Alice’s sciatica

Here is the testimonial of Alice who accepted to share with you her story and her experience of her sciatica. She wrote this post and allowed me to translate it in English and publish it here.

Part 1: The vicious circle

It all started in October 2018; I was 26 years old. After a hectic cycling session, I wake up overnight physically unable to stand up. A radiating pain catches me and prevents me from using my back. It was a sciatica of the left leg. I was then prescribed a treatment made of anti-inflammatory medication and a large amount of bed-rest until pain goes away (which I greatly regret). This vicious circle lasted almost 3 years with episodes: I was having medication and bed-rest every 2-3 months. Besides physical pain, invisible for others, I started feeling a real malaise. I was always wondering: “How explaining what is happening to me whereas I always have been cautious about having a perfect lifestyle?” I was a high-level athlete, I was exercising, I do not drink alcohol nor smoke … I decided I would find the mechanical cause of my symptoms.

Part 2: The end of the vicious circle and the beginning of physiotherapy

During these 3 years, I developed a fear of movement. I feared experiencing my back pain. To be safe, I avoided every activity which is wrongly thought to be dangerous: I stopped lifting heavy things, I never bended forward without bending the knees, I stopped physical activity … I avoided using my back to protect it. Despite all my precautions, I was still experiencing several pain episodes and still could not identify its cause. Until June 2021 where for the first time, anti-inflammatory medication did not help any more. I was suffering day and night, and I could barely sleep because pain was waking me up. I was then prescribed an MRI and its conclusion was that I had a disc herniation. I was then immediately referred to a specialist to have injections. The issue was that this option terrified me as one of my relatives had a bad experience with it. In consequence, I decided to get a second opinion with different doctors. One of them suggested me to try physiotherapy.

Part 3: what I learned with physiotherapy.

I did not know what physiotherapy was, but I had great expectations about it. During the first session, I learn that, as many of us, I was misinformed about back pain and that bed-rest may be unhelpful. As well as physiotherapy session, I started to progressively go back to normal life and be less cautious about using my back (I started lifting things, go back to sport …). As I was really involved in the process, I did my exercises between sessions with great diligence. I felt better but not done: my progression was really fluctuating, and I had that feeling of weakness in my left leg that never left me. I also was struggling to understand why I was not cured despite taking that therapeutic approach seriously. It was when I read a scientific paper about back pain that it finally made sense. I understood that my back pain was not necessarily linked with a mechanical factor but could also be linked with psychological factors. I realized that in one hand I was expecting too much of my physiotherapist which created an adverse pressure; and in the other hand I was doing my exercises in a robotic way without trying to feel their effects on me and hence not knowing what was good for me and what was not. As I was frustrated by not finding a mechanical cause since all these years; I kept digging in the psychological field winding up until 2018. Here I realized this year was emotionally overwhelming as I lost one of my parents, few months before the onset of my pain. As I am introverted, it may be likely that my uneasiness expressed throughout my back pain. After accepting all this, I approached my physiotherapy sessions with a new perspective: being more connected to my feelings in my body and being resilient. Since then, sessions have been more helpful.

Part 4: My life today

I am now able to cope and manage my pain, which means identify what exercises are helpful for me according to how I feel. I am not yet cured, I may never be, but I am happy to be back to an (almost) normal life!

Tennis Elbow = Lateral Elbow pain / tendinopathy LET = Epicondylalgia

Several names exist for this issue: Tennis elbow, lateral elbow pain / tendinopathy, epicondylalgia, epicondylitis … They all refer to the same diagnosis.

Is it frequent?

It is a frequent issue among 35-54 years old people. It affects 1-3% of general population with an increased risk among smokers, manual workers, or tennis players.

How long is it?

For many persons, symptoms are self-limiting. Studies show that 83 to 90% of people without any treatment improve significantly at one year, although sometimes incomplete recovery. However, 1/3 of people still experience discomfort after 1 year despite treatment. A large proportion of people experience recurrence of symptoms after initial episode. Estimates suggest that 5% of people do not respond to conservative interventions and undergo a surgery with variable outcomes.

