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Amanda Estep

Knowledge Evidence Essay

Introduction to the problem

Running has become an increasingly popular form of physical activity due to the

associated health benefits22 such as reducing the risk of cardiovascular disease,47 type II

diabetes88 and obesity.39 Apart from the health benefits, running is also easily accessible and does

not require special equipment or location, making it even more appealing to the general

population as a form of exercise. Running is also a source of stress relief and social interaction.

Habitual runners report feeling happier and more energetic, as well as have reported adopting

healthier eating and sleep habits and decreasing the use of alcohol and tobacco.5,30,31

In 2015, it was reported that approximately 48.5 million Americans run75 and while

associated with numerous health benefits, running can potentially lead to injury. In fact, it is

estimated that 27% to 70% of recreational and competitive distance runners experience an

overuse injury per year.22 With the growing popularity of running as a form of physical activity,

an increase in injury can also be expected.

Injury can result in a decrease in running participation and in some cases, complete

cessation. As a result of being unable to run or participate fully, feelings of guilt, irritability,

depression and decreased energy have been reported.5,31 In addition, as a rapidly increasing form

of physical activity for the general population, being unable to participate in running can lead to

overall decreases physical activity. Therefore, further understanding of the risk factors of

running-related injuries is an avenue to ensure that individuals can continue to enjoy being

physically active.
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Knowledge Evidence Essay

Overview of normal gait biomechanics

In order to understand the etiology of running injuries, it is important to understand the

normal joint kinematics that occur while running. The gait cycle can be divided into two distinct

phases, stance and swing. The stance phase is defined as the time in which the foot is in contact

with the ground. The swing phase is the time in which the foot is in the air and the leg is

advancing forward. The time spent in each of these phases is dependent on speed. During

running, the stance phase constitutes approximately 35% of the gait cycle, while 65% of the gait

cycle is spent in swing phase.61 Because of the impact experienced when the foot comes in

contact with the ground, kinematics during the stance phase are focused on.

When the foot strikes the ground, it does so in a more supinated position. As the stance

phase continues, the foot pronates until midstance. Foot pronation allows for shock absorption to

be attenuated over a longer period of time and accommodates for uneven surfaces. Peak

pronation is typically experienced by midstance. After midstance, it is necessary for the foot to

supinate in order to produce a stable lever for the runner to propel forward off of. Because of the

tight articulation of the talus and the tibia, pronation is accompanied by internal rotation of the

tibia. Conversely, foot supination is accompanied by external rotation of the tibia. At the knee,

initial contact indicates that the limb is being loaded. In response, the knee flexes to

approximately 45 as body weight is being accepted onto the single limb. In order for normal

knee flexion to occur, the tibia must internally rotate to allow the knee to unlock and flex. The

knee is also in an abducted position and remains abducted for most of the stance phase. After

midstance, knee flexion is reduced to 15 and the knee externally rotates. The hip, at initial

contact is flexed to approximately 30 and remains in this position until midstance. Internal

rotation and adduction also occurs. Hip adduction during the stance phase serves as shock
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Knowledge Evidence Essay
absorbing mechanism. After midstance, the hip externally rotates and hip adduction decreases to

a neutral position at the end of stance.17 After midstance, hip flexion decreases and is fully

extended at toe off.17

Prevalence and etiology of injury

Running injuries can be classified as acute traumatic or overuse. While acute traumatic

injuries, such as an ankle sprain or muscle strains do occur, overuse injuries are more prevalent.

Overuse injuries result from repeated stress placed on the body, without sufficient rest periods in

between, that when combined over time, exceed the bodys injury threshold. In other words, the

body is not able to repair itself quickly enough before more breakdown occurs; the rate of

breakdown exceeds the rate of repair. While the exact cause of running overuse injuries is

difficult to pinpoint, risk factors can be categorized as training errors, anatomical variables and

abnormal biomechanics. Training errors include running distance, training intensity, increasing

weekly mileage or intensity too quickly and stretching habits. Anatomical risk factors include

excessive foot arch height, ankle range of motion, leg length discrepancies and lower extremity

alignment such as, genu varum, excessive Q-angle and rear foot varus.14 Abnormal biomechanics

associated with running injuries will be discussed later on in this paper.

A systematic review on running injury incidence reported that the knee is the most

common site for overuse injury and accounts for up to half of all running injuries.72,83 The lower

leg is the second most common site for injury (9-32%), followed by the foot (5.7-39.3%), upper

leg (3.4-38.1%), ankle (3.9-16.6%) and hip/pelvis (3.3-11.5%). Overuse running injuries include

patellofemoral pain syndrome (PFPS), iliotibial band syndrome (ITBS), plantar fasciitis, Achilles
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Knowledge Evidence Essay
tendonitis and medial tibial stress syndrome.22 However, because of the prevalence of PFPS and

ITBS in runners, these two injuries will be the primary focus.

Patellofemoral pain syndrome

Etiology

Patellofemoral pain syndrome (PFPS) is the most common overuse running injury and is

characterized by aching pain under or around the knee cap. While running, the pain usually starts

when running has ceased and worsens over the next 1-12 hours. Pain is exacerbated by sitting for

extended periods of time, squatting, climbing stairs and jumping. While the cause of pain is still

debated, one explanation is increased stress on the patellofemoral joint from patella

malalignment. Individuals with PFPS often deal with chronic and recurring pain. In a

retrospective case-control study, 91% of subjects initially diagnosed with PFPS had reoccurring

symptoms 4-18 years later, with 36% of the subjects restricting their level of physical activity.81

Under normal alignment conditions, the femur is aligned vertically over tibia and the

patella articulates with the trochlear groove of the femur. The patella is anchored to the femur via

the quadriceps tendon and to the tibia via the patellar tendon. Because the forces exerted on the

patella at these attachment sites are not collinear, the patella is predisposed to lateral forces when

the quadriceps contract. Originally, it was thought that patellar misalignment resulted from the

patella moving in relation to the femur and ultimately resulted in PFPS. Therefore, treatment for

