Motor Control Retraining vs Close Kinetic Chain Exercises for Pain, Function and Vastus Medialis Oblique Strength in Patients With Patellofemoral Pain Syndrome (MCR VS CKC)

Comparative Effects of Motor Control Retraining and Close Kinetic Chain Exercises on Pain, Function and Vastus Medialis Oblique Strength in Patients With Patellofemoral Pain Syndrome

This study compares two treatments - motor control retraining and close kinetic chain exercises - to improves the pain, VMO strength, knee function. Fifty participants out of which 4 dropped out; will be randomly assigned to receive either motor control retraining or close kinetic chain exercises training for 45 minutes per session, three times per week, for six weeks. Pain intensity will be measured using the visual analogue scale. Knee function will be measured using Kujala anterior knee pain scale. Vastus medialis oblique strength will be measured using digital dynamometer. Dynamic knee valgus will be measured using Kinovea-2D video analysis. Q-angle will be measured using manual goniometer. Patellar maltracking will be measured using combined assessment of dynamic knee valgus and q-angle. This study aims to determine which treatment produces greater improvements, which may help physiotherapists choose more effective treatments for patient with patellofemoral pain syndrome in Pakistan.

Study Overview

• Status: Completed
• Conditions: Patellofemoral Pain Syndrome; Motor Control Retraining; Close Kinetic Chain Exercises
• Intervention / Treatment: Other: Motor Control Retraining; Other: Close Kinetic Chain Exercises

Detailed Description

Background: Patellofemoral pain syndrome, another name for anterior knee discomfort, is brought on by a combination of abnormal patellar tracking, changed biomechanics, and muscle imbalances that put more strain on the patellofemoral joint during activities including jogging, squatting, and stair climbing. In general practice, patellofemoral pain contributes to 11-17% of all knee pain syndromes. Motor control retraining is a rehabilitation treatment that focus on activation and timing of VMO, controlled functional movements, dynamic integration while close kinetic chain exercises is also a rehabilitation treatment that focus on low and moderate load close kinetic chain exercises with advanced functional exercises that focuses on VMO activation.

• Study Type: Interventional
• Enrollment (Actual): 50
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • Punjab Province
    • Faisalabad, Punjab Province, Pakistan, 38000
      • Department of Rehabilitation Sciences, The University of Faisalabad

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Age between 18 and 40 years old.
• Both genders male & female.
• Clinically diagnosed PFPS patients.
• Anterior knee pain >3 on VAS for > 2 weeks.
• Retropatellar pain during at least 3 of the following activities, i.e., jumping, kneeling, ascending & descending stairs, squatting, running, prolonged sitting.
• BMI range from 18.5 - 24.9 kg/m² .
• Not receiving previously knee physiotherapy.
• Insidious onset of symptoms unrelated to trauma.
• Patellar compression test positive.
• Clarke's test positive.
• Snapps questionnaire score 6 or greater.

Exclusion Criteria:

