Abstract
Background and aims
Patellofemoral pain (PFP) and patellofemoral joint osteoarthritis (PFJOA) are common non-self-limiting conditions causing significant pain and disability. The underlying pain pathologies lack consensus with evidence suggesting reduced pressure pain thresholds (PPTs) in adolescent females with PFP and individuals with knee osteoarthritis. A paucity of evidence exists for mixed-sex adults with PFP and PFJOA in isolation. Exploring if pain sensitisation is a dominant feature of PFP and PFJOA may have important implications for the delivery of a patient centred management approach. The primary aim was to measure local and remote PPTs in PFP and PFJOA patients compared to matched controls. Secondary aims were to evaluate the relationship between PPTs and (1) condition severity and (2) knee function.
Methods
13 PFP patients plus 20 matched controls and 15 PFJOA patients plus 34 matched controls were recruited from a UK mixed-sex adult population. Controls were matched on age, sex and activity level. Demographic details, Tegner activity level score, symptom duration, condition severity (Kujala and KOOS-PF scores for PFP and PFJOA, respectively) and knee function (Modified Whatman score rating of five single leg squats) were recorded. PPTs were measured at six sites: five local around the knee, one remote on the contralateral leg. Between-group differences were tested using a two-way mixed model analysis of variance with repeated measures. Strength of association between PPTs and condition severity and knee function were tested using Spearman’s rank order correlation.
Results
No statistically significant difference in PPTs were observed between the PFP patients [F(1,31) = 0.687, p = 0.413, η2 = 0.022] or PFJOA patients [F(1,47) = 0.237, p = 0.629, η2 = 0.005] and controls. Furthermore, no correlation was found between PPTs and condition severity or knee function in PFP or PFJOA (p > 0.05).
Conclusions
Results suggest mechanical pain sensitisation is not a dominant feature of UK mixed-sex adults with PFP or PFJOA.
Implications
PFP and PFJOA remain persistent pain complaints which may not be well explained by objective measures of sensitivity such as PPTs. The findings suggest that peripheral pain processing changes leading to pain sensitisation is not a key feature in PFP or PFJOA. Instead the underlying pain pathway is likely to remain primary nociceptive, possibly with a subgroup of patients who experience pain sensitisation and might benefit from a more targeted management approach.
Authors’ statements
Research funding: No funding.
Conflict of interest: No conflicts of interest.
Informed consent: Informed consent has been obtained from all included participants.
Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance the Helsinki Declaration with ethical approval gained from the Queen Mary University Research Ethics Committee (QMREC2014/24/105).
References
[1] Smith BE, Hendrick P, Logan P. Patellofemoral pain: challenging current practice – a case report. Man Ther 2016;22:216–9.10.1016/j.math.2015.09.002Search in Google Scholar PubMed
[2] McAlindon TE, Snow S, Cooper C, Dieppe PA. Radiographic patterns of osteoarthritis of the knee joint in the community: the importance of the patellofemoral joint. Ann Rheum Dis 1992;51:844–9.10.1136/ard.51.7.844Search in Google Scholar PubMed PubMed Central
[3] Smith BE, Selfe J, Thacker D, Hendrick P, Bateman M, Moffatt F, Rathleff MS, Smith TO, Logan P. Incidence and prevalence of patellofemoral pain: a systematic review and meta-analysis. PLoS One 2018;13:e0190892.10.1371/journal.pone.0190892Search in Google Scholar PubMed PubMed Central