What is it, what is happening?

Tennis elbow is multimodal, it is not only a mechanical or structural issue. Current models suggest changes in the tendon’s matrix and cells, in combination with changes of the pain system and modifications of sensory and motor system.

How is it diagnosed?

It is diagnosed through a clinical examination by reproducing symptoms loading affected tendons. Pain can be reproduced on the epicondyle with palpation, resisted contraction of extensors of wrist or middle or second finger, and gripping. An in-depth clinical examination may be required to exclude other possible causes.

Shall I undergo imaging?

MRI and Ultrasound imaging have a very good capacity to exclude this pathology but a poor capacity to identify it when signs on imaging are present. Indeed, the same changes on imagery can be found in asymptomatic people. Studies show that we find the same changes in MRI in 50% of cases and in 53% with US in asymptomatic persons! However, when symptoms are present changes can be found in 90% of cases. In addition, studies show that severity of changes on imaging are not related to severity of symptoms for this pathology and other chronic tendinopathies. Hence the fact that imagery can exclude this problem but not diagnose it.

Which factors can affect improvement?

Universal treatment efficient for every person with tennis elbow unfortunately does not exist. The fact that this issue varies greatly among individuals suggest that a tailored treatment may be more beneficial. 6 factors influencing outcomes have been identified:

  1. The stage of the problem: reactive / degenerative or in between. It may change the treatment suggested
  2. Severity of initial symptoms. When they are more intense and disabling, the long-term prognostic is not as good.
  3. When Central Sensitization (CS) is present, the prognosis worsens. CS is a complex modification of central nervous system making light stimuli very painful, with changes in temperature perception leading (among other) cold to become painful.
  4.  When shoulder or neck pain is associated, it may affect outcomes too. Neck pain is frequently associated with altered long-term results, while shoulder pain is frequently associated with altered short-term outcomes.
  5. Associated neuromuscular impairments lower prognosis. Strength deficit of extensor of wrist, grip, or all affected limb and a speed deficit and muscular reaction time of both arms in patient with unilateral tennis elbow have been reported. If these are not assessed and treated when present, they may contribute to chronicity.
  6. Psychosocial factors and work-related factors have been linked with increased risk of developing tennis elbow and with a lower one-year prognosis. They include use of tools, heavy loads, repetitive movements, activities involving strength with wrist flexion and low control on work.

In addition, we know that tendons’ health is largely affected by lifestyle. The following elements are risk factors of developing tendon issues:

  • Smoking
  • Obesity
  • High fatty food intake
  • Hish processed food intake
  • Physical inactivity
  • High cholesterol levels
  • Diabetes
  • Sudden changes in activity levels

What are available treatment options?

Pharmacotherapy: Results of oral nonsteroidal anti- inflammatory medication in the treatment of tennis elbow are conflicting. They are speculated to be more efficient in reactive phase.

Corticosteroid medication: We have strong evidence that corticoid injection therapy allows a short-term pain relief but lead to poorer outcomes at 6 month and 1 year and an increase in recurrences when compared to no treatment or physiotherapy. In addition, adding a multi- modal physical therapy program do not ameliorate the late delay in recovery or recurrence observed after a single corticosteroid injection. Therefore, corticosteroid injections are not recommended as a first line treatment.

Antidepressant or antiepileptic drugs may be appropriate for patients with severe pain where central sensitization is suspected, although no studies have been conducted in this population to date but it has on other groups like people with fibromyalgia.

Prolotherapy PRP and nitric oxide patches have demonstrated long term effects on patients with persistent epicondylalgia (>3 months). However, their efficacy depends on the technique used in combination as when used with stretching only they have not demonstrated any effects.
Despite current interest there is growing evidence that injection of autologous blood or platelet- rich blood products is not effective in treating tennis elbow.

Manual therapy (MT): We have moderate evidence of immediate effects of MT on pain and pain-free grip and short term benefits when used in conjunction with gradual exercises. There is also evidence that MT of cervical and thoracic spine has additional benefits in addition to local treatment when these areas present limitations.