PFPS focused on limiting motion of the patella and included strengthening of the quadriceps or

bracing/taping the patella. While this holds true for non-weight bearing activity, use of magnetic

resonance imaging during a weight bearing activities has shown that the femur actually internally

rotates in relation to the patella. Using magnetic resonance imaging, Powers et al. compared
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Knowledge Evidence Essay
patellofemoral joint kinematics between a non-weight bearing knee extension exercise and a

weight-bearing single-leg squat exercise in females with PFPS. During the non-weight bearing

knee extension exercise, lateral patellar displacement was greater than during the weight-bearing

single-leg squat exercise. Internal femoral rotation was significantly greater during the weight-

bearing single-leg exercise compared to the non-weight bearing exercise.68 Also using magnetic

resonance imaging, Souza et al. compared patellofemoral joint kinematics during a single-limb

squat in females with PFP to a healthy control group. Outcome measures included femur and

patella rotation, lateral patella tilt and lateral patella displacement at 45, 30, 15 and 0 of knee

flexion. Compared to the control group, females with PFPS exhibited greater lateral patella

displacement at all angles of knee flexion during the single-leg squat. Greater lateral patella tilt at

30, 15 and 0 and similar to results of Powers et al., increased medial femoral rotation at 45,

15 and 0 degrees were seen in the symptomatic group.79 It has been shown that as little as five

degrees of femoral internal rotation increases shear stress, subsequently increasing lateral patella

facet pressure.48 Rather than focusing solely on the knee, researchers have become interested in

how the knee can be affected proximally by hip mechanics and distally by foot mechanics.

Proximal influences on PFPS

Proximal joints, such as the hip, have been hypothesized to have influence on PFPS. The

hip and knee share a common bone, the femur. Therefore, excessive femoral movement has been

suggested to affect knee kinematics because of the articulation between the femur and the patella.

Specifically, increased hip adduction and hip internal rotation have been hypothesized as

potential risk factors for PFPS, however results are inconsistent. A study comparing lower

extremity mechanics in females with and without PFPS assessed lower extremity mechanics

across three different tasks. Each task was progressively more demanding than the previous and
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Knowledge Evidence Essay
was designed to elicit greater responses to external demands. Tasks included single-leg squat,

running and single-leg jump. In all three tasks, females with PFPS experienced increased hip

adduction. Hip internal rotation was not increased in this study. Authors hypothesize that the

decrease in hip internal rotation was a compensatory mechanism to decrease pain.89 Similar

results were produced in another study comparing hip kinematics in female runners with and

without PFPS. In addition to increased hip adduction, the PFPS group also demonstrated

increased internal rotation.58 In a prospective study that followed 400 female runners over two

years, females who developed PFPS demonstrated increased hip adduction compared to female

runners who did not develop PFPS. Contrary to retrospective evidence, increased hip internal

rotation was not found.57 Decreased hip muscle strength has been proposed to cause abnormal

hip and knee kinematics.

Decreases in hip strength have been suggested to result in abnormal hip kinematics and

subsequently altered knee kinematics. A limitation to the aforementioned studies is that muscle

strength was not measured. Rather, muscle strength was only hypothesized to cause the abnormal

kinematics. When hip strength and kinematics were evaluated together, results again are

inconsistent. During a stair descent task, females with PFPS demonstrated 24% less hip external

rotator torque and 26% less abductor torque compared to the control group. However, no

differences in hip adduction, internal rotation or knee valgus were found. Authors speculate that

absence of kinematic differences may have been because the stair descent task was not difficult

enough to challenge the hip musculature.4 Hip kinematics and muscle strength were assessed

during running, drop jump and step-down tasks in females with PFPS. When averaged across all

three tasks, the PFPS group demonstrated greater hip internal rotation that was accompanied by

14% decrease in hip abductor strength and 17% decrease in hip extensor strength when
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Knowledge Evidence Essay
compared to the control group. Significant differences were not seen in hip adduction between

the two groups.80 During a single-leg squat task, males and females with PFPS demonstrated

increased hip adduction and knee abduction along with reduced eccentric hip abduction and hip

external rotation strength compared to the control groups. Increased hip internal rotation was

only found in females with PFPS.52 Similar results were found during a step-down task. Males

and females with PFPS demonstrated increased hip adduction and knee abduction compared to

the control groups. Isometric hip abductor torque also reduced.53 During a run to fatigue task,

combined male and female runners with PFPS demonstrated decreased hip abduction strength

and hip external rotation strength both at the beginning of the run and at the end of the run

compared to the control group. However, at the beginning of the run, decreased hip abduction

strength was not associated with increased hip adduction. Only at the end of the run, when

subjects were in a fatigued state, did the relationship become significant. No association between

decreased hip external rotation strength and hip internal rotation was found for the PFPS group at

the beginning or end of the run.7 A recent systematic review and meta-analysis investigating hip

strength as a risk factor for PFPS in both males and females found conflicting results between

cross-sectional evidence and prospective evidence. Moderate cross-sectional evidence shows a

relationship between PFPS and decreased isometric hip muscle strength, moderate-to-strong

prospective evidence suggests no association between hip strength and risk of developing PFPS.

Authors of this review concluded that hip strength deficits may be a result of PFPS rather than

the cause.69

Distal influences on PFPS

Normal movement during gait includes subtalar joint pronation occurring during the first

30% of stance phase. In response, the tibia internally rotates 6 to 10.26,71 When pronation is
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Knowledge Evidence Essay
prolonged or the amount of pronation is excessive, pronation is deemed abnormal. The coupling

motion between the tibia and subtalar joint has led to the assumption that increased pronation

leads to increased tibial internal rotation which in turn stresses the tissues at the knee joint. While

this chain of events may be true for the tibiofemoral joint, increased tibial rotation actually

decreases the Q-angle and thus the lateral forces acting on the patella. In order for the

patellofemoral joint to be affected, the femur must implicated.66 Tiberio et al. described a

situation in which excessive pronation and increased tibial rotation would affect the

patellofemoral joint. In order for the patellofemoral joint to be affected by excessive internal

tibial rotation, compensatory internal rotation of the femur would have to occur, causing

abnormal patellar tracking with the trochlear groove of the femur. A situation in which

compensatory internal rotation of the femur would occur is when the foot is unable to supinate

during midstance as it is supposed to which subsequently causes the tibia to remain internally

rotated. For normal knee extension to occur, the tibia must externally rotate. In an effort to

compensate for the tibia remaining internally rotated, the femur internally rotates to align with

the tibia so that knee extension can occur.85 This may explain why studies investigating foot

mechanics in individuals with PFPS have not found significant results. In 36 runners, Messier et

al. found no significant differences in maximum pronation, maximum pronation velocity or total

rearfoot movement in comparison to the control group.50 Similarly, Powers et al. found no group

differences in magnitude and timing of peak foot pronation and tibial rotation when comparing

