Kinematic and Kinetic Gait Characteristics in People with Patellofemoral Pain: A Systematic Review and Meta-analysis

Males with patellofemoral pain have altered movements during step-down and single-leg squatting tasks compared to asymptomatic males: A cross-sectional study

Background and Aims

Patellofemoral pain (PFP) is common in males, causing reduced physical activity and chronic pain. One proposed cause of PFP is aberrant biomechanics during tasks loading the patellofemoral joint. Consistent evidence exists for females with PFP, but it is uncertain if males with PFP have altered biomechanics. This study investigated the kinematics of males with PFP compared to pain-free males during forward step-down (StDn) and single-leg squat (SLSq).

Methods

A cross-sectional study including 40 males aged 20-39 years (28.28 ± 5.46) was conducted (20 PFP, 20 pain-free). Participants performed StDn and SLSq while motion was captured with a video-based motion capture system (Motion Analysis Corporation). Triplanar peak angles and angular ranges of motion (ROM) of the trunk, pelvis, and weight-bearing hip, knee, and ankle were dependent variables. Mixed-model ANOVA tests were used to determine the presence of significant interactions and main effects of group and task.

Results

Males with PFP had significantly lower peak knee adduction angles compared to pain-free males (p = 0.01). Significant group x task interactions were found for hip and pelvis ROM (p < 0.05). PFP participants had increased hip and pelvis ROM during StDn in the frontal and transverse planes but reduced or nearly equal ROM for these variables during SLSq. Peak hip adduction, hip internal rotation, contralateral pelvic drop and anterior tilt, trunk flexion, and ankle dorsiflexion were greater during StDn compared to SLSq (p < 0.05). ROM of the hip, pelvis, trunk, and ankle were greater during StDn compared to SLSq (p < 0.05).

Conclusion

Males with PFP had reduced peak knee adduction angles in StDn and SLSq. Males with PFP demonstrated increased hip and pelvis ROM during StDn versus SLSq, particularly in the frontal and transverse planes. Clinicians should consider StDn as a clinical test since aberrant movement may be easier to detect than in SLSq.

Influence of musculoskeletal pain during gait on kinematics and selective motor control in individuals with spastic cerebral palsy: A pilot study

BACKGROUND

Individuals with cerebral-palsy commonly present with altered kinematics and selective-motor-control during gait, and may also experience musculoskeletal pain. This pilot study aims to investigate if the immediate experience of musculoskeletal pain during gait influences kinematics and selective-motor-control in individuals with spastic cerebral-palsy.

METHODS

Retrospective treadmill-based gait-analysis data for 145 individuals with spastic cerebral-palsy were screened. Participants were asked about experiencing lower-extremity musculoskeletal pain immediately during gait, with 26 individuals (18%) reporting this was the case (pain-group; mean 11.55 ± 3.15 years, Gross-Motor-Function-Classification-System levels I/II/III n = 5/13/8, Uni/bilateral involvement n = 11/15). Of the 77 individuals who did not report any pain, a no-pain group (n = 26) was individually matched. Kinematics were evaluated using the Gait-Profile-Score and spatiotemporal parameters (dimensionless-walking-speed, single-leg-support percentage and step-time). Selective-motor-control was assessed using the Walking-Dynamic-Motor-Control index.

FINDINGS

In the pain-group, 58% reported experiencing pain in their more-involved leg, 8% in the less-involved leg and 34% in both legs. Regarding the pain location, 38% of the pain-group reported experiencing pain in multiple locations. On a more specific level, 35%, 46% and 54% reported pain around the hip/thigh, knee/calf and ankle/ft, respectively. No significant differences were observed between the pain and no-pain groups for any of the outcome measures, in each leg or bilaterally.

INTERPRETATION

No significant differences in kinematics and selective-motor-control during gait were found between individuals with spastic cerebral-palsy, with and without musculoskeletal pain. This suggests that the individuals in this study may not present with obvious antalgic gait patterns, which may relate to the pre-existing altered kinematics and selective-motor-control.