Therapeutic exercises: Exercises are paramount in the treatment of tennis elbow with evidence of exercises alone or as a component of a multimodal approach. For patients with persistent epicondylalgia, exercises have shown a quicker reduction in pain, less sick leave, less medical appointments, and an increased work capacity. Despite clear benefits, currently there is no recommendations on type, intensity, frequency, or optimal duration for exercises. Current guidelines recommend a gradual increase in resistance, with focus on wrist extensors. There are conflicting views on pain during exercise, some authors insist on avoiding pain while others think it should stay tolerable (5<10). Given the heterogeneity of the clinical presentation and pathology it is more likely that optimal dosage may differ for each person according to stage, severity, and functional demand before injury.

Education: Natural history is self-limiting. Delays may be long 12 weeks of rehabilitation, sometimes 1 year to obtain an improvement of symptoms that may be incomplete. Recurrences may happen. Some factors increase the risk to develop the condition or that delay recovery. Rehabilitation is multimodal and tailored to individuals. Initial rest (regarding provoking activities) is important then gradual loading is required to recover the function of the limb. It is crucial to gradually reintroduce more strenuous tasks and to reduce tendon load if recurrence is experienced.

Bibliographie / Sources :

(Coombes, Bisset, & Vicenzino, 2015; Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013; Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949. https://doi.org/10.2519/jospt.2015.5841

Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119. https://doi.org/10.1136/bjsports-2012-091990

Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295. https://doi.org/10.1249/MSS.0000000000002128

Unsupervised isometric exercise versus wait-and-see for LET

(Vuvan, Vicenzino, Mellor, Heales, & Coombes, 2019)

Aims: To investigate the effect of an 8-week unsupervised program of isometric exercise compared to a wait-and-see approach on pain, disability, global improvement, and pain-free grip strength in participants with unilateral LET.

Methods: RCT in Australia. Inclusion: 18-70 years old, unilateral LET >6 weeks, pain >2 on average, provoked by 2 of grip, palpation, stretch, resisted contraction, reduced pain free grip strength. Exclusion: other diagnosis, other MSK complaint > to LET, major neurologic inflammatory, systemic condition, treatment in preceding 3 months, major trauma, fracture, or surgery in the last year. All participants were provided written and verbal general advice regarding self-management and ergonomics. Ex group: additional information about 8 week daily progressive isometric exercise program standardized and tailored to max voluntary contraction of each subject. Recording of exercises on a diary with adherence and symptoms. Adherence measured by % of 56 sessions done. Blinding of assessor, computer randomization (stratified <5 or >6 pain at baseline). PRTEE, GROC, and pain-free grip strength (3 measures 30 sec rest, mean). 20 / group = enough power to detect change. Stat analysis. 533 responders, 40 included n=21 exercise n=19 wait-and-see. Follow-up 98%.

Results: The exercise group had better PRTEE scores at 8 weeks compared to the wait–and-see group (SMD -0.92, 95% CI -1.58 to -0.26, P = 0.006). No ≠ in GROC nor in pain-free grip strength. 90% completed greater than 71% of prescribed sessions. No participants reported a serious adverse event. Use of co-interventions was similar between groups

Limitations: Power enough for PRTEE unknown for GROC & PFGS. Only non-severe patients. Program <10min / day.

In practice: This protocol of self-management isometrics for LET has moderate effect on PRTEE when compared to wait and see, but not on GROC nor pain-free grip strength at 8 weeks.

Vuvan, V., Vicenzino, B., Mellor, R., Heales, L. J., & Coombes, B. K. (2019). Unsupervised Isometric Exercise versus Wait-and-See for Lateral Elbow Tendinopathy. Medicine and Science in Sports and Exercise, 52(2), 287–295. https://doi.org/10.1249/MSS.0000000000002128

Does effectiveness of exercise therapy and mobilization techniques offer guidance for treatment of L & M epicondylitis?

