized, quasi control, prospective; n = 38, bilateral PFPS 3 months, 2 groups
Group 1: Supervised physical therapy (Thomee20 protocol)
Group 2: Supervised physical therapy + electrical stimulation
Both groups performed 4 direction kicks with tubing. Specified elastic resistance intensity and progression
↓ Pain,* both groups
↑ Functional score,* both groups
Strength, no significant difference, both groups
No significant difference between groups
Supervised physical therapy including elastic resistance effective at reducing pain and improving function without increasing strength; electrical stimulation provides no additional benefit
Doucette and Goble7
Pretest/posttest, retrospective; n = 28, lateral patellar compression syndrome Avg: 8-week treatment
Individualized, not standardized
Tubing exercises included seated leg press, single and double dips, resisted walking, knee flexion/extension. No specific prescription or progression of elastic exercises
84% pain-free Individualized physical therapy program including elastic resistance eliminated pain in 84% of PFPS patients; cause and effect cannot be established because of design
Eng et al8
Randomized, quasi control, prospective; n = 20 young females, PFPS and poor foot biomechanics 8 weeks, 2 groups
Group 1: Exercise
Group 2: Exercise + orthotics
Both groups progressed to straight leg raise exercise with weights or elastic looped around ankles; no specific prescription or progression of elastic exercises
↓ Pain* both groups
Exercise + orthotics = significantly more improvement
Exercise including elastic resistance significantly decreased pain in young females with PFPS; when elastic resistance is combined with orthotics, the reduction is significantly greater
Harrison et al9
Randomized, quasi control, prospective; n = 113, PFPS 1 month, 3 groups
Group 1: Home exercise program
Group 2: Exercise + manual therapy
Group 3: Exercise + taping and biofeedback
All groups suggested to use tubing hip adduction exercise; no specific prescription or progression of elastic exercises
↓ Pain,* all groups at 12 months
↑ Clinical score,* all groups at 12 months
↑ Function,* all groups at 12 months
Taping and biofeedback more effective than exercise and manual therapy at 1 month
Home exercise including elastic resistance exercise effective at reducing pain and improving function over long term; short-term relief better when exercise combined with patellar taping and biofeedback
Kettunen et al11
Randomized, quasi control, prospective; n = 56, chronic PFPS 8 weeks, 2 groups
Group 1: Home exercise program
Group 2: Home exercise program + arthroscopic surgery
Both groups performed elastic band kicks, leg pulls, and terminal knee extension; no specific prescription or progression of elastic resistance intensity levels (only repetitions are provided)
↓ Pain,* both groups
↑ Functional score,* both groups
↑ Cost,* surgical group
Home exercise program including elastic resistance exercise is effective at reducing pain and improving outcomes in PFPS; arthroscopic surgery provides no additional benefit and significantly increases health care costs compared with a home exercise program alone
Loudon et al13
Quasi randomized, pretest/posttest, controlled, prospective; n = 29, PFPS 8 weeks, 3 groups
Group 1: Home exercise program
Group 2: physical therapy clinic exercise
Group 3: Control
Both exercise groups performed elastic knee curls; no specific prescription or progression of elastic resistance intensity levels (only repetitions are provided)
↓ Pain,* both exercise groups
↑ Strength* and functional score,* both exercise groups
↓ Pain* in physical therapy group compared to home exercise group
Both home exercise and supervised physical therapy exercises including elastic resistance decrease pain and improve function and strength
Nakagawa et al15
Randomized, quasi control, prospective; n = 14, PFPS 6 weeks, 2 groups, home exercise program
Group 1: Quad exercises
Group 2: Quad + hip exercises
Group 2 included hip rotation, trunk stabilization, and lunges with elastic resistance
↓ Pain,* group 2
↑ Muscle activation,* group 2
↑ Knee strength,* both exercise groups
Hip strength, no significant difference, both groups
Additional hip exercises including elastic resistance are more effective at reducing pain in PFPS compared with knee exercise alone, without an increase in hip strength; however, sample size was small
Randomized, prospective, no control; n = 40 females, PFPS 12 weeks
Group 1: Isometric exercise (elastic)
Group 2: Eccentric exercise
Isometric group performed 4-direction elastic band kicks on both legs. Specified elastic resistance intensity and progression
85% pain-free across all participants
↓ Pain,* both groups
↑ Strength,* both groups
Both eccentric and isometric exercise including elastic resistance reduced pain and improved strength in females with PFPS; however, cause and effect cannot be established, because no control group was included

*Statistically significant.

[TableWrap ID: table2-1941738111398595] Table 2. 

PEDro scores from clinical trials using elastic resistance to treat patellofemoral pain syndrome.

PEDro Attribute Bily et al3 Doucette and Goble7 Eng et al8 Harrison et al9 Kettunen et al11 Loudon et al13 Nakagawa et al15 Thomee20
Random allocation
Concealed allocation
Baseline comparability
Blind subjects
Eligibility criteriaa
Blind therapist
Blind assessor
Adequate follow-up
Intention-to-treat analysis
Between-group comparison
Point estimates and variability
Total PEDro score 5 NA 3 5 7 2 7 5

aNot factored into total score.

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Keywords: patellofemoral pain, elastic resistance, therapeutic exercise.

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