24 females with PFP to 17 controls.67 Noehren and colleagues compared 16 female runners with

PFP to 16 healthy female runners and found no differences in foot mechanics. Interestingly, the

PFP group demonstrated greater internal tibial rotation despite absence of increased foot
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Knowledge Evidence Essay
pronation. Authors hypothesized that the increased internal rotation of the tibia may have been

the result of the abnormal hip mechanics also demonstrated in the PFP group.58

Influence of gender on PFPS

Females are twice as likely to develop PFPS, resulting in the majority of studies utilizing

females as their subjects, however males with PFPS also demonstrate abnormal kinematics, but

not in the same manner as females. Willy et al. investigated the differences in movement patterns

between males and females with and without PFPS while running and performing single-leg

squats. Results showed that males with PFP ran and performed single-leg squats with greater

peak knee adduction when compared to females with PFP and a healthy male population. When

differences between genders were considered, males demonstrated less hip adduction and greater

knee adduction. This study suggests that males run and perform single-leg squats in with an

excessive knee varum alignment90, placing stress on the medial aspect of the patellofemoral

joint,36 as opposed to females with PFPS who demonstrate increased knee valgus alignment,90

which places stress on the lateral aspect of the patellofemoral joint.36 These results suggest that

treatment for PFPS may need to be tailored to the individual, depending on gender.

Interventions to improve PFPS

Muscle strengthening

To improve control of lower extremity kinematics associated with PFPS, both hip and

quadriceps muscle strengthening protocols have been implemented. Traditionally, quadriceps

strengthening has been considered standard practice for treating PFPS. However with the high

reoccurrence rate of symptoms after completion of quadriceps strengthening protocols and

evidence that the femur rotates in relation to the patella during weight-bearing activity,
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Knowledge Evidence Essay
interventions have shifted their focus more proximally to include strengthening of the hip

musculature.

Various methods have been implemented to understand the efficacy of hip musculature

strengthening protocols in improving pain, function and hip strength. These methods include

investigating the effects of a hip strengthening only protocol in a single cohort44,86, comparing the

effects of protocols that combine hip and quadriceps strengthening to quadriceps strengthening

only protocols.2,8,20,21,38,54,70 and comparing the effects of a hip strengthening protocol to a

quadriceps strengthening protocol13,45

When assessing the effects of an 8-week hip musculature strengthening program,

Khayambashi et al. found that pain, health status and hip abductor and external rotator strength

improved in the group participating in the hip strengthening protocol compared to a no exercise

control group. Pain and health status remained improved 6-months after the intervention. Hip

abduction and external rotation strength were not reassessed, therefore it cannot be concluded

that the continued improvements in pain and health status resulted from improved muscle

strength.44 After a 6-week hip musculature strengthening and flexibility protocol, Tyler et al.

found that pain decreased in 66% of the participants. Decrease in pain was accompanied by

increases in iliopsoas and iliotibial band flexibility and hip flexion, abduction and adduction

strength. No control group was included in this study, but for further analysis, participants were

categorized as successful or unsuccessful based on whether they had experienced significant

decreases in pain. Interestingly, improvements in hip abduction and adduction strength were

found to be unrelated to success. Rather success was attributed to increases in flexibility of the

iliopsoas and iliotibial band and increased hip flexion strength.86


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Knowledge Evidence Essay
Evidence suggests that the addition of proximal hip musculature strengthening may

provide greater benefit than quadriceps strengthening alone. For example, several studies have

demonstrated the ability of additional hip strengthening to reduce pain in a more efficient

manner. In a randomized clinical trial, 33 females with PFPS underwent either an initial 4-week

hip strengthening protocol or an initial 4-week quadriceps strengthening protocol before

participating in a 4-week functional weight-bearing exercise protocol. Outcome variables

included pain, function and hip strength. Authors hypothesized that the group initially focused on

hip strengthening would show quicker improvements in symptoms and be better prepared for the

functional weight-bearing exercise protocol. After the 8-week intervention, both groups

experienced similar improvements in pain, function, and hip external rotator strength, however,

the hip strengthening group reported significant decreases in pain after only 4 weeks. Hip

abduction strength also increased significantly in the hip strengthening group. The initial

quadriceps strengthening group did not experience the same decrease in pain until the end of the

8-week protocol. 8 Studies conducted by Nakagawa et al. and Ismail et al. found that pain was

significantly reduced with the combined hip and quadriceps muscle strengthening in comparison

to a quadriceps only strengthening protocol. However neither of these studies found increased

hip strength in addition to the greater reductions in pain.38,54 With the inclusion of a no exercise

control group, in addition to a combined hip and quadriceps strengthening protocol and a

quadriceps only strengthening protocol and a no exercise control group, both rehabilitation

groups experienced increases in function and decreases in pain. In line with previous studies, the

combined hip and quadriceps strengthening group experienced greater reductions in pain during

the stair descent task. Strength was not measured in this study.21 In a follow-up study, the

combined hip and quadriceps strengthening group demonstrated greater function and less pain
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compared to the quadriceps strengthening only group. At 3, 6 and 12 months post-intervention,

the combined hip and quadriceps maintained improvements in pain and function at 3, 6 and 12

months post-intervention. The quadriceps strengthening only group experienced decreases in

pain only at 3 months and 6 month post-intervention. To date, this is the only study with a 1 year

follow-up and while it is only one study, it provides further support for the inclusion of hip

muscle strengthening in the treatment of PFPS.20

In an effort to determine which strengthening protocol produced superior results,

researchers have compared traditional quadriceps muscle strengthening to hip muscle