[4] Kobayashi S, Pappas E, Fransen M, Refshauge K, SimicM. The prevalence of patellofemoral osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage 2016;24:1697–707.10.1016/j.joca.2016.05.011Search in Google Scholar PubMed
[5] Thomas MJ, Wood L, Selfe J, Peat G. Anterior knee pain in younger adults as a precursor to subsequent patellofemoral osteoarthritis: a systematic review. BMC Musculoskelet Disord 2010;11:201.10.1186/1471-2474-11-201Search in Google Scholar PubMed PubMed Central
[6] Utting MR, Davies G, Newman JH. Is anterior knee pain a predisposing factor to patellofemoral osteoarthritis? Knee 2005;12:362–5.10.1016/j.knee.2004.12.006Search in Google Scholar PubMed
[7] Eijkenboom JFA, Waarsing JH, Oei EHG, Bierma-Zeinstra SMA, van Middelkoop M. Is patellofemoral pain a precursor to osteoarthritis?: Patellofemoral osteoarthritis and patellofemoral pain patients share aberrant patellar shape compared with healthy controls. Bone Joint Res 2018;7:541–7.10.1302/2046-3758.79.BJR-2018-0112.R1Search in Google Scholar PubMed PubMed Central
[8] Wyndow N, Collins N, Vicenzino B, Tucker K, Crossley K. Is there a biomechanical link between patellofemoral pain and osteoarthritis? A narrative review. Sports Med 2016;46:1797–808.10.1007/s40279-016-0545-6Search in Google Scholar PubMed
[9] Crossley KM. Is patellofemoral osteoarthritis a common sequela of patellofemoral pain? Br J Sports Med 2014;48: 409–10.10.1136/bjsports-2014-093445Search in Google Scholar PubMed
[10] Crossley KM, Stefanik JJ, Selfe J, Collins NJ, Davis IS, Powers CM, McConnell J, Vicenzino B, Bazett-Jones DM, Esculier JF, Morrissey D, Callaghan MJ. Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. Br J Sports Med 2016;50:839–43.10.1136/bjsports-2016-096384Search in Google Scholar PubMed PubMed Central
[11] Witvrouw E, Werner S, Mikkelsen C, Van Tiggelen D, Vanden Berghe L, Cerulli G. Clinical classification of patellofemoral pain syndrome: guidelines for non-operative treatment. Knee Surg Sports Traumatol Arthrosc 2005;13:122–30.10.1007/s00167-004-0577-6Search in Google Scholar PubMed
[12] Collins NJ, Crossley KM, Darnell R, Vicenzino B. Predictors of short and long term outcome in patellofemoral pain syndrome: a prospective longitudinal study. BMC Musculoskelet Disord 2010;11:11.10.1186/1471-2474-11-11Search in Google Scholar PubMed PubMed Central
[13] Collins NJ, Bierma-Zeinstra SM, Crossley KM, van Linschoten RL, Vicenzino B, van Middelkoop M. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med 2013;47:227–33.10.1136/bjsports-2012-091696Search in Google Scholar PubMed
[14] Dye SF. The pathophysiology of patellofemoral pain: a tissue homeostasis perspective. Clin Orthop Relat Res 2005;436:100–10.10.1097/01.blo.0000172303.74414.7dSearch in Google Scholar PubMed
[15] Boudreau SA, Kamavuako EN, Rathleff MS. Distribution and symmetrical patellofemoral pain patterns as revealed by high-resolution 3D body mapping: a cross-sectional study. BMC Musculoskelet Disord 2017;18:160.10.1186/s12891-017-1521-5Search in Google Scholar PubMed PubMed Central
[16] Jensen R, Hystad T, Kvale A, Baerheim A. Quantitative sensory testing of patients with long lasting Patellofemoral pain syndrome. Eur J Pain 2007;11:665–76.10.1016/j.ejpain.2006.10.007Search in Google Scholar PubMed
[17] Jensen R, Kvale A, Baerheim A. Is pain in patellofemoral pain syndrome neuropathic? Clin J Pain 2008;24:384–94.10.1097/AJP.0b013e3181658170Search in Google Scholar PubMed
[18] Schaible HG. Mechanisms of chronic pain in osteoarthritis. Curr Rheumatol Rep 2012;14:549–56.10.1007/s11926-012-0279-xSearch in Google Scholar PubMed
