Ankle dorsiflexion range of motion in patellofemoral pain: systematic review and meta-analysis

Catão, Álvaro Thyerre Miranda; Cunha, Mônica Batista; Klippel, Nathália Nazareth; Macedo, Leandro Roberto de; Zacaron, Katy Andrade Monteiro

doi:10.1590/fm.2025.38208

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REVIEW ARTICLE • Fisioter. Mov. 38 • 2025 • https://doi.org/10.1590/fm.2025.38208 linkcopy

Ankle dorsiflexion range of motion in patellofemoral pain: systematic review and meta-analysis

Amplitude de movimento de dorsiflexão do tornozelo na dor femoropatelar: revisão sistemática e metanálise

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction Decreased ankle dorsiflexion (ADF) range of motion (ROM) during dynamic activities has been reported in subjects with patellofemoral pain (PFP) and is theorised to play a role in its development.

Objective To compare the maximum ADF angle between individuals with PFP and asymptomatic controls.

Methods A systematic review and meta-analysis of studies of humans with PFP undergoing maximum ADF angle assessment, published in peer-reviewed journals in English. We searched CINAHL, Cochrane CENTRAL, EMBASE, LILACS, MEDLINE, PEDro, SciELO, SCOPUS, SPORTDiscus, and Web of Science databases. The outcome of interest was PFP, and the exposure of interest was maximum ADF ROM. Data extraction and risk-of-bias scoring were conducted in duplicate and independently. The Joanna Briggs Institute critical appraisal tools were used to assess the risk of bias. Effect sizes were pooled using random-effects models and reported as standardised mean differences (SMD). Subgroup analyses were conducted for ADF assessment characteristics.

Results Twelve studies providing 15 datasets were included. No significant difference in maximum ADF was found between individuals with PFP and asymptomatic controls (SMD = -0.3875; 95% CI: -1.02 to 0.25; p = 0.2123), with high heterogeneity (I² = 95.56%). Subgroup analysis showed differences related to the type of assessment (active or passive) but not to position or weight-bearing status.

Conclusion Maximum ADF does not consistently differ between individuals with PFP and asymptomatic controls. Assessment of this variable in isolation does not appear sufficient to explain the presence of patellofemoral pain.

Keywords:
Patellofemoral pain; Ankle; Dorsiflexion; Meta-analysis; Range of motion

Study	PFP participants^a	Control participants^a	PFP inclusion criteria	Activity
Barton et al., 2010²¹	n = 20; 75% female Age = 22.8 ± 4.1 years BMI = 23.7 ± 3.5 kg/m²	n = 20; 75% female Age = 21.9 ± 3.5 years BMI = 22.0 ± 3.3 kg/m²	> 6 weeks > 30 (VAS: 0-100)	MD
Branco et al., 2022³¹	n = 26; 19.2% female Age = 35.5 ± 5.6 years BMI = 25.0 ± MD kg/m²	n = 24; 29.7% female Age = 38.8 ± 7.6 years BMI = 24.5 ± MD kg/m²	> 12 weeks > 3 (NPS: 0-10)	Cycling
Emamvirdi et al., 2023⁸	n = 20; 100% female Age = 23.1 ± 2.1 years BMI = 20.2 ± 0.7 kg/m²	n = 20; 100% female Age = 22.8 ± 2.3 years BMI = 20.2 ± 0.6 kg/m²	> 12 weeks > 3 (NPRS: 0-10)	Basketbal
Hassan et al., 2022⁷	n = 70; 61% female Age = 25.5 ± 3.5 years BMI = 23.7 ± 3.2 kg/m²	n = 70; 50% female Age = 24.9 ± 6.1 years BMI = 24.0 ± 2.4 kg/m²	> 12 weeks > 3 (VAS: 0-10)	MD
Study	PFP participants^a	Control participants^a	PFP inclusion criteria	Activity
Manojlović et al., 2022²⁵	n = 18; 72.2% female Age = 24.6 ± 12.5 years BMI = 22.7 ± 3.8 kg/m²	n = 37; 70.3% female Age = 21.6 ± 8.8 years BMI = 21.9 ± 2.9 kg/m²	> 12 weeks > 3 (VAS: 0-10)	MD
Messier et at., 1991³³	n = 16; 25% female Age = MD ± MD years BMI = MD ± MD kg/m²	n = 20; 30% female Age = MD ± MD years BMI = MD ± MD kg/m²	MD MD	Running
Mølgaard et al., 2011³²	n = 13; 69% female Age = 16.9 ± 0.8 years BMI = 20.7 ± 1.8 kg/m²	n = 22; 68% female Age = 16.7 ± 0.1 years BMI = 21.4 ± 2.5 kg/m²	> 4 weeks MD	MD
Piva et al., 2005⁹	n = 30; 57% female Age = 25.8 ± 6.0 years BMI = 26.7 ± MD kg/m²	n = 30; 56.7% female Age = 25.7 ± 5.9 years BMI = 23.6 ± MD kg/m²	> 4 weeks > MD (NPRS: 0-10)	Mixed
Rodrigues et al., 2023²⁷	n = 15; 100% female Age = 26.3 ± 4.2 years BMI = 24.5 ± 3.6 kg/m²	n = 15; 100% female Age = 29 ± 5.2 years BMI = 23.1 ± 3.3 kg/m²	> 8 weeks > 3 (VAS: 0-10)	MD
Silva et al., 2018¹⁰	n = 23; 100% female Age = 34.3 ± 2.4 years BMI = 22.3 ± MD kg/m²	n = 23; 100% female Age = 34.3 ± 2.4 years BMI = 22.3 ± MD kg/m²	MD MD	MD
Steinberg et al., 2017²⁸	n = 271; 100% female Age = MD ± MD years BMI = 17.6 ± 1.1 kg/m²	n = 271; 100% female Age = MD ± MD years BMI = 17.7 ± 1.9 kg/m²	MD MD	Dance
Witvrouw et al., 2000²⁹	n = 24; 55% female Age = 18.6 ± MD years BMI = 21.2 ± MD kg/m²	n = 258; 45.7% female Age = 18.6 ± MD years BMI = 21.5 ± MD kg/m²	> 6 weeks MD	Mixed