(Hoogvliet, Randsdorp, Dingemanse, Koes, & Huisstede, 2013)

Aims: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis.

Methods: SR on 4 DB, 2 reviewers independently extracted data and assessed the methodological quality. English, German, French, Dutch language. Quality assessed according to a scale (Furlan). Heterogeneity made synthesis impossible, hence best evidence synthesis.

Results: Moderate evidence for a short-term effect of stretching plus strengthening exercises compared to ultrasound plus friction massage. Short-term and mid-term effect of manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of the wrist and forearm in patients with LE. For all other interventions, only limited, conflicting or no evidence was found

Limitations: No meta-analysis, poor level of evidence (1 paper high, other moderate low).

In practice: We do not have strong evidence for treatment of epicondylitis. To our current knowledge the best available option is exercise therapy + stretching +/- manual therapy as adjunct.

Hoogvliet, P., Randsdorp, M. S., Dingemanse, R., Koes, B. W., & Huisstede, B. M. A. (2013). Does effectiveness of exercise therapy and mobilization techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. British Journal of Sports Medicine, 47(17), 1112–1119. https://doi.org/10.1136/bjsports-2012-091990

Management of lateral elbow tendinopathy

(Coombes, Bisset, & Vicenzino, 2015)

Aims: To collate evidence and expert opinion on the pathophysiology, clinical presentation, and differential diagnosis of LET. Factors that might provide prognostic value or direction for physical rehabilitation are canvassed. Clinical recommendations for physical rehabilitation are provided, including the prescription of exercise and adjunctive physical therapy and pharmacotherapy.

Methods: Not mentioned. Authors’ literature analysis

Results: Frequent pathology among 35- 54 years old people, 1-3% of general population, with increased risk if smokers, tennis player, or manual workers. Self-limiting pathology 83% to 90% of people without treatment improve, even though not fully recover after 1 year. 1/3 of patients may still experience symptoms after 1 year even with treatment. Large proportion of recurrence. 5% de not have benefits of conservative treatment and undergo surgery with variable outcomes.

Multimodal pathology (tendon continuum model + neuro-motor & nociceptive changes).

Examination: Symptom reproduction with loading of tendon (palpation, resisted contraction, stretching). Rule-out other causes. Check elbow, shoulder, neck, thoracic spine. PRTEE & Pain-free grip test & PSFS to measure function.

Imagery can rule out not diagnose. Lack of association between severity of imaging and symptoms. Prognostic factors: location on continuum tendon model, initial severity and functional impairment, central sensitization, associated with shoulder / neck pain, associated neuromuscular impairments, psychosocial / work factors. Treatments: oral NSAIDS in acute phase, injections not recommended (delay in recovery), antidepressant or antiepileptic drugs if central sensitization, PRP no evidence of effectiveness, prolotherapy and nitric oxide patches if associated with load may help if limited outcomes at 6 months. Manual therapy: short term benefits if adjunct to exercises. No data on type, intensity, frequency, or duration of exercise. Currently it is recommended to gradually increase load with focus on wrist extensors. Heterogeneity in presentations => tailored dosage according to severity, stages, and functional demand. Education to reassure, inform, and advice.

Low risk: Education, advice, self-medication = wait & see, + physio after 6-12 week if no improvement.

Moderate risk: 8 to 12 weeks of physiotherapy recommended.

High risk (PRTEE >54): Central sensitization: pain management then physio.

Imagery if not responding to physiotherapy, if not other diagnostic found then try patches or prolotherapy.

Limitations: Guidelines (not a study, methodology unknown)

Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of Lateral Elbow Tendinopathy: One Size Does Not Fit All. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 938–949. https://doi.org/10.2519/jospt.2015.5841

Should exercises be painful in the management of chronic MKS pain? A SR with MA

(Smith, Hendrick, O Smith, & Al., 2017)

Aims: To compare the effect of exercises where pain is allowed / encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials.

Method: Systematic review on exercises into pain vs non-pain exercises on pain, function or disability. 9 papers included, total of 385 participants with pain > 3 months (chronic).