Reliability and validity of the Turkish version of the patellofemoral pain severity scale in patients with patellofemoral pain syndrome

PURPOSE

The aim of this study was to investigate the Turkish validity and reliability of the Patellofemoral Pain Severity Scale (PSS) in patients with patellofemoral pain (PFP) and to adapt it to Turkish.

MATERIALS AND METHODS

A pilot study was conducted with 10 patients. 123 patients underwent PSS test-retest at 24-48 h intervals. Construct validity, correlations of PSS with other scales Timed Up and Go Test (TUG), Stair Climbing and Descending Test (SCD), Anterior Knee Pain Scale (AKPS), Tegner Activity Scale (TAS), Lysholm Knee Scoring Scale (LDSS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL) were evaluated.

RESULTS

The content validity index value of the scale was 0.95. The overall internal consistency (Cronbach α: 0.88) was high. Item-total correlations of the scale were between 0.51 and 0.7. In the evaluation of the convergent validity of the PSS, it was found that there was a positive correlation between the PSSS and TUG and SCD, and a negative correlation between the PSS, TAS, LDSS and KOS-ADL (p = 0.000).

CONCLUSIONS

In this study, it was determined that the PSSS scale had good internal consistency, test-retest validity and adequate construct validity when compared with the KOS-ADL, LDSS and AKPS.

Changes in Hip and Knee Strength Are Not Associated With Improved Clinical Outcomes After Rehabilitation in Individuals With Patellofemoral Pain: A Critically Appraised Topic

CLINICAL SCENARIO

Patellofemoral pain (PFP) is a widespread knee disorder encountered in clinical practice. Clinicians have often focused on strengthening hip and knee musculature to improve pain and disability, which are the ultimate clinical goals of PFP treatment. However, PFP literature has shown improvement in pain and disability without concurrent changes in lower-extremity strength after rehabilitation. Although some researchers have achieved a significant increase in strength after rehabilitation in PFP cohorts, there was no association with improved pain and disability. The inconsistent improvements in strength and the lack of association with clinical outcomes call for a critical appraisal of the available evidence to better understand the association between changes in hip and knee strength and improved clinical outcomes in individuals with PFP.

CLINICAL QUESTION

Are changes in hip and knee strength associated with improved pain and disability after rehabilitation in individuals with PFP?

SUMMARY OF KEY FINDINGS

Four studies met the inclusion criteria and were included in the appraisal. Following rehabilitation, one study achieved strength improvements in knee extension. One study achieved strength improvements in knee extension, but not in hip external rotation and hip abduction. Two studies did not achieve strength improvements in hip external rotation, hip abduction, hip extension, or knee extension. All included studies achieved improvements in pain or disability after rehabilitation. None of the studies found a significant association between changes in hip and knee strength (either improved or not) and improved pain and disability.

CLINICAL BOTTOM LINE

There is consistent evidence that changes in hip and knee strength are not associated with improved clinical outcomes after rehabilitation in adults with PFP.

STRENGTH OF RECOMMENDATION

Collectively, the body of evidence included is to answer the clinical question aligns with the strength of recommendation of B based on the Strength of Recommendation Taxonomy.

The effect of marathon running on the lower extremity kinematics and muscle activities during walking and running tasks

Patellofemoral pain syndrome (PFPS) is a common injury among runners, and it is thought that abnormal lower extremity biomechanics contribute to its development. However, the relationship between biomechanical changes after a marathon and PFPS injury remains limited. This study aims to investigate whether differences in knee and hip kinematics and lower extremity muscle activities exist in recreational runners before and after a marathon. Additionally, it aims to explore the relationship between these biomechanical changes and the development of PFPS injury. 12 recreational runners participated in the study. Kinematics and muscle activities of the lower extremity were recorded during walking (5 km/h) and running (10 km/h) tasks within 24 hours before and within 5 hours after a marathon. After the marathon, there was a significant decrease in peak knee flexion (walking: p = 0.006; running: p = 0.006) and an increase in peak hip internal rotation (walking: p = 0.026; running: p = 0.015) during the stance phase of both walking and running compared to before the marathon. The study demonstrates a decrease in knee flexion and an increase in hip internal rotation during the stance phase of gait tasks after completing a marathon, which may increase the risk of developing PFPS injury.