Study	Method	Knee extended		Knee flexed
Study	Method	PFP	Control	PFP	Control
Manojlović et al., 2022²⁵	Non-weight-bearing	18.2^Pα	15.2^Pα	—	—
Messier et at., 1991³³		6.3^Aα	6.4^Aα	—	—
Mølgaard et al., 2011³²		22.2^Pα*	17.7^Pα	—	—
Piva et al., 2005⁹		7.4^Aα*	17.6^Aα	14.8^Aα*	21.7^Aα
Steinberg et al., 2017²⁸		12.3^Pα*	11.0^Pα	—	—
Rodrigues et al., 2023²⁷		—	—	34.3^Pα	31.8^Pα
Barton et al., 2010²¹	Weight-bearing	40.9^Aβ	34.8^Aβ	47.5^Aβ	43.7^Aβ
Branco et al., 2022³¹		—	—	44.6^Aβ	43.2^Aβ
Emamvirdi et al., 2023⁸		—	—	41.0^Aβ*	46.9^Aβ
Hassan et al., 2022⁷		21.6^Aβ	22.9^Aβ	30.2^Aβ*	33.2^Aβ
Silva et al., 2018¹⁰		—	—	17.3^Aβ*	34.1^Aβ
Witvrouw et al., 2000²⁹		32.1^Aα*	35.2^Aα	—	—

Subgroup	No. of data (n)	Effect size (95% CI)	p-value	I² (%)	p heterogeneity	p for between*
ADF movement	-		0.0155	85.00	-
Active	10 (888)	-0.45 (-1.00 to 0.09)	0.0934	88.43	< 0.0001	< 0.0001
Passive	4 (662)	0.42 (0.01 to 0.83)	0.0463	29.73	0.2781	< 0.0001
Knee	-		0.5583	91.18	-
Extended	8 (1,190)	-0.07 (-0.76 to 0.61)	0.8056	92.78	< 0.0001	< 0.0001
Flexed	6 (360)	-0.33 (-1.17 to 0.51)	0.3606	87.51	< 0.0001	< 0.0001
Weight-bearing	-		0.9761	90.79	-
NWB	7 (818)	-0.19 (-1.14 to 0.76)	0.6447	93.84	< 0.0001	< 0.0001
WB	7 (732)	-0.19 (-0.70 to 0.33)	0.4075	78.84	0.0011	< 0.0001
Knee extended	-		0.8377	92.43	-
NWB	5 (728)	-0.02 (-1.33 to 1.28)	0.9611	94.38	< 0.0001	< 0.0001
WB	3 (462)	-0.20 (-1.15 to 0.74)	0.4521	58.00	0.1049	< 0.0001
Knee flexed	-		0.5686	89.09	-
NWB	2 (90)	-0.60 (-11.2 to 9.1)	0.6017	92.20	0.0004	< 0.0001
WB	4 (270)	-0.19 (-1.35 to 0.97)	0.6358	85.76	0.0005	< 0.0001

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[TFN1] Note: BMI = body mass index; MD = missing data; NPRS = Numerical Pain Rating Scale; NPS = Numerical Pain Scale; PFP = patellofemoral pain;

[TFN2] VAS = visual analogue scale. Age and BMI values are presented as mean ± standard deviation.