strengthening. Similar to results found from studies adding hip muscle strengthening to a

quadriceps strengthening protocol, Ferber et al. found that after a 6-week intervention, both

groups demonstrated improvements in pain, function strength. Although, individuals in the

hip/core strengthening group experienced a reduction in pain earlier than the quadriceps

strengthening group accompanied by greater improvements in hip abduction and hip extension

strength.13 These results agree with Khayambashi et al. who also found that improvements were

still present at 6-months post-intervention. As in the short term results, both groups maintained in

improvements at 6-months, but those who participated in the hip muscle strengthening

demonstrated superior results.45 While the aforementioned studies show the benefits of proximal

hip musculature strengthening in improving pain, function and strength, a limitation is that

changes in lower extremity kinematics were not investigated. It was speculated that by increasing

muscle strength, lower extremity kinematics would also be affected, particularly in the frontal

and transverse planes of the hip and knee. In some studies, strength was not assessed, meaning

no conclusions could be drawn about the relationship between hip muscle strength and lower

extremity kinematics.
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Knowledge Evidence Essay
Muscle strengthening to control lower extremity kinematics, such as hip adduction and

hip internal rotation, have become a popular treatment option for individuals with PFPS. This

being said, studies actually investigating kinematic changes in response to muscle strengthening

protocol are limited. Earl et al. investigated the effects of a proximal strengthening program on

hip strength, core endurance, pain, function and lower extremity running biomechanics. Nineteen

females with PFPS participated in an 8-week proximal stability program focused on improving

strength and neuromuscular control of hip and core musculature. After the intervention,

significant improvements were seen in pain, functional ability, hip abductor and external rotator

strength and lateral core endurance. Changes in lower extremity biomechanics included a

reduction in knee abduction moment. No differences were observed in joint range of motion for

rear foot eversion, knee abduction, hip abduction or hip external rotation. Absence of kinematic

differences after the intervention was unexpected because of the association between hip muscle

weakness and excessive joint motion. At the 6-month follow-up, 4 participants reported that

their pain level remained decreased, while 4 participants reported a slight increase in pain, but

still below pre-intervention pain levels.9 Ferber et al. investigated changes in knee biomechanics

after a 3-week hip-abductor strengthening protocol in runners with PFPS. Compared to the

control group, individuals who participated in hip-abductor strengthening protocol demonstrated

increased hip abductor strength and reduced pain and decreased stride-to-stride knee joint

variability while running. Interestingly, no changes in peak knee genu valgum were observed,

suggesting that evaluation of peak joint angles may not a sufficient measure to gauge progress

after an intervention15 Lastly, a randomized clinical trial investigated the effects of a functional

stabilization training protocol on pain, lower extremity and trunk kinematics during a single-leg

squat, trunk endurance and eccentric torque. Thirty-one females with PFPS were randomly
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assigned to an 8-week functional stabilization protocol or quadriceps strengthening protocol. The

functional stabilization protocol combined hip and knee strengthening with verbal feedback on

correct lower extremity alignment during functional exercise. Females assigned to the functional

stabilization protocol demonstrated greater improvements in pain, physical function, lower limb

and trunk kinematics, trunk muscle endurance and eccentric strength of the hip and knee

musculature when compared to females who participated in the quadriceps only strengthening

protocol. In this study, changes in kinematics associated with PFPS were seen in response to hip

abductor, extensor and lateral rotator muscle strengthening after the functional stabilization

training protocol. Specifically, during the single-leg squat task, decreased contralateral pelvic

depression, hip adduction and knee abduction movement were observed. At the 3-month follow-

up, the functional stabilization group experienced greater decreases in pain than the quadriceps

strengthening group. The incorporation of verbal feedback in the functional stabilization protocol

makes the findings of this study unique and brings to question the benefits of including verbal

feedback on dynamic lower extremity alignment in treatment of PFPS. While changes in

kinematics during a single-leg squat were seen, it is not possible to determine if the functional

stabilization exercises were responsible for the changes in kinematic or if the addition of verbal

cues made the intervention more effective.3

Gait retraining

Gait retraining has also been used to correct abnormal kinematics in individuals with

PFPS. Using real-time kinematic feedback of hip adduction angle, subjects with PFPS and

excessive hip adduction underwent 8 gait retraining sessions. While on a treadmill, each subjects

hip adduction angle was projected on a computer screen. Subjects were instructed to keep their

hip adduction angle within the grey region of the curve, which represented a normal hip
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adduction angle. Verbal cues including contract gluteal muscles, run with their knees pointing

forward and maintain a level pelvis were also included in the retraining sessions. Based on a

faded feedback protocol, visual feedback was provided continuously for the first 4 sessions and

then gradually removed for the last 4 sessions. Learning was assessed by skill transfer of altered

mechanics to a single-leg squat. Results showed that all subjects were able to reduce hip

adduction and contralateral pelvic drop and maintain reductions at 1-month follow up. Only

reduction in hip adduction transferred to the single-leg squat. Impact loading was also reduced.60

Using both visual and auditory feedback, 10 female runners with patellofemoral pain ran on a

treadmill with a full length mirror placed in front of them to provide visual feedback on lower

extremity alignment. Verbal instructions were given which included run with knees apart and

with knee caps pointing straight ahead and to squeeze buttocks. At the first training session,

each subject was shown a video of themselves running and were educated on their abnormal hip

mechanics. For training sessions 1 through 4, run time and visual and verbal feedback time were

gradually increased from 15 minutes to 30 minutes. For training sessions 4 through 8, visual and

verbal feedback were gradually removed. Results showed that all subjects were able to reduce

hip adduction, contralateral pelvic drop and hip abduction moment and maintain improvements

at 1 month and 3 month follow-ups. Skill transfer to an untrained functional task was assessed

through performance of a single leg squat and step descent. Improvements in hip adduction,

contralateral pelvic drop and hip abduction moment were also seen during performance of

single-leg squat and stair descent and were maintained at 1-month and 3-month follow-ups.

