Relationship between rearfoot, tibia and femur kinematics in runners with and without patellofemoral pain

doi:10.1016/j.gaitpost.2018.02.008

Gait & Posture

Volume 61, March 2018, Pages 416-422

https://doi.org/10.1016/j.gaitpost.2018.02.008 Get rights and content

Highlights

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Lower limb kinematic correlation is different between runners with and without PFP.
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Only the PFP group showed a correlation between rearfoot eversion and femur adduction.
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Distal factors in PFP runners should be considered in the clinical settings.

Abstract

Background

Patellofemoral pain (PFP) is the most common running overuse injury. Excessive rearfoot eversion is commonly considered as a PFP risk factor and the relationship between ankle-foot complex movement and lower limb may be involved with this dysfunction. The purpose of this study was to evaluate the correlation between rearfoot eversion with tibia and femur kinematics in frontal and transverse planes during running in individuals with and without PFP. The secondary purpose was to compare the lower limb kinematics between runners with and without PFP.

Methods

Fifty-four recreational runners were divided into 2 groups: healthy runners (CG, n = 27) and runners with patellofemoral pain (PFPG, n = 27). Kinematics during running were assessed using three-dimensional motion analysis system. Pearson's correlation coefficients (r) were calculated to establish the correlation of rearfoot eversion with tibial and femur movements.

Findings

Greater peak rearfoot eversion was correlated with greater peak femur adduction in PFP runners. Greater peak rearfoot eversion was correlated with greater peak tibial internal rotation and tibial adduction in the PFPG and CG. Additionally, greater peak rearfoot eversion was correlated with greater tibial internal rotation range of motion in the PFPG and CG. No significant differences were found between the PFPG and CG for all kinematics variables.

Interpretation

Correlation between greater rearfoot eversion and greater peak hip adduction in the PFPG might be related to PFP persistence in runners with excessive rearfoot eversion, and indicates that treatment strategies aimed at controlling the movement of the rearfoot could help modify the symptoms.

Introduction

The quest for a healthier lifestyle has resulted in an increasing number of people practicing physical activity around the world [1]. The number of runners and running events has been increasing steadily since the 2000 s [2]. However, running has been associated with a potential injury risk that accompanies the accelerated pace of activity growth at a competitive and recreational level [3]. Patellofemoral pain (PFP) is the most common overuse running injury in the knee joint (prevalence of 7.4–15.6%) [4].

The etiology of PFP is not yet clearly defined [5] and remains an issue [6]. Although some possible mechanisms have been discussed in the literature, one theory is that PFP results from increased patellofemoral joint stress [[7], [8]]. Excessive subtalar pronation (measured as rearfoot eversion) can be considered as an intrinsic risk factor related to a higher lateral patellofemoral stress and subsequent development of PFP [6].

According to Tiberio's theory [9], an excessive or prolonged foot pronation during the stance phase of gait could result in greater tibial internal rotation. To achieve knee extension during the midstance, the femur should internally rotate to ensure adequate motion for the screw-home mechanism [10]. Furthermore, due to the tight fit of the talus within the ankle, the excessive subtalar pronation could increase the tibia and femur motion in the frontal plane (tibia abduction and femur adduction) [[10], [11]]. These kinematic variations would result in an increase of the Q angle (quadriceps angle) and the lateral patellofemoral stress [10].

Studies have shown an absence of coupling relationship between the ankle-foot complex magnitude of motion and the lower limb rotation in the transverse plane during gait in healthy individuals [[12], [13], [14]]. However, other results reported a coupled relationship between the rearfoot and the tibial internal rotation during running [[15], [16], [17], [18], [19]]. Furthermore, Resende et al. [20] reported the existence of a coupling between rearfoot eversion and femur internal rotation during gait in the same population. To the best of the authors’ knowledge, two studies evaluated the correlation between the rearfoot eversion and lower limb kinematics in individuals with PFP [[6], [21]]. De Oliveira Silva et al. [21] reported no significant correlation between peak rearfoot eversion and peak hip adduction in healthy and PFP women during stair ascent. Barton et al. [6] reported that greater peak rearfoot eversion was correlated with greater peak tibial internal rotation in the PFP group and greater rearfoot eversion range of motion (ROM) was correlated with greater hip adduction ROM during gait. It is possible that the relationship between rearfoot and lower limb motion explains the foot orthoses effectiveness application in PFP patients symptoms reduction [[22], [23], [24], [25], [26], [27], [28], [29], [30]]. There is no evidence of the relationship between rearfoot eversion with femur and tibia kinematics in patients with PFP during running.