[19] Arendt-Nielsen L, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, Graven-Nielsen T. Sensitization in patients with painful knee osteoarthritis. Pain 2010;149:573–81.10.1016/j.pain.2010.04.003Search in Google Scholar PubMed
[20] Pazzinatto MF, de Oliveira Silva D, Barton C, Rathleff MS, Briani RV, de Azevedo FM. Female adults with patellofemoral pain are characterized by widespread hyperalgesia, which is not affected immediately by patellofemoral joint loading. Pain Med 2016;17:1953–61.10.1093/pm/pnw068Search in Google Scholar PubMed
[21] Pazzinatto MF, de Oliveira Silva D, Pradela J, Coura MB, Barton C, de Azevedo FM. Local and widespread hyperalgesia in female runners with patellofemoral pain are influenced by running volume. J Sci Med Sport 2017;20:362–7.10.1016/j.jsams.2016.09.004Search in Google Scholar PubMed
[22] Rathleff MS, Rathleff CR, Stephenson A, Mellor R, MatthewsM, Crossley K, Vicenzino B. Adults with patellofemoral pain do not exhibit manifestations of peripheral and central sensitization when compared to healthy pain-free age and sex matched controls – an assessor blinded cross-sectional study. PLoS One 2017;12:e0188930.10.1371/journal.pone.0188930Search in Google Scholar PubMed PubMed Central
[23] Fingleton C, Smart K, Moloney N, Fullen BM, Doody C. Pain sensitization in people with knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage 2015;23:1043–56.10.1016/j.joca.2015.02.163Search in Google Scholar PubMed
[24] Graven-Nielsen T, Arendt-Nielsen L. Assessment of mechanisms in localized and widespread musculoskeletal pain. Nat Rev Rheumatol 2010;6:599–606.10.1038/nrrheum.2010.107Search in Google Scholar PubMed
[25] Noehren B, Shuping L, Jones A, Akers DA, Bush HM, Sluka KA. Somatosensory and biomechanical abnormalities in females with patellofemoral pain. Clin J Pain 2016;32:915–9.10.1097/AJP.0000000000000331Search in Google Scholar PubMed PubMed Central
[26] Rathleff MS, Roos EM, Olesen JL, Rasmussen S, Arendt-Nielsen L. Lower mechanical pressure pain thresholds in female adolescents with patellofemoral pain syndrome. J Orthop Sports Phys Ther 2013;43:414–21.10.2519/jospt.2013.4383Search in Google Scholar PubMed
[27] Rathleff MS, Petersen KK, Arendt-Nielsen L, Thorborg K, Graven-Nielsen T. Impaired conditioned pain modulation in young female adults with long-standing patellofemoral pain: a single blinded cross-sectional study. Pain Med 2016;17:980–8.10.1093/pm/pnv017Search in Google Scholar PubMed
[28] Holden S, Straszek CL, Rathleff MS, Petersen KK, Roos EM, Graven-Nielsen T. Young females with long-standing patellofemoral pain display impaired conditioned pain modulation, increased temporal summation of pain, and widespread hyperalgesia. Pain 2018;159:2530–7.10.1097/j.pain.0000000000001356Search in Google Scholar PubMed
[29] van der Heijden RA, Rijndertse MM, Bierma-Zeinstra SMA, van Middelkoop M. Lower pressure pain thresholds in patellofemoral pain patients, especially in female patients: a cross-sectional case-control study. Pain Med 2018;19:184–92.10.1093/pm/pnx059Search in Google Scholar PubMed
[30] World Medical Association Declaration of Helsinki. Recommendations guiding physicians in biomedical research involving human subjects. Cardiovasc Res 1997;35:2–3.Search in Google Scholar
[31] von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014;12:1495–9.10.1097/EDE.0b013e3181577654Search in Google Scholar PubMed
[32] Barton CJ, Levinger P, Menz HB, Webster KE. Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Gait Posture 2009;30:405–16.10.1016/j.gaitpost.2009.07.109Search in Google Scholar
