Strain Counterstrain Versus Graston Technique for Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome (PFPS) is a common musculoskeletal condition characterized by anterior knee pain, especially during activities like squatting, climbing stairs, or prolonged sitting. Conservative management through manual therapy is widely used, but comparative effectiveness of different techniques remains unclear.

This randomized clinical trial was designed to compare the effects of Strain Counterstrain (SCS) technique versus Graston Technique on pain intensity, knee range of motion, and functional status in patients diagnosed with patellofemoral pain syndrome.

A total of 60 participants diagnosed with PFPS were recruited and randomly allocated into two equal groups, with 30 patients in each group. Group A received Strain Counterstrain technique, which involves passive positioning of the affected tissue to achieve a position of comfort and reduce tender point sensitivity. Group B received Graston Technique, an instrument-assisted soft tissue mobilization (IASTM) therapy that uses specialized stainless steel instruments to detect and treat soft tissue restrictions, scar tissue, and fascial adhesions around the knee.

The intervention period lasted for 12 weeks with 3 sessions per week. Outcome measures were assessed at baseline and post-intervention. Pain was evaluated using the Kujala Anterior Knee Pain Scale, also known as the Kujala Scoring System, which is a validated tool for PFPS. Functional status was assessed using a substructural questionnaire evaluating daily activities. Knee range of motion was measured using a standard goniometer.

The primary objective of this study is to determine whether Strain Counterstrain or Graston Technique provides superior outcomes in terms of pain reduction, improved range of motion, and enhanced functional capacity in patients with patellofemoral pain syndrome. The findings will help clinicians select the most effective manual therapy approach for managing PFPS.

• Strain Counterstrain (Procedure), also known as Positional Release Therapy, SCS: Strain Counterstrain is a manual therapy technique that involves identifying tender points in muscles and fascia. The therapist passively positions the patient's body to a position of comfort that reduces or eliminates the tenderness. This position is held for 90 seconds to allow neuromuscular reset, followed by slow return to neutral. The technique aims to reduce muscle spasm, normalize proprioceptive activity, and decrease pain in patients with patellofemoral pain syndrome. Sessions were administered 3 times per week for 12 weeks.
• Graston Technique (Procedure), also known as Instrument-Assisted Soft Tissue Mobilization, IASTM: Graston Technique is an evidence-based form of instrument-assisted soft tissue mobilization (IASTM). It uses six specialized stainless steel instruments to scan, detect, and treat soft tissue lesions, scar tissue, and fascial restrictions. The instruments are used by trained clinicians to apply controlled microtrauma to affected areas around the knee, promoting tissue healing and remodeling. The goal is to break down adhesions, reduce pain, and improve range of motion and function in patients with patellofemoral pain syndrome. Sessions were administered 3 times per week for 12 weeks.

Primary outcomes

• Change in Pain and Function using Kujala Anterior Knee Pain Scale [Baseline and 12 weeks post-intervention]: The Kujala Anterior Knee Pain Scale, also known as Kujala Scoring System, was used to assess pain and functional limitations related to patellofemoral pain syndrome. This is a 13-item self-administered questionnaire evaluating symptoms such as pain during walking, stair climbing, squatting, running, and prolonged sitting. The total score ranges from 0 to 100 points, where 0 represents complete disability and 100 represents no disability. A higher score indicates less pain and better knee function. Change from baseline was calculated to determine treatment effectiveness.

Secondary outcomes

• Change in Knee Range of Motion [Baseline and 12 weeks post-intervention]: Knee flexion and extension range of motion was measured using a standard universal goniometer. Active range of motion was recorded in degrees. Increased range of motion indicates improvement in knee function.
• Change in Functional Status [Baseline and 12 weeks post-intervention]: Functional status was assessed using a substructural questionnaire evaluating the impact of patellofemoral pain syndrome on daily activities such as walking, stair climbing, squatting, and prolonged sitting. Higher scores indicate better functional capacity.

Sex: All, ages: 18 Years to 45 Years

Inclusion Criteria:

* Age 18-45 years.
* Anterior or peripatellar knee discomfort reproduced by a minimum of two aggravating exercises (e.g., squatting, stairs, running, prolonged sitting).
* No history of trauma.
* On the Numerical Pain Rating Scale (NPRS), pain severity is ≥3/10 at baseline.
* Symptom duration ≥2 months.
* Ability to understand instructions and provide informed consent (or parental consent for minors).

Exclusion Criteria:

* Individuals who have had lower limb surgery within the previous 12 months
* Existence of other knee pathologies (e.g., meniscal tear with locking, tibiofemoral osteoarthritis, inflammatory arthritis).
* Skin infection, open wound, or dermatological condition at the treatment site.
* Use of anticoagulants/bleeding disorders or recent corticosteroid injection within 3 months.
* Receipt of manual therapy (SCS, IASTM/Graston) to the affected knee within the past 4 weeks.