Results: Small but significant difference favouring exercises into pain in the short-term, moderate quality evidence, small effect size (-0,27) on patient reported pain.

Appears to be no difference in patient reported pain on medium and long-term due to moderate to low quality evidence. The instructions regarding pain were different, not clear if that had an effect.

Limitations: None of the studies recorded levels of pain during exercise.
The framing of pain vs no pain can potentially affect the outcome, the effects are unclear.
Studies included different areas, LBP, shoulder pain, Achilles pain, plantar heel pain.

In practice: Affects advice / conversations with patients. Pain during exercises in chronic pain not harmful, does not prevent improvements.

Smith, B., Hendrick, P., O Smith, T., & Al., E. (2017). Should Exercises be painful in the management of chronic msk pain. BJSM, 1–10. https://doi.org/10.1136/bjsports-2016097383

Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging

(Takasaki et al., 2011)

Aims: The purpose of this study was 1) to examine measurement reliability of segmental upper cervical movements using magnetic resonance imaging and 2) to investigate the content validity of the FRT

Methods: MRI study measurement on 19 healthy women.

Results: FRT is a valid and reliable (substantial reliability) measure of Upper Cervical Spine UCS Rotation (Better if taken 2 times than one). Normal range 45° each side. Positive test if <33°.

Limitations: Small sample, healthy, only women, young 22yo, 141m average height.

In Practice: FRT is a valid and reliable method to measure C1-C2 rotation.

Takasaki, H., Hall, T., Oshiro, S., Kaneko, S., Ikemoto, Y., & Jull, G. (2011). Normal kinematics of the upper cervical spine during the Flexion-Rotation Test – In vivo measurements using magnetic resonance imaging. Manual Therapy, 16(2), 167–171. https://doi.org/10.1016/j.math.2010.10.002

Induction of nocebo and placebo effects on itch and pain by verbal suggestions

(Van Laarhoven et al., 2011)

Aims: To study verbally induced nocebo and placebo effects on itch and pain.

Methods: 105 healthy female subjects were randomly assigned to one of 4 groups: (Itch nocebo n=36 vs Control n=20 or Pain nocebo n=33 vs Control n=16). In itch / pain nocebo groups patients were told a verbal suggestion stating that 95% of healthy people will experience Itch / pain and in control groups a neutral suggestion stating only 5% may experience Itch, 5% pain otherwise nothing. All groups tested for mechanical stimuli (Von Frey), electrical stimuli, ionophoresis of Histamine. Then all nocebo group undertook another ionophoresis stimuli. With either placebo suggestion of reduction of itch / pain or control with suggestion of same gel and that everyone feels itch or pain but not the other according to the group. All group rated pain and itch on VAS scales before and every 30 seconds during test, and after.

Results: Subjects who received verbal suggestions to induce high pain expectations reported significantly more pain than subjects who received verbal suggestions inducing low pain expectations. Subjects who received verbal suggestions inducing high itch expectations experienced significantly higher levels of itch evoked by the somatosensory stimuli than subjects who received verbal suggestions inducing low itch expectations. The nocebo effects induced by verbal suggestions appeared to be stronger for itch than for pain.

Itch levels decreased to a greater extent when suggestions of itch reduction were given than when suggestions of pain reduction were given, while the decrease in itch was not significantly different when it was suggested that itch would be reduced in comparison to neutral suggestions and same for pain.

Limitations: Only women, from one university of Netherlands, small sample. Part 2 habituation of histamine effect possible. Lab setting can be a cofounding factor. Lack control group with no expectations at all. Healthy subjects only. Small effect: MIDC not reached, low levels of itch / pain in general.

In practice: Itch and pain can be induced by only giving verbal suggestions. The perception of different ambiguous stimuli can be influenced by negative suggestions, in such a way that negative expectations can adversely influence the intensity of itch or pain experienced.