• Age > 40 years old.
• Knee joint effusion .
• BMI < 18 & > 29 kg/m².
• Any other significant injury that affect lower limb .
• Any history of previous knee surgery.
• Having referred pain from the lumbar, hip, ankle, feet, and SIJ .
• Any history of knee pathology, including OA, meniscus injury, ligament injury, tendon injury, cartilage injury, iliotibial band involvement, intra articular pathology, patellar instability, osgood-schlatter syndrome, pes anserine pain, RA of knee .
• Any history of neurological condition .
• Pregnant females .
• Any condition affected muscle strength, i.e., gout, DM, RA .
• History of head injury, vestibular disorder within 6 months.
• Any history of patellar dislocation or subluxation .
• Signs and symptoms < 1 month.
• Use of corticosteroids, anti-inflammatory & intra-articular injections.
• Heart condition that precluded performing exercises.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Motor control retraining Group; Motor control retraining will receive baseline treatment including static stretching of the hamstrings, iliotibial band, and calf muscle of the affected limb with 2 sets of 5 repetitions with a 5-second hold, followed by a Motor Control Retraining program focused on vastus medialis oblique isometric activation with visual feedback, quadriceps setting with VMO emphasis; seated short arc quads (0-30°) with manual cueing will performed at low intensity by participant for 1st and 2nd week. In phase 2 (controlled functional recruitment), mini-squats with verbal and tactile cueing to optimize VMO activation and lateral step-downs focusing on medial quadriceps control will performed withlow to moderate intensity by participant for 3rd and 4th week. In phase 3 (dynamic integration), single leg squat to 45° with feedback and functional tasks (stair scent/descent drills,controlled landing from 20 cm) will performed with moderate intensity by participant for 5th and 6th week.	Other: Motor Control Retraining; What: A supervised exercise program consisting of motor control retraining exercises designed to improve neuromuscular control, movement coordination, muscle activation, and postural stability. The exercises are performed under supervision three times per week for 6 weeks. When: 45 minutes per session, 3 sessions per week, for 6 consecutive weeks (total 18 sessions). How much: Each exercise performed for 10-15 seconds, with 3×5 reps, with rest periods as needed. By whom: Licensed physiotherapist trained in motor control retraining exercises. Where: Outpatient rehabilitation department of MTH (Madinah Teaching Hospital), Faisalabad; Pro Health Rehab & Medical Centre, Faisalabad; United Hospital, Faisalabad.; Other Names: Motor control retraining exercise
Active Comparator: Close kinetic chain exercises Group; Close kinetic chain exercises will receive baseline treatment including static stretching of the hamstrings, iliotibial band, and calf muscle of the affected limb with 2 sets of 5 repetitions with a 5-second hold, followed by a Closed Kinetic Chain Exercise program including wall squats / mini-squats (0-30°) and terminal knee extension in mini-CKC (band resistance) will performed with low intensity by participant for 1st and 2nd week. In phase 2 (moderate load CKC), step-ups / step-downs (20 cm) and forward lunges (partial range) will performed with low to moderate intensity by participant for 3rd and 4th week. In phase 3 (advanced functional), single-leg squat (to 45°) and lateral lunges will performed with moderate intensity by participant for 5th and 6th week. The dosage of these exercises will 3 sets × 10 reps with 5 sec hold for 3 days /week for 6 weeks. The mode of administration was one-on-one.	Other: Close Kinetic Chain Exercises; What: A supervised exercise program consisting of closed kinetic chain exercises designed to improve muscle strength, joint stability, neuromuscular control, and functional movement. The exercises are performed under supervision three times per week for 6 weeks. When: 45 minutes per session, 3 sessions per week, for 6 consecutive weeks (total 18 sessions). How much: Each exercise performed for 10-15 seconds, with 3×5 reps, with rest periods as needed. By whom: Licensed physiotherapist trained in close kinetic chain exercises. Where: Outpatient rehabilitation department of MTH (Madinah Teaching Hospital), Faisalabad; Pro Health Rehab & Medical Centre, Faisalabad; United Hospital, Faisalabad.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Intensity	The visual analogue scale (VAS), a robust and trustworthy self-reported measure of pain, was used to gauge pain severity. The VAS is a 10-cm straight line, with "no pain" at one end and "worst pain" at the other. The participants were asked to mark the location that most accurately reflected the level of pain they were experiencing at the time. Greater pain severity was reflected by higher scores. With reported validity coefficients ranging from r = 0.71 to 0.78 and great reliability (ICC = 0.97), the visual analogue scale is a reliable and valid tool for measuring pain intensity.	Baseline (week 0, before first intervention session), mid-intervention; week 3, after 9th session, and post-intervention (week 6, within 48 hours after the final intervention session)