Gait biomechanics do not differ between adolescents with and without patellofemoral pain

OBJECTIVES

To determine if adolescents with patellofemoral pain exhibit different biomechanical characteristics to asymptomatic adolescents during walking and running.

METHODS

Twenty-eight adolescents with patellofemoral pain (16 male, 12 female, mean [SD] age: 14.3 [1.7] years) and 24 asymptomatic adolescents (13 male, 11 female, mean [SD] age: 14.1 [1.6] years) participated. Participants walked and ran on an instrumented treadmill in a standardized athletic shoe. Continuous hip, knee, and ankle joint angles and moments, and frontal plane pelvic motion were compared between groups using one-dimensional statistical parametric mapping independent t-tests (alpha <0.05). Cadence and stride length were compared between groups using independent t-tests.

RESULTS

During walking, adolescents with patellofemoral pain had a higher hip extension moment at 7%-8% of the gait cycle (p = 0.04) and walked with a shorter stride length (mean difference [95% confidence interval] = -0.07 [-0.1, -0.01] m). There were no other differences between groups during walking. During running, adolescents with patellofemoral pain had greater knee flexion than asymptomatic adolescents at 35%-40% of the gait cycle (p = 0.04) and ran with a higher cadence (mean difference [95% confidence interval] = 5.8 [2.0, 9.5] steps/min). There were no other statistically significant differences between groups during running.

CONCLUSIONS

Adolescents with patellofemoral pain demonstrate few biomechanical differences to asymptomatic adolescents during walking and running. The identified differences are likely of limited clinical importance. Biomechanical alterations which have been previously associated with patellofemoral pain in adults, may not need to be the target of management of adolescent patellofemoral pain.

Effectiveness of Interventions Aimed at Changing Movement Patterns in People With Patellofemoral Pain: A Systematic Review With Network Meta-analysis

OBJECTIVE: To summarize the effectiveness of interventions for changing movement during weight-bearing functional tasks in people with patellofemoral pain (PFP). DESIGN: Systematic review with network meta-analysis (NMA). LITERATURE SEARCH: Medline, Embase, CINAHL, SPORTDiscus, and Cochrane Library were searched from inception up to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials involving people with PFP and nonsurgical, nonpharmacological interventions on task kinematics were included. DATA SYNTHESIS: NMA was conducted for frontal knee movement data, and pairwise meta-analysis was used to pool data when NMA was not possible. Reduced movements were those changes that indicated movements occurring with less amplitude. The GRADE approach was used to grade the certainty of the evidence. RESULTS: Thirty-seven trials were included (n = 1235 participants). Combining knee/hip exercises with internal feedback had the strongest effect on reducing frontal knee movements (standardized mean difference [SMD] from NMA = -2.66; GRADE: moderate evidence). On pairwise comparisons, the same combination of interventions reduced frontal hip movements (SMD = -0.47; GRADE: moderate evidence) and increased sagittal knee movements (SMD = 1.03; GRADE: moderate evidence), with no effects on sagittal hip movements (GRADE: very low evidence), compared to knee/hip exercises alone. There was no effect for single applications of braces on the frontal knee movement (GRADE: very low evidence) and taping on movements of the knee, hip, and ankle (GRADE: very low to low evidence) compared to no intervention. CONCLUSION: Knee/hip exercises combined with internal feedback techniques may change knee and hip movements in people with PFP. The combination of these interventions can reduce frontal knee and hip movements, and can increase sagittal knee movements. J Orthop Sports Phys Ther 2023;53(12):1-13. Epub 14 September 2023. doi:10.2519/jospt.2023.11956.