Considering that PFP as one of the most common dysfunction in runners and the alteration in the coupling between the ankle-foot complex and the lower limb movements in the transverse and frontal planes may be involved with this dysfunction, it is important to evaluate the relationship between the rearfoot eversion and tibia and femur kinematics in subjects with PFP during running. Thus, the primary aim of this study was to evaluate the correlation between rearfoot eversion and tibia and femur kinematics in frontal and transverse planes in runners with and without PFP. The secondary purpose was to compare the lower limb kinematics between runners with and without PFP. Even in the absence of differences in kinematics between the groups the correlation of the movements between the segments may be different. It was hypothesized that greater peak rearfoot eversion is correlated with greater tibial internal rotation and abduction (peak and ROM), and with greater femur adduction (peak and ROM) and internal rotation (peak) in individuals with PFP; and this relationship is different between individuals with and without PFP.

Section snippets

Participants

Fifty-four recreational runners were divided into 2 groups: healthy runners (CG, n = 27) and runners with patellofemoral pain (PFPG, n = 27). An a priori sample size was calculated (G*Power software, Version 3.1.3) using the Pearson correlation test (significance level α = 0.05, β = 0.80 and r = 0.39). The r value was performed according to the correlation between the peak rearfoot eversion and peak tibial internal rotation using the Pearson correlation coefficient analyses [6], which resulted

Results

Demographic characteristics for both groups are shown in Table 1. PFP subjects had a significantly lower running distance (km/week) (P = 0.046) and running experience time (P = 0.018) compared to CG. All other variables were similar between groups. The mean of the worst pain intensity for PFP group was 4/10. The mean scores of the AKPS and LEFS questionnaires were 78/100 and 66/80, respectively for this group.

Discussion

Previous theoretical studies have suggested that one of the risk factors for the PFP development is the correlation between the excessive rearfoot eversion with the tibia and femur kinematics [[9], [10]]. However, few studies have evaluated this correlation in patients with PFP [[6], [21]]. To our knowledge, no study has evaluated this relationship in runners with PFP. This is an important consideration since PFP is the most prevalent overuse injury in the runner’s knee. Although the peak

Conclusion

PFPG showed peak rearfoot eversion correlation with: peak tibial internal rotation, peak femur adduction, peak tibial adduction and tibial internal rotation ROM. The only different correlation of the CG was between peak rearfoot eversion and peak femur adduction, which indicates a possible relationship with the persistent PFP in runners with greater rearfoot eversion. This study highlights the need to address distal factors (i.e., foot orthoses) in runners’ rehabilitation with PFP and greater

Conflict of interest statement

The authors do not have any conflict of interest that could inappropriately influence this research.

Acknowledgements

The authors gratefully acknowledge the financial support from the Coordenação de Apoio a Pessoal de Ensino Superior (CAPES). These sponsors had no involvement with the study design, data collection, analysis and interpretation of data, in the writing of this manuscript, or in the decision to submit it for publication.

References (57)

C.J. Barton et al.
The relationship between rearfoot: tibial and hip kinematics in individuals with patellofemoral pain syndrome
Clin. Biomech.
(2012)
C. Nester
The relationship between transverse plane leg rotation and transverse plane motion at the knee and hip during normal walking
Gait Posture
(2000)
B.M. Nigg et al.
Effects of arch height of the foot on angular motion of the lower extremities in running
J. Biomech.
(1993)
A. Stacoff et al.
Tibiocalcaneal kinematics of barefoot versus shod running
J. Biomech.
(2000)
M.B. Pohl et al.
Changes in foot and lower limb coupling due to systematic variations in step width
Clin. Biomech.
(2006)
M. Eslami et al.
Forefoot-rearfoot coupling patterns and tibial internal rotation during stance phase of barefoot versus shod running
Clin. Biomech.
(2007)
R.A. Resende et al.
Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking
Gait Posture
(2015)
D. De Oliveira Silva et al.
Proximal mechanics during stair ascent are more discriminate of females with patellofemoral pain than distal mechanics
Clin. Biomech.
(2016)
C.J. Barton et al.
Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review
Gait Posture
(2009)
J.A. Zeni et al.
Two simple methods for determining gait events during treadmill and overground walking using kinematic data
Gait Posture
(2008)

R.E. Fellin et al.

Comparison of methods for kinematic identification of footstrike and toe-off during overground and treadmill running

J. Sci. Med. Sport

(2010)

E.S. Grood et al.

A joint coordinate system for the clinical description of three-dimensional motions: application to the knee

J. Biomech. Eng.

(1983)

B. Noehren et al.

Prospective evidence for a hip etiology in patellofemoral pain

Med. Sci. Sports Exerc.

(2013)

T.A. Dierks et al.

Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run

J. Orthop. Sports Phys. Ther.

(2008)

R.B. Souza et al.

Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain

J. Orthop. Sports Phys. Ther.

(2009)

M.J. Callaghan et al.

Gait analysis in patients with anterior knee pain

Clin. Biomech.

(1994)

A.D. Wirtz et al.

Hong DA: Patellofemoral joint stress during running in females with and without patellofemoral pain

Knee

(2012)

J. Selfe et al.

Are there three main subgroups within the patellofemoral pain population? A detailed characterisation study of 127 patients to help develop targeted intervention (TIPPs)

Br. J. Sports Med.

(2016)

H.H. Huberti et al.

Patellofemoral contact pressures: the influence of q-angle and tendofemoral contact

J. Bone Joint Surg. Am.

(1984)

J.E. Taunton et al.

Retrospective case-control analysis of 2002 running injuries

Br. J. Sports Med.

(2002)

K.B. Fields et al.

Prevention of running injuries

Curr. Sports Med. Rep.

(2010)

R.T.H. Cheung et al.

Association of footwear with patellofemoral pain syndrome in runners

Sports Med.

(2006)

A.D. Lopes

Hespanhol Júnior LC: yeung SS, costa LOP: what are the main running-related musculoskeletal injuries? a systematic review

Sports Med.

(2012)

R.B. Souza et al.

Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis

J. Orthop. Sports Phys. Ther.

(2010)

V. Sanchis-Alfonso et al.

Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young

Am. J. Knee Surg.

(1999)

J. Heino Brechter et al.

Patellofemoral stress during walking in persons with and without patellofemoral pain

Med. Sci. Sports Exerc.

(2002)

D. Tiberio

The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model

J. Orthop. Sports Phys. Ther.

(1987)

C.M. Powers

The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective

J. Orthop. Sports Phys. Ther.

(2003)