[33] Zhang W, Doherty M, Peat G, Bierma-Zeinstra MA, Arden NK, Bresnihan B, Herrero-Beaumont G, Kirschner S, Leeb BF, Lohmander LS, Mazières B, Pavelka K, Punzi L, So AK, Tuncer T, Watt I, Biilsma JW. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis 2010;69:483–9.10.1136/ard.2009.113100Search in Google Scholar
[34] Stefanik JJ, Neogi T, Niu J, Roemer FW, Segal NA, Lewis CE, Nevitt M, Guermazi A, Felson DT. The diagnostic performance of anterior knee pain and activity-related pain in identifying knees with structural damage in the patellofemoral joint: the Multicenter Osteoarthritis Study. J Rheumatol 2014;41:1695–702.10.3899/jrheum.131555Search in Google Scholar
[35] Schiphof D, van Middelkoop M, de Klerk BM, Oei EH, Hofman A, Koes BW, Weinans H, Bierma-Zeinstra SM. Crepitus is a first indication of patellofemoral osteoarthritis (and not of tibiofemoral osteoarthritis). Osteoarthritis Cartilage 2014;22:631–8.10.1016/j.joca.2014.02.008Search in Google Scholar
[36] Hinman RS, Lentzos J, Vicenzino B, Crossley KM. Is patellofemoral osteoarthritis common in middle-aged people with chronic patellofemoral pain? Arthritis Care Res (Hoboken) 2014;66:1252–7.10.1002/acr.22274Search in Google Scholar
[37] Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behvioural, and biomedical sciences. Behav Res Methods 2007;39:175–91.10.3758/BF03193146Search in Google Scholar
[38] Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985;198:43–9.10.1097/00003086-198509000-00007Search in Google Scholar
[39] Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy 1993;9:159–63.10.1016/S0749-8063(05)80366-4Search in Google Scholar
[40] Crossley KM, Macri EM, Cowan SM, Collins NJ, Roos EM. The patellofemoral pain and osteoarthritis subscale of the KOOS (KOOS-PF): development and validation using the COSMIN checklist. Br J Sports Med 2018;52:1130–6.10.1136/bjsports-2016-096776Search in Google Scholar PubMed
[41] Whatman C, Hing W, Hume P. Physiotherapist agreement when visually rating movement quality during lower extremity functional screening tests. Phys Ther Sport 2012;13:87–96.10.1016/j.ptsp.2011.07.001Search in Google Scholar PubMed
[42] Portney L, Watkins M. Foundations of clinical research: applications to practice. New Jersey: Prentice Hall, 2000.Search in Google Scholar
[43] Cohen J. Statistical power analysis for the behavioural sciences, 2nd ed. New York: Lawrence Erlbaum Associates, 1988.Search in Google Scholar
[44] De Oliveira Silva D, Rathleff MS, Petersen K, Azevedo FM, Barton CJ. Manifestations of pain sensitization across different painful knee disorders: a systematic review including meta-analysis and metaregression. Pain Med 2018. doi: 10.1093/pm/pny177. [Epub ahead of print].10.1093/pm/pny177Search in Google Scholar PubMed
[45] La Hausse de Lalouvière L, Ioannou Y, Fitzgerald M. Neural mechanisms underlying the pain of juvenile idiopathic arthritis. Nat Rev Rheumatol 2014;10:205–11.10.1038/nrrheum.2014.4Search in Google Scholar PubMed
[46] Duncan R, Peat G, Thomas E, Hay EM, Croft P. Incidence, progression and sequence of development of radiographic knee osteoarthritis in a symptomatic population. Ann Rheum Dis 2011;70:1944–8.10.1136/ard.2011.151050Search in Google Scholar PubMed
[47] Collins NJ, Oei EHG, de Kanter JL, Vicenzino B, Crossley KM. Prevalence of radiographic and MRI features of patellofemoral osteoarthritis in young and middle-aged adults with persistent patellofemoral pain. Arthritis Care Res (Hoboken) 2018. doi: 10.1002/acr.23726. [Epub ahead of print].10.1002/acr.23726Search in Google Scholar PubMed