Reductions in hip internal rotation were not observed.91 Altering foot strike pattern has also been

proposed as a gait retraining protocol to reduce PFPS. Approximately 75% of shod runners are

considered rear foot strikers. Runners with a rear foot strike have been found to be a greater risk
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Knowledge Evidence Essay
for developing knee pain than rear foot strikers. Additionally, rear foot strikers report less injury

to the knee. This discrepancy between forefoot strikers and rear foot strikers is thought be the

result of greater shock and loading rate associated with a rear foot strike. Use of a forefoot strike

is also associated with decreased patellofemoral contact force and stress. Therefore, Roper et al.

investigated if runners with PFPS benefitted from gait retraining that altered their foot mechanics

from a rear foot strike to a forefoot strike. Runners with PFPS assigned to the experimental

group participated in 8 training sessions in which mirror feedback, similar to Willy et al., was

used to allow participants to see themselves running with a forefoot strike. Verbal cues were also

provided such as run on your toes and/or run on the balls of your feet. Continuous feedback

was provided during the first 4 gait retraining sessions and gradually removed over the last 4

sessions. Runners assigned to the control group also participated in 8 training sessions with

mirror feedback and verbal cues. However the verbal cues were designed not to modify gait.

Instead, verbal cues provided encouragement and included keep it up or nice job. Participants

in the experimental group reported significant reductions in PFP compared to the control group.

Decreases in pain were also associated with a decrease in knee abduction angle and an increase

in knee flexion angle at initial contact. Dynamic knee abduction has been shown to contribute to

PFPS, while increases in knee flexion most likely resulted in reduced knee loading. As a result of

decreased knee abduction, patellofemoral joint contact force and patellofemoral stress were also

reduced. Positive outcomes were maintained at the 1-month follow-up.73

Overall, gait retraining appears to be an effective treatment for PFPS, but there is a need

for longer follow-up periods to determine how long improvements last. Currently the longest

follow-up period is 3 months. Longer follow-up periods will allow for better determination of

gait retraining effectiveness. Additionally, these studies were performed in a laboratory setting
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with special equipment including gait analysis equipment and a screen in which to project real-

time hip adduction angle feedback on. Equipment requirements alone may reduce the practicality

of gait retraining interventions. Furthermore, changes in lower extremity kinematics are

occurring while running on a treadmill in a controlled environment. It is possible that these

positive changes may be difficult to maintain once running outside where terrain can be uneven

and unpredictable and speed is not controlled by the speed of moving treadmill belt. The use of

verbal cues such as run with knees apart and with knee caps pointing straight ahead and to

squeeze buttocks may provide sufficient stimulus to induce change in lower extremity

kinematics, however in the previous studies, verbal cues have been in addition to other types of

feedback. Effectiveness of just verbal cues cannot be determined. It would be interesting to

determine the effect of just verbal cues, such as the examples mentioned previously, on gait

kinematics. Use of verbal cues would be a more convenient method of altering gait kinematics,

as opposed to use of real-time feedback. Other aspects of gait retraining that require further

investigation include the effect of changes in kinematics on running economy and likelihood that

new gait patterns will be adopted and used outside of the gait retraining sessions. Changes in gait

that are difficult to maintain or do not feel natural may decrease adherence. Similarly, gait

changes that are unnatural or deviate too far from the normal gait pattern for a person may

increase the difficulty of running. Alongside with investigating whether new gait patterns are

adopted or not is determining if any adverse side effects result from altering gait characteristics.

For example, while rear foot striking is associated with running injuries, forefoot striking can

place more stress on the ankle joint and possibly result in injury. Roper et al. did investigate

adverse effects associated with changing foot strike patterns, but only for a short time period.

Immediately after the invention, participants in the experimental group experienced calf soreness
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during the gait retraining sessions, but the pain subsided by the end of the intervention. At the 1-

month follow-up, two participants reported ankle soreness, but the pain was not enough to deter

them from running. Longer follow-up periods are necessary to investigate whether changes in

foot strike pattern led to any injury. Noehren et al. and Willy et al. did not assess whether

participants experienced any adverse effects in response to the gait alterations.60,91

Iliotibial Band Syndrome

Etiology

Iliotibial band syndrome (ITBS) is the second most common running injury and accounts

for approximately 8% of running injuries.84 In individuals with ITBS, a sharp, burning pain on

the lateral side of the knee is experienced and worsens as running continues.10 Pain is typically

relieved by keeping the knee in a fully extended position. Two theories exist explaining the cause

of ITBS. The first theory, developed by Orchard et al. suggested that ITBS results from friction.

As the knee repetitively flexes and extends, as seen during running, the IT band moves forward

and backward across the lateral femoral epicondyle.62 This theory was challenged by researchers

who argued that the IT band is securely anchored to its attachment sites and is not capable of

moving anteriorly and posteriorly across the lateral femoral epicondyle.11,12 Using MRI

technology, Fairclough et al. found that at 30 of knee flexion, the IT band compresses against

the lateral femoral condyle. Regardless of mechanism, both theories agree that ITBS results from

irritation and inflammation of the bursa sac located between the IT band and the lateral femoral

epicondyle.
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Knowledge Evidence Essay

Abnormal biomechanics associated with ITBS

Onset of lateral knee pain at 20-30 of knee flexion led researchers to believe that an

impingement zone existed. Naturally, sagittal plane biomechanics at the knee were investigated

in runners with ITBS. Despite the suggested impingement zone, no differences in sagittal plane

knee kinematics were found between runners with ITBS compared to their non-injured leg.