Knee Function	The kujala anterior knee pain scale (AKPS), a disease-specific questionnaire intended to assess symptoms and functional limitations associated with patellofemoral diseases, was used to measure knee function. Thirteen elements make up the scale, which evaluates pain, limping, swelling, stair climbing, squatting, jogging, jumping, extended sitting, and other functional tasks. Better knee function and less complaints are indicated by higher scores, which range from 0 to 100. A highly valid and reliable tool for assessing symptoms and functional limitations related to patellofemoral diseases is the Kujala Anterior Knee Pain Scale (AKPS). It exhibits great test-retest reliability, greater internal consistency (Cronbach's α = 0.83-0.91), and strong validity (r = 0.90-0.92).	Baseline (week 0, before first intervention session), mid-intervention; week 3, after 9th session, and post-intervention (week 6, within 48 hours after the final intervention session)
Vastus Medialis Oblique Strength	A hand-held dynamometer (Lafayette Instrument Model 01160) was used to evaluate the strength of the vastus medialis oblique (VMO) muscle. In standardized testing positions, participants executed maximal voluntary isometric contractions, and the force produced was measured. Stronger quadriceps and VMO muscles were indicated by higher values. A Hand-Held Dynamometer (HHD; Lafayette 01160) was used to measure the strength of the Vastus Medialis Oblique (VMO) muscle at 60° knee flexion. The HHD's application for assessing lower-extremity muscle strength is supported by its moderate to strong validity (r = 0.62-0.91) and acceptable to excellent reliability (ICC ≥ 0.70).	Baseline (week 0, before first intervention session), mid-intervention; week 3, after 9th session, and post-intervention (week 6, within 48 hours after the final intervention session)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Dynamic Knee Valgus	Kinovea 2D motion analysis software was used to measure dynamic knee valgus. Functional exercises like squatting, step-down chores, and single-leg movements were captured on video. Frontal-plane knee motion was measured and lower-limb alignment was examined using Kinovea software. Greater dynamic knee valgus was indicated by increased medial displacement of the knee during movement. For evaluating lower-extremity kinematics and dynamic movement patterns, such as Dynamic Knee Valgus, Kinovea 2D Motion Analysis Software has shown great concurrent validity and excellent reliability (ICC = 0.916)	Baseline (week 0, before first intervention session) and post-intervention (week 6, within 48 hours after the final intervention session)
Q-Angle	The q-angle was measured using a universal manual goniometer. An imagined line was drawn from the ASIS to the patella center, and another line was drawn from the patella center to the tibial tuberosity in order to calculate the angle. Increased lateral patellar tracking and modified patellofemoral biomechanics are linked to higher Q-angle values. A viable and trustworthy tool for determining the Q-angle is the manual goniometer. Good validity, greater intra-rater reliability (ICC = 0.88), and moderate to high inter-rater reliability (ICC = 0.77-0.85) have all been shown.	Baseline (week 0, before first intervention session) and post-intervention (week 6, within 48 hours after the final intervention session)
Patellar Maltracking	Dynamic knee valgus analysis and q-angle measurements were coupled to evaluate functional patellar maltracking. Instead of static anatomical malalignment, a normal Q-angle in the presence of severe dynamic knee valgus may suggest functional patellar maltracking because of changed lower-extremity movement patterns. This evaluation helped detect aberrant movement patterns causing anterior knee pain and shed light on the mechanics of the patellofemoral joint during functional activities A useful measure of lower-limb alignment during practical activities, functional patellar maltracking assessment using the combination of Normal Q-angle and High Frontal Plane Projection Angle (FPPA) has demonstrated acceptable to strong validity (r ≈ 0.64-0.78) and excellent reliability (ICC ≈ 0.88-0.89).	Baseline (week 0, before first intervention session) and post-intervention (week 6, within 48 hours after the final intervention session)