[48] Graven-Nielsen T, Wodehouse T, Langford RM, Arendt-Nielsen L, Kidd BL. Normalization of widespread hyperesthesia and facilitated spatial summation of deep-tissue pain in knee osteoarthritis patients after knee replacement. Arthritis Rheum 2012;64:2907–16.10.1002/art.34466Search in Google Scholar PubMed
[49] Imamura M, Imamura ST, Kaziyama HH, Targino RA, HsingWT, de Souza LP, Cutait MM, Fregni F, Camanho GL. Impact of nervous system hyperalgesia on pain, disability, and quality of life in patients with knee osteoarthritis: a controlled analysis. Arthritis Rheum 2008;59:1424–31.10.1002/art.24120Search in Google Scholar PubMed
[50] Lundblad H, Kreicbergs A, Jansson KA. Prediction of persistent pain after total knee replacement for osteoarthritis. J Bone Joint Surg Br 2008;90:166–71.10.1302/0301-620X.90B2.19640Search in Google Scholar PubMed
[51] Neogi T, Frey-Law L, Scholz J, Niu J, Arendt-Nielsen L, Woolf C, Nevitt M, Bradley L, Felson DT. Sensitivity and sensitisation in relation to pain severity in knee osteoarthritis: trait or state? Ann Rheum Dis 2015;74:682–8.10.1136/annrheumdis-2013-204191Search in Google Scholar PubMed PubMed Central
[52] Skou ST, Graven-Nielsen T, Rasmussen S, Simonsen OH, Laursen MB, Arendt-Nielsen L. Facilitation of pain sensitization in knee osteoarthritis and persistent post-operative pain: a cross-sectional study. Eur J Pain 2014;18:1024–31.10.1002/j.1532-2149.2013.00447.xSearch in Google Scholar PubMed
[53] Wylde V, Palmer S, Learmonth ID, Dieppe P. Somatosensory abnormalities in knee OA. Rheumatology (Oxford) 2012;51:535–43.10.1093/rheumatology/ker343Search in Google Scholar PubMed
[54] Wylde V, Palmer S, Learmonth ID, Dieppe P. The association between pre-operative pain sensitisation and chronic pain after knee replacement: an exploratory study. Osteoarthritis Cartilage 2013;21:1253–6.10.1016/j.joca.2013.05.008Search in Google Scholar PubMed
[55] Lautenbacher S. Experimental approaches in the study of pain in the elderly. Pain Med 2012;13(Suppl 2):S44–50.10.1111/j.1526-4637.2012.01326.xSearch in Google Scholar PubMed
[56] Bartley EJ, King CD, Sibille KT, Cruz-Almeida Y, Riley JL, Glover TL, Goodin BR, Sotolongo AS, Herbert MS, Bulls HW, Staud R, Fessler BJ, Redden DT, Bradley LA, Fillingim RB. Enhanced pain sensitivity among individuals with symptomatic knee osteoarthritis: potential sex differences in central sensitization. Arthritis Care Res (Hoboken) 2016;68:472–80.10.1002/acr.22712Search in Google Scholar PubMed PubMed Central
[57] Kavchak AJ, Fernández-de-Las-Peñas C, Rubin LH, Arendt-Nielsen L, Chmell SJ, Durr RK, Courtney CA. Association between altered somatosensation, pain, and knee stability in patients with severe knee osteoarthrosis. Clin J Pain 2012;28:589–94.10.1097/AJP.0b013e31823ae18fSearch in Google Scholar PubMed
[58] Lee YC, Lu B, Bathon JM, Haythornthwaite JA, Smith MT, Page GG, Edwards RR. Pain sensitivity and pain reactivity in osteoarthritis. Arthritis Care Res (Hoboken) 2011;63:320–7.10.1002/acr.20373Search in Google Scholar PubMed PubMed Central
[59] Speed TJ, Richards JM, Finan PH, Smith MT. Sex moderates the effects of positive and negative affect on clinical pain in patients with knee osteoarthritis. Scand J Pain 2017;16:66–73.10.1016/j.sjpain.2017.03.005Search in Google Scholar PubMed PubMed Central
[60] Glass N, Segal NA, Sluka KA, Torner JC, Nevitt MC, Felson DT, Bradley LA, Neogi T, Lewis CE, Frey-Law LA. Examining sex differences in knee pain: the multicenter osteoarthritis study. Osteoarthritis Cartilage 2014;22:1100–6.10.1016/j.joca.2014.06.030Search in Google Scholar PubMed PubMed Central