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Patellofemoral Pain Syndrome is the most common cause of anterior knee pain, especially in active young people. This study aimed to evaluate the effect of lumbopelvic manipulation on electromyography parameters of gluteus medius and vastus medialis in patients with patellofemoral pain syndrome.
In this double-blind placebo-controlled randomized clinical trial study, 26 patients with a diagnosis of patellofemoral pain syndrome were randomly divided into two groups. The first group received Lumbopelvic manipulation and the second group was a control group that received placebo manipulation. Electromyography activity of vastus medialis and gluteus medius muscles were evaluated as primary outcomes during the single-leg squat; pain intensity during rest and functional tasks (step up, step down, single leg squat) were assessed by numerical pain rating scale. Functional status was evaluated by step-down test and the score of the Kujala patellofemoral questionnaire, as secondary outcomes. All evaluations were performed before and after the intervention, except pain intensity at rest and the Kujala patellofemoral questionnaire that were assessed before the intervention and one week after.
In both groups, no significant difference was observed before and after the intervention in terms of average amplitude and the onset of gluteus medius and vastus medialis. However, in the lumbopelvic manipulation group, pain intensity during rest and functional tests significantly decreased compared to the control group. Functional status significantly improved in the lumbopelvic manipulation group, with no significant difference between group comparisons.
Lumbopelvic manipulation caused a reduction in pain intensity and improvement of functional status in the rehabilitation of patients with patellofemoral Pain Syndrome. However, it seems that this method could not change the EMG activity of muscles in these patients.
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  The results of present study can help physiotherapists to understand the possible underlying pathomechanics of patellofemoral pain syndrome and more effective treatment of these group of patients.
Are proximal and distal neuromuscular parameters able to predict hip and knee frontal plane kinematics during single-leg landing?
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Specifically, weakness of hip abductors, extensors, and external rotators were associated with greater knee valgus during single-leg landing (Dix et al., 2019). However, an important relationship between hip and ankle/foot movements has also been observed, which can mutually contribute to excessive dynamic knee valgus (Lee & Powers, 2014; Luz et al., 2018). Adjustments through movements at the ankle and hip are adopted to keep the center of gravity close to the support base (Horak, 1987), demonstrating a coordinated control of the hip and ankle for maintaining balance.
To determine if proximal and distal neuromuscular parameters (EMG amplitude and median frequency – MDF) can predict frontal plane kinematics during single-leg landing.
Cross sectional study.
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Fifteen participants (7 female) performed six single-leg landings with measures of frontal plane kinematics and EMG obtained 230 ms after first foot contact, totalizing 90 landings.
(i) 2D hip adduction [hip ADD] and knee frontal plane projection angle [knee FPPA]; (ii) EMG amplitude and MDF of gluteus medius [GMed], tensor fascia latae [TFL], peroneus longus [PL] and tibialis anterior [TA].
We observed that MDF of TA was a significant predictor of hip ADD (p = 0.037; β = −0.049 Hz; R²c = 0.30). Also, MDF of PL was significant predictor of knee FPPA (p = 0.043; β = 0.042 Hz; R²c = 0.37). Hip muscles and EMG amplitude parameters were not considered predictors of frontal plane kinematics.
The firing frequency of ankle muscles predicted the variance of hip and knee frontal plane kinematics during single-leg landing.
Do hip strength, flexibility and running biomechanics predict dynamic valgus in female recreational runners?
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On the other hand, models to estimate PHIR and EHIR had a negative correlation with peak ankle eversion. Recent studies did not find a strong correlation and coupling between ankle eversion and hip internal rotation during running [27]. The observed negative correlations could be explained by the weak coupling between peak ankle eversion and hip internal rotation.
Dynamic valgus has been the focus of many studies to identify its association to an increased risk of running-related injuries. However, it is not known which physical and biomechanical variables are associated with this movement dysfunction. Research question: This study aimed to test the correlation between strength, flexibility and biomechanical variables and dynamic valgus in female runners.
Twenty-nine healthy females ran on a treadmill at 2.92 m/s and performed strength, range of motion and endurance tests. Pelvic, hip and ankle kinematics were measured with a 3D motion analysis system. Six multiple linear regression models were used to identify the ability of physical and biomechanical variables to predict excursion and peak of contralateral pelvic drop, hip adduction and internal rotation.
Contralateral pelvic drop and hip adduction were positively correlated to ankle eversion and step cadence. Hip internal rotation had a negative correlation with ankle eversion. Despite significance, predictor variables explained less than 30% of dynamic valgus variance during running. No interest variable had significant correlation with the hip strength and hip and ankle passive range of motion.
The results showed that distal joint kinematics and spatiotemporal variables should be considered during biomechanical running analysis to identify their possible relationship with joint overload caused by dynamic valgus. Caution should be taken when linking hip disorders during running to posterolateral hip strength and stiffness, core endurance, and ankle dorsiflexion range of motion since no correlation occurred amongstthese variables in this sample of female runners.
A low-cost wireless system of inertial sensors to postural analysis during human movement
2019, Measurement: Journal of the International Measurement Confederation
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One of the methods to investigate the causes of PFP has been to observe the rearfoot strike pattern by analyzing human movement based on video recordings. This strategy has been applied usually using commercial devices with sampling rate with around 200 Hz [30,31,14]. However, the information for gait patterns corresponds to 0.6–5.0 Hz [32–35].
The dynamics of the human body has generated considerable recent research interest among scientist devoted to reducing the number of injuries and for performance improvement. In these studies, the investigation is usually addressed by means of commercial devices based on video recordings. However, these systems based on video recordings are usually expensive and require suitable laboratories for their use, which makes it unfeasible to collect data for activities outside controlled environments. In this work, we have shown that it is possible to present similar results with a much lower sampling rate, focusing on the evaluation of minimum and maximum values of the gait. As a result, it has been possible to develop a wearable, compact, portable, low-cost, wireless and embedded system to simultaneously analyze the three-dimensional angular position in eight points. This technology can be used in many sorts of environments. It is also possible to access information in real time with reliable and accurate measurements by means of simple modelling for the use of fusion techniques implemented in the microcontroller. Tests were conducted to evaluate the metrological characteristics of the system using the Complementary Filter (CF) and the Kalman Filter (KF). An algorithm of evolutionary strategies tuned both filters, providing errors of less than 5% for static situations in the measurement of the angular position over the entire system utilization range. Our results have been compared with the commercial system Qualisys Motion-Capture. The statistical method elaborated by Bland and Altman has been used. We have found our method yields a motion analyses in good agreement with results using post-processed video.
Effects of medially wedged insoles on the biomechanics of the lower limbs of runners with excessive foot pronation and foot varus alignment
2019, Gait and Posture
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The insole increased knee range of motion in the frontal plane and reduced hip adduction during the stance phase. This finding is in accordance with the findings of a previous study demonstrating that hip adduction is correlated with foot pronation during the stance phase of running of runners with patellofemoral syndrome [44]. Therefore, the reduction in foot pronation caused by the insole help to explain why the insole also reduced hip adduction.
Excessive foot pronation during running in individuals with foot varus alignment may be reduced by medially wedged insoles.
This study investigated the effects of a medially wedged insole at the forefoot and at the rearfoot on the lower limbs angles and internal moments of runners with excessive foot pronation and foot varus alignment.
Kinematic and kinetic data of 19 runners (11 females and 8 males) were collected while they ran wearing flat (control condition) and medially wedged insoles (insole condition). Both insoles had arch support. We used principal component analysis for data reduction and dependent t-test to compare differences between conditions.
The insole condition reduced ankle eversion (p = 0.003; effect size = 0.63); reduced knee range of motion in the transverse plane (p = 0.012; effect size = 0.55); increased knee range of motion in the frontal plane in early stance and had earlier knee adduction peak (p = 0.018; effect size = 0.52); reduced hip range of motion in the transverse plane (p = 0.031; effect size = 0.48); reduced hip adduction (p = 0.024; effect size = 0.50); reduced ankle inversion moment (p = 0.012; effect size = 0.55); and increased the difference between the knee internal rotation moment in early stance and midstance (p = 0.012; effect size = 0.55).
Insoles with 7˚ medial wedges at the forefoot and rearfoot are able to modify motion and moments patterns that are related to lower limb injuries in runners with increased foot pronation and foot varus alignment with some non-desired effects on the knee motion in the frontal plane.
Effect of patellofemoral pain on foot posture and walking kinematics
2019, Gait and Posture
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Barton et al. [4] identified low associations between the range of rearfoot eversion and hip adduction in both PFP and healthy controls, and between peak rearfoot eversion and tibial internal rotation only in PFP, suggesting tibial rotation is involved in PFP pathology. Other studies refuted an association between tibial rotation and peak rearfoot eversion [5] and foot pronation [6]. Discrepant findings may be partly attributable to different kinematic foot models and in particular to the use of single-segment foot modelling, which focuses on rearfoot motion.
Background Excessive pronation has been implicated in patellofemoral pain (PFP) aetiology and foot orthoses are commonly prescribed for PFP patients. Pronation can be assessed using foot posture tests, however, the utility of such tests depends on their association with foot and lower-limb kinematics.
Research questions Do PFP participants compared with healthy participants (1) have a more pronated foot measured with static foot tests and a kinematic multi-segmental foot model and (2) is there an association between static foot posture and foot and lower limb kinematics during walking?
Methods A case-control study including 22 participants (n = 11 PFP, 5 females per group, aged 24 ± 3 (mean ± SD) years) was conducted. Foot posture measures included Arch Height Ratio, Navicular Drop (ND), and Foot Posture Index. Between-group comparisons of foot posture, segment and joint angle magnitudes, and associations between foot posture and kinematic data during gait were evaluated.
Results There were no group differences in foot posture tests and mean joint angles. PFP participants had greater internal rotation of the shank and rearfoot segments, and adduction of the mid- and forefoot in the transverse plane (all p < 0.05). Greater ND was associated with increased forefoot abduction (rho=-0.68, p = 0.02) in healthy participants but no relationships were found between foot posture and kinematics in PFP participants.
Significance Foot posture and kinematic data did not indicate excessive pronation in PFP participants questioning the use of orthoses to correct pronation. Larger studies are needed to determine the utility of foot posture tests as indicators of gait abnormalities in PFP.