Collaborators and Investigators

• Sponsor: University of Faisalabad

Publications and helpful links

General Publications

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• Almeida GP, Silva AP, Franca FJ, Magalhaes MO, Burke TN, Marques AP. Q-angle in patellofemoral pain: relationship with dynamic knee valgus, hip abductor torque, pain and function. Rev Bras Ortop. 2016 Feb 9;51(2):181-6. doi: 10.1016/j.rboe.2016.01.010. eCollection 2016 Mar-Apr.
• Alba-Martín P, Gallego-Izquierdo T, Plaza-Manzano G et al. (2015) Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: A systematic review. Journal of Physical Therapy Science 27(7): 2387-2390. Almeida G, Silva A, França F et al. (2016) Q-angle in patellofemoral pain: Relationship with dynamic knee valgus, hip abductor torque, pain and function. Revista Brasileira De Ortopedia 51(2): 181-186. Alrshood A, El Alwani A, Amein NE et al. (2017) A systematic review of the effect of open and closed kinetic chain exercises on the vastus medialis oblique and vastus lateralis muscles of patients with patellofemoral pain syndrome. International Journal of Orthopaedics 3(1): 152-161. Arhos E, Lang C, Steger-May K et al. (2021) Task-specific movement training improves kinematics and pain during the Y-balance test and hip muscle strength in females with patellofemoral pain. Journal of International Society Arthroscopy Knee Surgery and Orthopaedic Sports Medicine 6(5): 277-282. Ayık B, Armağan O and Bakılan F (2025) Comparison of open and closed kinetic chain exercises on vastus medialis and vastus medialis oblique in patellofemoral pain syndrome: A randomized single-blinded, prospective study. Turkish Journal of Physical Medicine & Rehabilitation (2587-1250) 71(2): 216-225. Balci P, Tunay V, Baltaci G et al. (2009) The effects of two different closed kinetic chain exercises on muscle strength and proprioception in patients with patellofemoral pain syndrome. Acta Orthopaedica Et Traumatologica Turcica 43(5): 419-425. Baldon RDM, Serrão FV, Scattone SR et al. (2014) Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: A randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy 44(4): 240-251. Begum MR and Hossain MA (2019) Validity and reliability of visual analogue scale (VAS) for pain measurement. Journal of Medical Case Reports and Review
• Petersen W, Ellermann A, Gösele-Koppenburg A et al. (2014) Patellofemoral pain syndrome. Knee Surgery, Sports Traumatology, Arthroscopy 22(10): 2264-2274. Powers CM (2003) The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: A theoretical perspective. Journal of Orthopaedic & Sports Physical Therapy 33(11): 639-646. Scholtes SA and Salsich GB (2017) A dynamic valgus index that combines hip and knee angles: Assessment of utility in females with patellofemoral pain. International Journal of Sports Physical Therapy 12(3): 333. Scholtes SA and Salsich GB (2020) Consistency of dynamic knee valgus kinematics and pain across functional tasks in females with patellofemoral pain: A cross-sectional study. International Journal of Sports Physical Therapy 15(6): 985. Sheehan FT, Derasari A, Fine KM et al. (2010) Q-angle and j-sign: Indicative of maltracking subgroups in patellofemoral pain. Clinical Orthopaedics and Related Research® 468(1): 266-275. Skouras AZ, Kanellopoulos AK, Stasi S et al. (2022) Clinical significance of the static and dynamic q-angle. Cureus 14(5): e24911. Smith B, Selfe J, Thacker D et al. (2018) Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis. Plos One 13(1): e0190892.
• Ismail M, Gamaleldein M, Hassa K et al. (2013) Closed kinetic chain exercises with or without additional hip strengthening exercises in management of patellofemoral pain syndrome: A randomized controlled trial. The European Journal of Physical and Rehabilitation Medicine 49(5): 687-698. Ittenbach RF, Huang G, Barber Foss KD et al. (2016) Reliability and validity of the anterior knee pain scale: Applications for use as an epidemiologic screener. Plos One 11(7): e0159204. Jamaludin NI, Sahabuddin FNA, Rasudin NS et al. (2022) The concurrent validity and reliability of single leg squat among physically active females with and without dynamic knee valgus. International Journal of Sports Physical Therapy 17(4): 574. Kim H (2025) Effects of selective training on the vastus medialis oblique in patients with patellofemoral pain syndrome. Physical Therapy Rehabilitation Science 14(1): 91-101. Llurda-Almuzara L, Pérez-Bellmunt A, Lopez-De-Celis C et al. (2020) Normative data and correlation between dynamic knee valgus and neuromuscular response among healthy active males: A cross-sectional study. Scientific Reports 10(1): 17206. Mentiplay BF, Perraton LG, Bower KJ et al. (2015) Assessment of lower limb muscle strength and power using hand-held and fixed dynamometry: A reliability and validity study. Plos One 10(10): e0140822. Minoonejad H, Rajabi R, Ebrahimi-Takamjani et al. (2012) Combined open and closed kinetic chain exercises for patellofemoral pain syndrome: A randomized controlled trial. World J Sport Sci 6(3): 278-85. Mozafaripour E, Seidi F, Minoonejad H et al. (2022) The effectiveness of the comprehensive corrective exercise program on kinematics and strength of lower extremities in males with dynamic knee valgus: A parallel-group randomized wait-list controlled trial. BioMed Central Musculoskeletal Disorders 23(1): 700.