Specifically, no differences were seen in peak knee flexion angle, knee flexion angle at heel

strike or in the percent of time spent in knee flexion. Results suggested that kinematics in the

transverse and frontal planes of motion may be associated with ITBS.62

The IT band originates proximally at the hip from the fascia of the gluteus maximus,

gluteus medius and the tensor fascia latae. This thick band of fibrous connective tissue extends

down the lateral thigh and inserts into the lateral femoral condyle and Gerdys tubercle on the

tibia.76 Its primary functions include acting as both a hip and knee stabilizer by resisting hip

adduction and knee internal rotation.16,46,92 As a result of its attachment points to both the femur

and the tibia, abnormal kinematics of the hip and foot have been suggested to contribute to the

development of ITBS.28 A retrospective study, conducted by Ferber et al., compared running

kinematics in 35 female runners with a history of ITBS to a group of 35 female runners with no

history of running-related injuries. It was hypothesized that female runners with a history of

ITBS would exhibit increased peak rear foot eversion, knee internal rotation, knee flexion and

hip adduction angles during stance. Results showed that runners with a history of ITBS

demonstrated greater peak knee internal rotation angles and greater peak hip adduction angles

compared to the control group and remained in greater hip adduction and knee internal rotation

throughout the stance phase. Similar to previous studies investigating sagittal plane knee

mehcanics62, no differences were seen in peak knee flexion angle or peak rear foot eversion
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Knowledge Evidence Essay
angle.18 As part of a large prospective study investigating lower extremity injuries in female

runners, a group of healthy female recreational runners underwent a 3D gait analysis and were

then followed over a period of two years. Kinematics of individuals who developed ITBS were

compared to an age and mileage matched control group. Authors hypothesized that the

participants who developed ITBS would show increased hip adduction, increased knee internal

rotation and increased rear foot eversion angles. Knee flexion angles were not expected to differ

between groups. Results from this prospective study showed that the ITBS group demonstrated

greater hip adduction and knee internal rotation compared to the control group. Contrary to the

authors hypothesis, rear foot eversion did not differ between groups.56 These results are in

agreement with the retrospective study conducted by Ferber et al.18 A continuation of this study

was conducted by Hamill et al. to compare pre-existing strain, strain rate and duration of

impingement in the IT band between female runners who develop ITBS and healthy controls

who did not go on to develop any injury. Using the same kinematic data as Noehren et al.56, it

was hypothesized that runners who developed ITBS would demonstrate greater strain throughout

the stance period of running, particularly at touchdown and maximum knee flexion. Strain rate

and duration of impingement were also expected to be greater in the ITBS group compared to the

healthy group. IT band strain was calculated specific to each subject using a model of the lower

extremity produced by SIMM software. Compared to the control group and the unaffected limb,

strain rate was significantly greater in the limb experiencing ITBS suggesting that increased

strain may lead to the development of ITBS.28 Strength, flexibility and running mechanics were

assessed in males only with ITBS. Compared to a control group, males with ITBS exhibited

increased hip internal rotation and knee adduction angles during the early stance phase. Hip

external rotator strength was also reduced in this male population.59


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Knowledge Evidence Essay
Weakness of the gluteus medius is frequently implicated in ITBS because of the potential

for weakness of this muscle to lead to increased hip adduction. In a study using healthy

recreational runners who manipulated their step width to increase hip adduction, results showed

that a narrower step width was associated with significantly greater IT band strain and strain rate

than with a preferred step width and a wider step width. Calculation of effect sizes suggests that

step width has a moderate to large effect on IT band strain and small to moderate effect on IT

band strain rate. Without sufficient gluteus medius strength, the tensor fascia latae and the IT

band must compensate to stabilize the knee during dynamic movement, potentially increasing the

strain on the IT band.49 Fredericson et al. compared hip abductor strength in long distance

runners with ITBS to the unaffected limb and to a control group. Hip abductor muscle strength

was significantly reduced in runners with ITBS compared to their unaffected limb and the

control group.19 While not focused specifically on ITBS, Niemeth et al. reported reduced hip

abductor muscle strength in runners with various musculoskeletal injuries, including ITBS. This

finding further supports association between hip abductor strength and ITBS.55 However, not all

studies support the association between hip abductor weakness and ITBS. Grau et al. compared a

group of runners with ITBS to a control group and found no differences in concentric, eccentric

or isometric peak torque of the hip abductors and adductors nor was any difference found in the

concentric endurance quotient. This measure assesses the difference between dynamic hip

abduction and adduction with the normal population experiencing stronger adductors. In the

current study, both groups of runners had similar ratios that indicated they had stronger

abductors, compared to the normal population suggesting that as a group runners exhibit stronger

hip abductors compared to hip adductors. Authors concluded at this time, hip abductor muscle
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Knowledge Evidence Essay
weakness was not involved in the etiology of ITBS in runners. However it is important to note,

that participants at the time of testing were asymptomatic.25

Influence of gender on ITBS

Gait kinematics in males and females with ITBS were compared in an effort to determine if

differences existed based on gender. It was hypothesized that females with ITBS would

demonstrate greater frontal and transverse plane knee kinematics compared to males with ITBS.

In comparison to males with ITBS, females demonstrated greater hip external rotation angles.64

Interventions to improve ITBS

Muscle strengthening

In comparison to PFPS, interventions to improve running mechanics associated with ITBS are

scarce. After determining that hip abductor strength was significantly reduced in long distance

runners with ITBS, Fredericson et al. employed a 6-week rehabilitation program targeting the

gluteus medius. The rehabilitation protocol consisted of two IT band stretches, side-lying hip

abduction exercises and pelvic drops performed once per week under supervision of a physical

therapist. Additionally, Twenty-four long-distance runners with ITBS completed the

rehabilitation protocol. After completion, increases in hip abductor strength of the injured limb

were demonstrated in both males and females. Twenty-two of the 24 runners were able to return

to running pain free and remained pain free at the 6-month follow-up. A limitation to this study

was that no kinematics were assessed. Authors did assess hip abductor strength before and after

the intervention, but investigation of the effect of hip abductor strengthening on running

kinematics was not included.


Amanda Estep
Knowledge Evidence Essay

Gait retraining

While strengthening of hip abductor musculature to improve ITBS symptoms is supported, it has

been suggested that muscle strengthening alone may not be sufficient enough to improve running

mechanics. Therefore, a running retraining protocol was implemented to determine the effects on

pain, function and lower-extremity biomechanics in a female recreational runner with ITBS.