[61] Racine M, Tousignant-Laflamme Y, Kloda LA, Dion D, Dupuis G, Choinière M. A systematic literature review of 10 years of research on sex/gender and experimental pain perception – part 1: are there really differences between women and men? Pain 2012;153:602–18.10.1016/j.pain.2011.11.025Search in Google Scholar PubMed
[62] Finan PH, Buenaver LF, Bounds SC, Hussain S, Park RJ, Haque UJ, Campbell CM, Haythornthwaite JA, Edwards RR, Smith MT. Discordance between pain and radiographic severity in knee osteoarthritis: findings from quantitative sensory testing of central sensitization. Arthritis Rheum 2013;65:363–72.10.1002/art.34646Search in Google Scholar PubMed PubMed Central
[63] Skou ST, Graven-Nielsen T, Lengsoe L, Simonsen O, Laursen MB, Arendt-Nielsen L. Relating clinical measures of pain with experimentally assessed pain mechanisms in patients with knee osteoarthritis. Scand J Pain 2013;4:111–7.10.1016/j.sjpain.2012.07.001Search in Google Scholar PubMed
[64] Skou ST, Graven-Nielsen T, Rasmussen S, Simonsen OH, Laursen MB, Arendt-Nielsen L. Widespread sensitization in patients with chronic pain after revision total knee arthroplasty. Pain 2013;154:1588–94.10.1016/j.pain.2013.04.033Search in Google Scholar
[65] Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory hypersensitivity occurs soon after whiplash injury and is associated with poor recovery. Pain 2003;104:509–17.10.1016/S0304-3959(03)00078-2Search in Google Scholar
[66] Meeus M, Vervisch S, De Clerck LS, Moorkens G, Hans G, Nijs J. Central sensitization in patients with rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum 2012;41:556–67.10.1016/j.semarthrit.2011.08.001Search in Google Scholar
[67] Brechter JH, Powers CM. Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. Gait Posture 2002;16:115–23.10.1016/S0966-6362(02)00090-5Search in Google Scholar
[68] Crossley KM, Cowan SM, Bennell KL, McConnell J. Knee flexion during stair ambulation is altered in individuals with patellofemoral pain. J Orthop Res 2004;22:267–74.10.1016/j.orthres.2003.08.014Search in Google Scholar PubMed
[69] de Oliveira Silva D, Barton CJ, Pazzinatto MF, Briani RV, de Azevedo FM. Proximal mechanics during stair ascent are more discriminate of females with patellofemoral pain than distal mechanics. Clin Biomech (Bristol, Avon) 2016;35:56–61.10.1016/j.clinbiomech.2016.04.009Search in Google Scholar PubMed
[70] Silva Dde O, Briani RV, Pazzinatto MF, Ferrari D, Aragão FA, Azevedo FM. Reduced knee flexion is a possible cause of increased loading rates in individuals with patellofemoral pain. Clin Biomech (Bristol, Avon) 2015;30:971–5.10.1016/j.clinbiomech.2015.06.021Search in Google Scholar PubMed
[71] McKenzie K, Galea V, Wessel J, Pierrynowski M. Lower extremity kinematics of females with patellofemoral pain syndrome while stair stepping. J Orthop Sports Phys Ther 2010;40:625–32.10.2519/jospt.2010.3185Search in Google Scholar PubMed
[72] de Oliveira Silva D, Barton CJ, Briani RV, Taborda B, Ferreira AS, Pazzinatto MF, Azevedo FM. Kinesiophobia, but not strength is associated with altered movement in women with patellofemoral pain. Gait Posture 2018;68:1–5.10.1016/j.gaitpost.2018.10.033Search in Google Scholar PubMed
[73] Domenech J, Sanchis-Alfonso V, López L, Espejo B. Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients. Knee Surg Sports Traumatol Arthrosc 2013;21:1562–8.10.1007/s00167-012-2238-5Search in Google Scholar PubMed
[74] Doménech J, Sanchis-Alfonso V, Espejo B. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc 2014;22:2295–300.10.1007/s00167-014-2968-7Search in Google Scholar PubMed
©2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