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Full length articleRelationship between rearfoot, tibia and femur kinematics in runners with and without patellofemoral pain

Highlights

Abstract

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Participants

Results

Discussion

Conclusion

Conflict of interest statement

Acknowledgements

Clin. Biomech.

Gait Posture

J. Biomech.

J. Biomech.

Clin. Biomech.

Clin. Biomech.

Gait Posture

Clin. Biomech.

Gait Posture

Gait Posture

J. Sci. Med. Sport

J. Biomech. Eng.

Med. Sci. Sports Exerc.

J. Orthop. Sports Phys. Ther.

J. Orthop. Sports Phys. Ther.

Clin. Biomech.

Knee

Br. J. Sports Med.

J. Bone Joint Surg. Am.

Retrospective case-control analysis of 2002 running injuries

Br. J. Sports Med.

Prevention of running injuries

Curr. Sports Med. Rep.

Association of footwear with patellofemoral pain syndrome in runners

Sports Med.

Hespanhol Júnior LC: yeung SS, costa LOP: what are the main running-related musculoskeletal injuries? a systematic review

Sports Med.

Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis

J. Orthop. Sports Phys. Ther.

Pathogenesis of anterior knee pain syndrome and functional patellofemoral instability in the active young

Am. J. Knee Surg.

Patellofemoral stress during walking in persons with and without patellofemoral pain

Med. Sci. Sports Exerc.

The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model

J. Orthop. Sports Phys. Ther.

The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective

J. Orthop. Sports Phys. Ther.

Full length article
Relationship between rearfoot, tibia and femur kinematics in runners with and without patellofemoral pain