• Fehr GL, Cliquet Junior A, Cacho ÊWA et al. (2006) Effectiveness of the open and closed kinetic chain exercises in the treatment of the patellofemoral pain syndrome. Revista Brasileira De Medicina Do Esporte 12(2): 66-70. Fernández-González P, Koutsou A, Cuesta-Gomez A et al. (2020) Reliability of kinovea software and agreement with a three-dimensional motion system for gait analysis in healthy subjects. Sensors 20(11): 3154. Frings J, Dust T, Frosch K et al. (2020) Objective assessment of patellar maltracking with 3 T dynamic magnetic resonance imaging: Feasibility of a robust and reliable measuring technique. Scientific Reports 10(1): 16770. Fukuda TY, Rossetto FM, Magalhães E et al. (2010) Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: A randomized controlled clinical trial. Journal Of Orthopaedic & Sports Physical Therapy 40(11): 736-742. Harvie D, O'leary T, Kumar S et al. (2011) A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: What works? Journal of Multidisciplinary Healthcare 4(2011): 383-392. Holden S, Boreham C, Doherty C et al. (2017) Two-dimensional knee valgus displacement as a predictor of patellofemoral pain in adolescent females. Scandinavian Journal of Medicine & Science in Sports 27(2): 188-194.
• Bolgla L, Gibson H, Hannah D et al. (2023) Comparison of the frontal plane projection angle and the dynamic valgus index to identify movement dysfunction in females with patellofemoral pain. International Journal of Sports Physical Therapy 18(3): 619. Chamorro C, Armijo-Olivo S, De La Fuente C et al. (2017) Absolute reliability and concurrent validity of hand held dynamometry and isokinetic dynamometry in the hip, knee and ankle joint: A systematic review and meta-analysis. Open Medicine 12(1): 359-375. Chang W, Huang W and Lai P (2015) Muscle activation of vastus medialis oblique and vastus lateralis in sling-based exercises in patients with patellofemoral pain syndrome: A cross-over study. Evidence-Based Complementary and Alternative Medicine 2015(1): 740315. Crossley K, Callaghan M and Van Linschoten R (2016a) Patellofemoral pain. British Journal of Sports Medicine 50(4): 247-250. Crossley K, Van Middelkoop M, Callaghan M et al. (2016b) Patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, manchester. Part 2: Recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). British Journal of Sports Medicine 50(14); 844-852. Darabseh M, Aburub A, Altaim T et al. (2024) Validity and reliability of an arabic version of the survey instrument for natural history, aetiology and prevalence of patellofemoral pain studies: A cross-sectional study. International Journal of Environmental Research and Public Health 21(6): 732. De Souza Júnior J, Rabelo P, Lemos T et al. (2024) Effects of two gait retraining programs on pain, function, and lower limb kinematics in runners with patellofemoral pain: A randomized controlled trial. Plos One 19(1): e0295645. Dolak KL, Silkman C, Mckeon JM et al. (2011) Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: A randomized clinical trial. Journal Of Orthop
• Ayık B, Armağan O and Bakılan F (2025) Comparison of open and closed kinetic chain exercises on vastus medialis and vastus medialis oblique in patellofemoral pain syndrome: A randomized single-blinded, prospective study. Turkish Journal of Physical Medicine & Rehabilitation (2587-1250) 71(2): 216-225. Balci P, Tunay V, Baltaci G et al. (2009) The effects of two different closed kinetic chain exercises on muscle strength and proprioception in patients with patellofemoral pain syndrome. Acta Orthopaedica Et Traumatologica Turcica 43(5): 419-425. Baldon RDM, Serrão FV, Scattone SR et al. (2014) Effects of functional stabilization training on pain, function, and lower extremity biomechanics in women with patellofemoral pain: A randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy 44(4): 240-251. Begum MR and Hossain MA (2019) Validity and reliability of visual analogue scale (VAS) for pain measurement. Journal of Medical Case Reports and Reviews 2(11): 2589-8647.
• Arhos EK, Lang CE, Steger-May K, Van Dillen LR, Yemm B, Salsich GB. Task-specific movement training improves kinematics and pain during the Y-balance test and hip muscle strength in females with patellofemoral pain. J ISAKOS. 2021 Sep;6(5):277-282. doi: 10.1136/jisakos-2020-000551. Epub 2021 May 17.
• Alrshood A, El Alwani A, Amein NE et al. (2017) A systematic review of the effect of open and closed kinetic chain exercises on the vastus medialis oblique and vastus lateralis muscles of patients with patellofemoral pain syndrome. International Journal of Orthopaedics 3(1): 152-161.

Study record dates

Study Major Dates

• Study Start (Actual): April 24, 2026
• Primary Completion (Actual): July 10, 2026
• Study Completion (Actual): August 9, 2026

Study Registration Dates

• First Submitted: August 10, 2026
• First Submitted That Met QC Criteria: August 10, 2026
• First Posted (Actual): August 14, 2026

Study Record Updates

• Last Update Posted (Actual): August 14, 2026
• Last Update Submitted That Met QC Criteria: August 10, 2026
• Last Verified: August 1, 2026

More Information

Terms related to this study

• Keywords: Patellofemoral pain syndrome; knee function; Motor control retraining; Close kinetic chain exercises; Vastus medialis oblique; dynamic knee valgus
• Additional Relevant MeSH Terms: Musculoskeletal Diseases; Joint Diseases; Patellofemoral Pain Syndrome
• Other Study ID Numbers: 2024-MS-PT-017

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No