A data mining approach for determining biomechanical adaptations in runners who experienced and recovered from patellofemoral pain syndrome

Patellofemoral pain (PFP) is a common musculoskeletal pain disorder experienced by runners. While biomechanics of those with PFP have been extensively studied, methodological considerations may omit important adaptations exhibited by those experiencing and recovered from pain. Instead of a priori selection of discrete biomechanical variables, a data mining approach was leveraged to account for the high dimensionality of running gait data. Biomechanical data of runners symptomatic for, recovered from, and who had never experienced PFP were collected at the 1st (M1) and 21st (M21) minutes of a treadmill run. Principal component analysis and a logistic regression model were used to classify healthy and symptomatic runners, and a feature ranking process determined the important features. The M1 model achieved an accuracy of 82.76% with features related to knee flexion angle, hip abduction moment and gluteus maximus activation, while the M21 model required an additional nine features to achieve an accuracy of 79.31%. Data for recovered runners were projected onto the models, resulting in five and seven out of twelve symptomatic classifications at M1 and M21, respectively. Following the onset of pain, a greater number of features were required to classify runners with PFP, suggesting they may experience individual pain adaptation strategies.

Muscle synergies analysis shows altered neural strategies in women with patellofemoral pain during walking

Several studies suggest that the central nervous system coordinates muscle activation by modulating neural commands directed to groups of muscles combined to form muscle synergies. Individuals with patellofemoral pain (PFP) move differently from asymptomatic individuals. Understanding the neural strategies involved in the execution of tasks such as walking can help comprehend how the movement is planned and better understand this clinical condition. The objective of this study was to compare muscle synergies between women with and without PFP during walking. Eleven women with PFP and thirteen asymptomatic women were assessed using three-dimensional kinematics and electromyography (EMG) while walking at self-selected speed. Kinematics of the trunk, pelvis and lower limbs were analyzed through the Movement Deviation Profile. Muscle synergies were extracted from the EMG signals of eight lower limb muscles collected throughout the whole gait cycle. Kinematic differences between the two groups (p<0.001, z-score = 3.06) were more evident during loading response, terminal stance, and pre-swing. PFP group presented a lower number of muscle synergies (p = 0.037), and greater variability accounted for (VAFtotal) when using 3 (p = 0.017), 4 (p = 0.004), and 5 (p = 0.012) synergies to reconstruct all EMG signals. The PFP group also presented higher VAFmuscle for rectus femoris (p = 0.048) and gastrocnemius medialis (p = 0.019) when considering 4 synergies. Our results suggest that women with PFP show lower motor complexity and deficit in muscle coordination to execute gait, indicating that gait in PFP is the result of different neural commands compared to asymptomatic women.

Cumulative patellofemoral force and stress are lower during faster running compared to slower running in recreational runners

Management strategies for patellofemoral pain often involve modifying running distance or speed. However, the optimal modification strategy to manage patellofemoral joint (PFJ) force and stress accumulated during running warrants further investigation. This study investigated the effect of running speed on peak and cumulative PFJ force and stress in recreational runners. Twenty recreational runners ran on an instrumented treadmill at four speeds (2.5-4.2 m/s). A musculoskeletal model derived peak and cumulative (per 1 km of continuous running) PFJ force and stress for each speed. Cumulative PFJ force and stress decreased with faster speeds (9.3-33.6% reduction for 3.1-4.2 m/s vs. 2.5 m/s). Peak PFJ force and stress significantly increased with faster speeds (9.3-35.6% increase for 3.1-4.2 m/s vs. 2.5 m/s). The largest cumulative PFJ kinetics reductions occurred when speeds increased from 2.5 to 3.1 m/s (13.7-14.2%). Running at faster speeds increases the magnitude of peak PFJ kinetics but conversely results in less accumulated force over a set distance. Selecting moderate running speeds (~3.1 m/s) with reduced training duration or an interval-based approach may be more effective for managing cumulative PFJ kinetics compared to running at slow speeds.