After baseline collection of 3D gait kinematics, the participants symptomatic limb was

compared to her unaffected limb. In comparison to the unaffected limb, the symptomatic limb

demonstrated reduced pelvic external rotation, increased knee external rotation and external

rotation foot progression angles. While these biomechanical abnormalities differ from previous

literature which has reported increased hip adduction and knee internal rotation in individuals

with ITBS, tension on the IT band is still increased. Based on the results of the gait analysis, the

gait retraining protocol focused on increasing pelvic rotation angle. Using both visual and

auditory feedback, gait retraining sessions took place over the span of 4 weeks with 2 sessions

per week during the first 3 weeks and 3 session per week during the final week. Real-time visual

feedback of pelvic rotation angle was provided on a computer monitor placed in front the

treadmill. Auditory feedback was provided by an alarm that buzzed when the amount of pelvic

rotation deviated 1 SD from the amount of normal pelvic rotation. Verbal cues were also

provided such as keep the knee pointing forward, reduce the arm swing and keep the foot

pointing forward. Feedback was gradually removed using a faded feedback design to decrease

reliance on feedback to alter gait and promote internalization of the task. After completion of

running retraining sessions, the participant was instructed to return to running 3 times per week

using the new gait pattern and gradually increasing running time. Results from the post-

intervention showed that the amount of pelvic external rotation did not improve and remained
Amanda Estep
Knowledge Evidence Essay
decreased. However, knee external rotation angle and external rotation foot progression angle

improved by decreasing and moving towards a more internally rotated position. At the one-

month follow-up, pelvic external rotation decreased even more, while knee external rotation and

external rotation foot progression angles continued to decrease and become more internally

rotated. Pain and function were also improved in response to the gait retraining intervention.

Limitations to this study are similar to the limitations seen in the gait retraining studies for

individuals with PFPS. A laboratory setting with specific equipment is needed to carry out the

gait retraining sessions, which limits the practicality of this type of intervention. Side effects of

altering gait kinematics were monitored during the intervention, but only during the intervention.

It was not made clear if the researchers investigated any negative side effects at the 1-month

follow-up and no follow-up beyond 1-month was conducted. During the intervention, the

participant did report stiffness in her thoracic spine after the second training session, but these

symptoms disappeared by the third training session with no complaints being reported for the

remainder of the intervention. Researchers also investigated the time it took for the participant to

easily alter her running gait pattern, which the participant reported being able to do by the fourth

training session. However, this change was not maintained at the end of the intervention or at the

1-month follow. It is known whether the participant continued to incorporate altered gait pattern

beyond 1-month post-intervention.37 Another case study investigated the effects of step rate

manipulation on a 36 year old female recreational runner presenting with ITBS. Previous

literature, not specific to ITBS, has demonstrated that increases in step rate above preferred

cadence are associated with decreases in joint loading at the hip and knee joint6,34, decreases in

peak hip adduction and knee internal rotation angles34 and increases in muscle firing of the

gluteus medius and gluteus maximus.35 Because ITBS has been associated with increased hip
Amanda Estep
Knowledge Evidence Essay
adduction and internal rotation angles and hip muscle weakness, authors hypothesized that

individuals with ITBS may benefit from increasing running cadence above their preferred rate.

Based on the participants preferred running speed, the goal of the intervention was to increase

step rate by 5%. To increase step rate, a metronome was used while running to provide auditory

feedback. The metronome was used until the participant felt like she could easily and

consistently match the beat of the metronome. The participant was also instructed to run

quietly and let your feet strike under your body as you fall forward. After 6 weeks of gait

retraining combined with hip strengthening and flexibility exercises, the participant was able to

return to running pain free while incorporating the increased running cadence. When visually

inspecting her gait using video analysis, the participants running form had improved and

included striking the ground closer to her center of mass and a slightly forward trunk lean, both

of which have been shown to decrease impact forces. Additionally, contralateral pelvic was

improved and the participant demonstrated greater control over dynamic knee valgus. At 4-

months post-intervention, running mileage had increased to 13.1 miles with maintenance of

increased running cadence. The primary focus of the intervention was on increasing running

cadence, but the intervention also included hip muscle strengthening exercises as well as IT band

flexibility exercises. As a result, improvements in pain, contralateral pelvic drop and control of

dynamic knee valgus cannot solely be attributed to increasing running cadence. Increases in hip

muscle strength were also demonstrated which may have contributed to the participants

increased control of dynamic valgus. Verbal cues were also given, such as let your feet strike

under your body as you fall forward that potentially influenced running form and subsequently

may also have contributed to observed improvements.1 While both of the aforementioned studies
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Knowledge Evidence Essay
were case studies, results do support the use of gait retraining in the treatment of ITBS. Future

studies including larger sample sizes are needed to further determine effectiveness.

Movement variability

A more novel approach to understanding the relationship between lower extremity

kinematics and injury is by investigating kinematic variability. Human movement variability is

defined as normal variations that occur in motor performance across multiple repetitions of a

task. As it relates to the gait cycle, no two steps taken are the exact same.82

Traditionally, increased variability has been viewed as a negative aspect of human movement

and considered to be error. Less variability was associated with stability and mastery of a

task.77,78 However, the incorporation of dynamic systems theory and optimal variability theory,

into how movement is studied, has changed the way variability is viewed.

According to dynamic systems theory, a certain amount of variability is a necessity to

maintain normal function. Variability represents flexibility and adaptability to a changing

environment and allows for the same task to be completed in multiple ways.29 The ability to

complete the same task in multiple ways is suggested to decrease repeated stress placed on the

body.27 Optimal variability theory states than an ideal amount of variability exists and deviating

away from this value represents pathology. Whether increased or decreased variability is

associated with pathology is dependent on the task.29 For example, variability demonstrated in

the interbeat interval in the human heartbeat represents healthy, normal function. Absence of

variability is indicative of cardiac disease.24 Within postural control, variability can be healthy

and exploratory, as long as basic postural stability can be achieved. In a study comparing center

of pressure (COP) excursion between young subjects and healthy older adults during quiet
Amanda Estep
Knowledge Evidence Essay
standing, results showed that older adults demonstrated less COP excursion. In addition, older

adults were unable to lean as far forward relative to their base of support compared to younger

subjects and at the maximum lean condition, postural variability was greater. Authors concluded

that the younger subjects met basic postural stability demands and as result, were able to lean

farther forward relative to their base of support and remain stabilized. The greater COP

excursions shown during quiet standing represented an exploratory form of variability. The older