Van Laarhoven, A. I. M., Vogelaar, M. L., Wilder-Smith, O. H., Van Riel, P. L. C. M., Van De Kerkhof, P. C. M., Kraaimaat, F. W., & Evers, A. W. M. (2011). Induction of nocebo and placebo effects on itch and pain by verbal suggestions. Pain, 152(7), 1486–1494. https://doi.org/10.1016/j.pain.2011.01.043

Reliability, validity and diagnostic accuracy of palpation of the sciatic, tibial and common peroneal nerves in the exam of LB related leg pain.

(Walsh & Hall, 2009)

Aim: The aim of this study was to determine the reliability, validity and diagnostic accuracy of manual palpation of the sciatic, tibial and common peroneal nerves in the examination of low-back related leg pain.

Methods: 45 subjects. Palpation compared to SLR + Slump. Inclusion: presence of unilateral low-back related leg pain, 18 to 70yo, English speaking. Exclusion: signs of serious pathology, history of spinal surgery or neurological disease, unable to tolerate testing process.

Palpation at the sciatic nerve at the midway point of a line from ischial tuberosity to the greater trochanter of the femur; the tibial nerve where it bisects the popliteal fossa at the mid-point of the popliteal crease; and the common peroneal nerve where it passes behind the head of fibula to wind around the neck of fibula. Bilateral simultaneous palpation. Positive if pain or discomfort on one leg or more on one leg if bilaterally. Following palpation: PPT measured at same spots. 3 measures 10 s rest, asymptomatic leg then symptomatic, mean of 3 measures taken. Proximal to distal. 2nd blinded examiner did Slump and SLR. For each test, reproduction of presenting symptoms, which was made worse by dorsiflexion, was recorded as a positive finding. Positive if +ve Slump AND +ve SLR. First 20 subjects did the exact same procedure with a 3rd examiner to measure inter tester reliability.

Results: Reliability: Substantial agreement was found for all palpation tests. K=0,7-0,8. PPT reliability demonstrated excellent inter-tester reliability.

Validity: There were no significant differences in PPTs between sides at any of the nerves in subjects who were negative on manual palpation. In subjects who were positive on manual palpation, mean PPTs were significantly lower on the symptomatic side compared to the asymptomatic side for each of the nerves

Limitations: Small sample from Australia, SLR and Slump non gold standard.

In Practice: This study provides support for the use of nerve palpation in clinical examination, with evidence of excellent reliability and diagnostic accuracy as well as validity of manual palpation for three lower limb nerve sites.

Walsh, J., & Hall, T. (2009). Reliability, validity and diagnostic accuracy of palpation of the sciatic, tibial and common peroneal nerves in the examination of low back related leg pain. Manual Therapy, 14(6), 623–629. https://doi.org/10.1016/j.math.2008.12.007

Patellofemoral Pain

(Willy et al., 2019)

Aims: Guidelines on PFP

Methods: Review of literature & experts’ consensus.

Limitations: May be bias in experts’ opinion. Broad topic. Expert consensus

In Practice:

Diagnosis: The presence of retro-patellar or peri-patellar pain, (2) reproduction of retro-patellar or peri-patellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position, and (3) exclusion of all other conditions that may cause anterior knee pain.

Assessment: Clinicians should use the Anterior Knee Pain Scale (AKPS), the patellofemoral pain and osteoarthritis sub-scale of the Knee injury and Osteoarthritis Outcome Score (KOOS-PF), or the (VAS) for activity, for worst pain, for usual pain, or the numeric pain-rating scale (NPRS) to measure pain.

Treatment: Should include exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve patient-reported outcomes and functional performance in the short, medium, and long term.

Clinicians may use tailored patellar taping in combination with exercise therapy to assist in immediate pain reduction, and to enhance outcomes of exercise therapy in the short term (4 weeks).

Clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only in the short term (up to 6 weeks).

Willy, R. W., Hoglund, L. T., Barton, C. J., Bolgla, L. A., Scalzitti, D. A., Logerstedt, D. S., … Torburn, L. (2019). Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy, 49(9), CPG1–CPG95. https://doi.org/10.2519/jospt.2019.0302