The effects of a two-week neuromuscular intervention on biopsychosocial variables in people with patellofemoral pain: an observational study

Introduction

Patellofemoral pain (PFP) is common and predominately affects active populations. Altered biomechanics and psychosocial variables have been reported in people with PFP, but the effects of neuromuscular exercise on these variables is unknown. We aimed to investigate changes in biopsychosocial measures following a two-week neuromuscular intervention in people with PFP.

Materials and Methods

We measured pain (visual analogue scale), function (Kujala), activity level (Tegner), psychological well-being (Orebro), lower-limb isometric strength (handheld dynamometry), three-dimensional (3D) lower limb kinematics, and surface electromyography (sEMG), in people with PFP. 3D lower-limb kinematics and sEMG were synchronously sampled during step-up, step-down, and overground running. All measures were repeated after participants had completed a two-week neuromuscular intervention consisting of three exercises completed once per day, five days per week.

Results

18 participants completed pre/post testing (60% females, mean age 30.6 years ±7.0, height 173.4cm ±10.4, mass 70.2kg ±12.4, symptom duration 39.0 months ±58.8), with three of 21 participants lost to follow-up. Across all clinical measures (muscle onsets, muscle activation and kinematics), the 95% bootstrapped confidence intervals (CI) of the mean difference contained the null hypothesis following the two-week neuromuscular intervention, indicating no significant differences.

Conclusion

A two-week neuromuscular intervention did not change biomechanical or psychosocial measures in people with PFP. Interventions with a longer duration or greater load magnitude are required to fully evaluate the biopsychosocial mechanisms of effect for exercise in people with PFP.

The effect of biomechanical foot-based interventions on patellofemoral joint loads during gait in adults with and without patellofemoral pain or osteoarthritis: a systematic review protocol

BACKGROUND

Patellofemoral pain is highly prevalent across the lifespan, and a significant proportion of people report unfavourable outcomes years after diagnosis. Previous research has implicated patellofemoral joint loading during gait in patellofemoral pain and its sequelae, patellofemoral osteoarthritis. Biomechanical foot-based interventions (e.g., footwear, insoles, orthotics, taping or bracing) can alter patellofemoral joint loads by reducing motions at the foot that increase compression between the patella and underlying femur via coupling mechanisms, making them a promising treatment option. This systematic review will summarise the evidence about the effect of biomechanical foot-based interventions on patellofemoral joint loads during gait in adults with and without patellofemoral pain and osteoarthritis.

METHODS

MEDLINE (Ovid), the Cumulative Index to Nursing and Allied Health Literature CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), SPORTdiscus (EBSCO) and Embase (Ovid) will be searched. Our search strategy will include terms related to 'patellofemoral joint', 'loads' and 'biomechanical foot-based interventions'. We will include studies published in the English language that assess the effect of biomechanical foot-based interventions on patellofemoral joint loads, quantified by patellofemoral joint pressure, patellofemoral joint reaction force and/or knee flexion moment. Two reviewers will independently screen titles and abstracts, complete full-text reviews, and extract data from included studies. Two reviewers will assess study quality using the Revised Cochrane Risk of Bias (RoB 2) tool or the Cochrane Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tool. We will provide a synthesis of the included studies' characteristics and results. If three or more studies are sufficiently similar in population and intervention, we will pool the data to conduct a meta-analysis and report findings as standardised mean differences with 95% confidence intervals. If a meta-analysis cannot be performed, we will conduct a narrative synthesis of the results and produce forest plots for individual studies.

DISCUSSION

This protocol outlines the methods of a systematic review that will determine the effect of biomechanical foot-based interventions on patellofemoral joint loads. Our findings will inform clinical practice by identifying biomechanical foot-based interventions that reduce or increase patellofemoral joint loads, which may aid the treatment of adults with patellofemoral pain and osteoarthritis.

TRIAL REGISTRATION

Registered with PROSPERO on the 4th of May 2022 (CRD42022315207).