adults were unable to meet basic postural stability demands and when asked to lean forward, they

became unstable, resulting in detrimental greater variability in the maximal lean condition. In

order to complete the quiet standing task, COP excursion was reduced, resulting in decreased

variability.87 Within human gait, variability of certain stride characteristics have been found to be

indicators of pathology. Increased stride duration variability is associated with risk of falling in

the elderly population. In addition, increased stride duration variability has also been

demonstrated in individuals with Parkinsons disease and Huntingtons disease.32

Variability can be measured using both linear and non-linear methods. Using linear measures,

such as standard deviation and coefficient of variation, data is averaged together and a mean

picture of movement is generated. In addition, linear measures quantify the magnitude of

variability. Non-linear measures of variability provide insight into the structure and evolution of

variability over time. Methods of non-linear measures include approximate entropy, detrended

fluctuation analysis and Lyapunov exponent. Approximate entropy is measure of signal

regularity and predictability. Typically, approximate entropy values range from 0-2 with higher

values illustrating greater irregularity/less predictability in the time series signal. Conversely,

lower values are reflective of increased regularity or smoothness for the given signal.65

Detrended fluctuation analysis is a self-similarity parameter used to identify strength of long-


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Knowledge Evidence Essay
range correlations in a time series. Stronger long range correlations indicate greater predictability

of the time series. Weaker long range correlations indicate more flexibility.63 Lyapunov exponent

is a measure of stability. By assessing the rate of divergence or convergence of trajectories,

stability of a system is quantified. A positive Lyapunov exponent represents divergence of

trajectories, while a negative Lyapunov exponent represents convergence. A Lyapunov exponent

of zero shows that trajectories are not converging or diverging. Instability arises from trajectories

that separate rapidly.74

A number of studies have addressed variability during walking and running in regards to

spatio-temporal features. Hausdorff et al. was the first to determine that stride interval

fluctuations demonstrated while walking were not random noise. Instead, these fluctuations

represented long-range correlations, meaning that stride intervals at any point in time series is

dependent on previous stride intervals.33 Long-range correlations have also been found in stride

interval of running,41 stride length, step interval and step length while walking and running.

Furthermore, the amount and structure of variability appear to be dependent on speed. While

walking and running at a preferred speed and speeds above and below, the amount of variability

for stride interval, step interval, stride length and step length decreased as speed increased. When

looking at the structure of variability, deviations away from preferred walking and running speed

resulted in increases in the strength of long-range correlations.4143 Increased strength of long-

range correlations represents greater predictability and less adaptability and variability. The

opposite is true for reduced strength in long-range correlations. This may suggest that walking

and running above and below preferred speed introduces a biological stress to the body and thus

degrees of freedom are reduced in order to complete the task. Walking and running at a preferred

speed resulted in a decrease in strength of long-range correlations showing that at preferred


Amanda Estep
Knowledge Evidence Essay
speed, gait is most flexible and adaptable. When comparing stride interval variability in walking

to running, walking demonstrated stronger long-range correlations, compared to running.40

Decreased variability in lower extremity biomechanics has been demonstrated in individuals

experiencing a running injury. Using continuous relative phase to measure joint coordination,

runners with patellofemoral joint pain demonstrated decreased variability in comparison to

healthy runners, across entire gait cycle for joint couplings including thigh flexion/extension and

tibial rotation, thigh abduction/adduction and tibial rotation, tibial rotation and foot

inversion/eversion and femoral rotation and tibial rotation.27 In another study of individuals with

patellofemoral pain, joint coordination was obtained using a modified vector coding technique.

Joint coordination for each subjects injured limb was compared to their healthy limb. When

averaged across the entire gait cycle, no differences were seen between injured limb and healthy

limb. However, when the gait cycle was broken down into phases and analyzed, reduced

variability for thigh/leg rotation coupling was demonstrated in the limbs with patellofemoral pain

at heel strike. A study comparing joint coordination variability, as measured by continuous

relative phase, between runners with a history of iliotibial band syndrome and a healthy control

group during an exhaustive run showed decreased variability for thigh adduction/abduction and

foot inversion/eversion joint coupling. This difference was only demonstrated when the entire

gait cycle was analyzed. Interestingly, runners with a history of iliotibial band syndrome

demonstrated increased variability in knee flexion/extension and foot adduction/abduction joint

coupling during stance and swing phases.10 Using approximate entropy, sagittal plane knee

variability was examined in 10 individuals who had experienced an anterior cruciate ligament

rupture. Each individuals ACL deficient knee was compared to the intact contralateral knee

while walking at different speeds on a treadmill. Authors hypothesized that the ACL deficient
Amanda Estep
Knowledge Evidence Essay
knee would exhibit less variability compared to the intact contralateral knee. In line with the

authors hypothesis, the ACL deficient knee demonstrated significantly less variability across all

walking speeds compared to the contralateral intact knee. Results of this study suggest that the

ACL deficient knee is less adaptable to unexpected changes in the environment and may be more

susceptible to future pathology.23

What is next?

A gap exists in the literature when trying to identify the mechanisms behind

improvements in muscle strengthening protocols in relieving pain and improving function in

individuals experiencing a running injury. When the relationship between muscle strength and

changes in kinematics is investigated, results are not only limited, but they are also inconclusive.

For example, Earl et al. investigated the effects of a proximal strengthening program on hip

strength, core endurance, pain, function and lower extremity running biomechanics. Increases in

hip strength were demonstrated, however joint kinematics remained the same. Ferber et al.

investigated changes in knee biomechanics after a 3-week hip-abductor strengthening protocol in

runners with PFPS. Compared to the control group, individuals who participated in hip-abductor

strengthening protocol demonstrated increased hip abductor strength and reduced pain and

decreased stride-to-stride knee joint variability while running. Interestingly, no changes in peak

knee genu valgum were observed. The investigation of changes in variability, as opposed to

solely relying on peak joint angles, provided a more sensitive measure to detect changes in

kinematics. Incorporating the use of non-linear dynamics, such as approximate entropy, when

evaluating kinematic changes after an intervention to improve abnormal kinematics may provide

further insight into gait pathology.


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Knowledge Evidence Essay
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