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From the Human Performance Laboratory and the Sport Medicine Centre,
University of Calgary, Calgary, Alberta, Canada
Background: Identification of mechanical factors associated with patellofemoral pain, the most prevalent running injury, is
necessary to help in injury prevention, but unfortunately they remain elusive.
Hypothesis: Runners who develop patellofemoral pain have increased knee joint angular impulse in the frontal plane.
Study Design: Case control study; Level of evidence, 3.
Methods: A retrospective study compared knee abduction impulses of 20 patellofemoral pain patients with those of 20 asymptomatic patients. A second prospective study quantified knee angular impulses during the stance phase of running of 80 runners
at the beginning of the summer running season. Epidemiologic data were then collected, recording the type and severity of injury
of these runners during a 6-month running period.
Results: The patellofemoral pain patients in the retrospective study had significantly higher (P = .026) knee abduction impulses
(17.0 8.5 Nms) than did the asymptomatic patients (12.5 5.5 Nms). Six patients developed patellofemoral pain during the
prospective study. The prospective data showed that patients who developed patellofemoral pain had significantly higher (P =
.042) knee abduction impulses (9.2 3.7 Nms) than did matched patients who remained uninjured (4.7 3.5 Nms).
Conclusion: The data indicate that increased knee abduction impulses should be deemed risk factors that play a role in the
development of patellofemoral pain in runners.
Clinical Relevance: Footwear and running style can influence knee angular impulse, and the appropriate manipulation of these
variables may play a preventive role for patients who are predisposed to patellofemoral pain.
Keywords: joint loading; biomechanics; injuries; locomotion
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Figure 1. Schematic illustration showing the resultant knee abduction moment and the calculation of the knee abduction impulse
during the stance phase of running. The knee abduction impulse (shaded region) represents the area under the moment-time curve.
METHODS
Retrospective Case Control Study
Two groups of runners were analyzed using a case control
study design. These groups included the following:
1. Patellofemoral pain group (PFP group): group of
patients with patellofemoral pain at time of study,
with no other injuries to the lower extremity in the
past 3 months.
TABLE 1
Patient Characteristics of the 40 Runners Who
Participated in the Retrospective Studya
Group
Age, y
Height, cm
Mass, kg
ASYMP
PFP
20
20
34.4 (10.3)
34.6 (9.8)
176.5 (9.4)
170.0 (9.4)
70.8 (13.4)
66.8 (12.5)
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Stefanyshyn et al
Prospective Study
The data collected in this investigation consisted of 2 parts.
The first aspect was a detailed kinematic and kinetic analysis during the stance phase of running for 140 runners at
the beginning of the summer running season. The second
aspect was an epidemiologic study quantifying the type
and severity of injury of these runners as they undertook a
6-month running period. As the patients constituted a relatively experienced group of runners, 89% reported at least
1 previous running-related injury. However, all runners were
free from pain or injury at the onset of the study. Eighty
patients (Table 2) fully completed the study with detailed
running logs and injury data after the 6-month period.
Informed written consent in agreement with the university
ethics committees policy was obtained from all patients.
Using similar methodology as in the retrospective case
control study, force and movement data were collected in the
laboratory at a running speed of 4.0 0.2 m/s. Although
training paces of the patients varied, all patients were
TABLE 2
Patient Characteristics of the 80 Runners Who
Completed the Prospective Investigationa
Women
Men
Age, y
Height, cm
Mass, kg
39
41
35.9 (8.0)
39.8 (8.9)
166.9 (7.7)
179.1 (7.1)
61.5 (8.8)
77.3 (10.6)
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TABLE 3
Comparison of the Patient Characteristics of the
6 Patients Who Developed Patellofemoral Pain
and the Uninjured Patients Who Were Used
as Matched Controls in the Prospective Study
Patient
Injured
Leg
Gender
Mileage,
km
Experience,
y
Mass,
kg
40
40
55
60
12
15
40
35
30
30
15
15
1.5
4.0
20.0
15.0
1.0
0.7
16.0
14.0
1.5
4.0
1.0
2.0
79.1
84.0
82.5
75.2
65.5
59.0
59.3
63.5
76.0
74.1
76.6
76.2
32.0
32.5
6.8
6.6
73.2
72.0
1 injured
Match 1
2 injured
Match 2
3 injured
Match 3
4 injured
Match 4
5 injured
Match 5
6 injured
Match 6
Right
Male
Left
Male
Left
Female
Left
Female
Right
Male
Right
Female
Mean
Injured
Noninjured
RESULTS
Physical examination
1. No or minimal articular or periarticular effusion or
bursitis
2. No significant joint line tenderness
3. No intra-articular ligamentous instability
4. Peripatellar tenderness mild inferior patellar
pole tenderness
5. No patellar apprehension
To analyze the knee joint impulses of the injured (PFP
group) patients, 2 different analyses were performed. The
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Stefanyshyn et al
Individual results for the knee joint impulses are presented in Figure 4. Individual values for each PFP group
patient are compared with the mean knee abduction
impulse of the ASYMP group. There is an approximately
equal distribution of PFP group patients who had knee
abduction impulses higher and lower than the mean of the
ASYMP group. However, 10 of 20 patients had more than
50% larger abduction impulses compared to the ASYMP
group, with 6 patients having impulses that were more
than 100% larger. In contrast, only 1 patient within the
ASYMP group had more than a 50% larger impulse than
the ASYMP group mean.
Prospective Study
Six patients (3 men and 3 women) were clinically diagnosed
with patellofemoral pain. The mean resultant knee joint
moments during running showed similar patterns (Figure 5)
DISCUSSION
The first purpose of this investigation was to determine
whether knee angular impulses in the frontal plane are associated with patellofemoral pain. The data from the retrospective case control study showed that abduction impulses are
related to patellofemoral pain, as mean knee abduction
moments in the PFP group were significantly higher than
those in the ASYMP group by 36%. The second purpose was
to determine whether these abduction impulses are causally
related to the onset of patellofemoral pain. In the prospective
study, the patients who developed patellofemoral pain had
knee abduction impulses that were, on average, 19% higher
than those in the remaining runners who did not develop
patellofemoral pain. These differences were not significantly
different; however, they were confounded by various factors.
The main confounding factor was that some of the patients,
although currently uninjured, had a history of patellofemoral
pain. Another confounding factor was that some of these
patients developed other running injuries such as iliotibial
band syndrome or tibial stress syndrome. It may be that these
runners modified their training programs or running styles
as a result of these injuries, thus preventing the onset of
patellofemoral pain. Consequently, an attempt was made to
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compare the patients with patellofemoral pain in the prospective study to similar (matched on the basis of gender, running
mileage, running experience, and mass) uninjured patients.
Research has shown that joint moments are influenced by
mass and gender25; thus, it was important to match for these
criteria. Furthermore, injury has been related to weekly running distance and years of running experience34; thus, it was
deemed necessary to match for these criteria as well. The
prospective data show that the patients who developed
patellofemoral pain had significantly higher (97%) knee
abduction impulses before injury than did uninjured matched
controls. Thus, the hypothesis that runners characterized
by increased knee abduction impulses are predisposed to
patellofemoral pain was supported. The data from these 2
studies indicate that knee abduction impulses should be
deemed risk factors that play a role in the development of
patellofemoral pain in runners.
Although several studies1,16,17 have quantified patellofemoral loads and pressures in vitro, it is obviously difficult
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Stefanyshyn et al
ACKNOWLEDGMENT
This work was supported by the Canadian Fitness and
Lifestyle Research Institute. The authors thank Darren
Hinton for his assistance in data analysis.
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