1

1 KINEMATIC AND KINETIC ANALYSIS OF THE SINGLE-LEG TRIPLE HOP

2 TEST IN WOMEN WITH AND WITHOUT PATELLOFEMORAL PAIN

3  
4 Amir Curcio dos Reis, PT, MS1, João Carlos Ferrari Correa, PT, PhD1, André Serra
5 Bley, PT, MS1, Nayra Deise dos Anjos Rabelo, PT MS1, Thiago Yukio Fukuda, PT,
6 PhD2, Paulo Roberto Garcia Lucareli, PT, PhD1
7
1
8 Department of Rehabilitation Science, Human Motion Analysis Laboratory,
9 Universidade Nove de Julho, São Paulo, Brazil,
2
10 Irmandade da Santa Casa de Misericórdia, São Paulo, Brazil.
11
12

13 The protocol for this study was approved by the Universidade Nove de Julho Human

14 Research Ethics Committee.

15
16
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17 The authors certify that they have no affiliations with or financial involvement in any
18 organization or entity with a direct financial interest in the subject matter or materials
19 discussed in the article.
20

21

22 Corresponding Author: Dr. Paulo Roberto Garcia Lucareli

23 Professional Address: UNINOVE, Rua Vergueiro, 235, São Paulo, SP, Brazil

24 Phone number: (55+11)26339327

25 E-mail: plucareli@hotmail.com / paulolucareli@uninove.br
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26

27
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28 Study Design: Cross-sectional study.

29 Objectives: To compare the biomechanical strategies of the trunk and lower extremity

30 during the transition period between the first and second hop of a single-leg triple-hop

31 test (SLTHT) in women with and without patellofemoral pain (PFP).

32 Background: Recent literature has shown that PFP is associated with biomechanical

33 impairments of the lower extremities. A number of studies have analyzed the position of

34 the trunk and lower extremities for functional activities such as walking, squatting,

35 jumping, and the step-down test. However, studies on more challenging activities, such

36 as the SLTHT, may be more representative of sports requiring jumping movements..

37 Methods: Females between 18 and 35 years of age (control group, n=20; PFP group,

38 n=20) participated in the study. Three dimensional kinematic and kinetic data were

39 collected during the transition period between the first and second hop while
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40 participants performed the SLTHT.

41 Results: Compared to the control group, women with PFP exhibited greater (P<.05)

42 anterior and ipsilateral trunk lean, contralateral pelvic drop, hip internal rotation and

43 adduction, and ankle eversion. A significant difference (P<.05) was also found between

44 groups for all time to peak joint angle analyzed, with the exception of anterior pelvic tilt

45 and hip flexion. In addition, women with PFP exhibited greater (P<.05) hip and knee

46 abductor internal moments.

J Orthop Sports Phys Ther

47 Conclusion: Compared to the control group, women with PFP exhibited altered trunk,

48 pelvis, hip, knee, and ankle kinematics and kinetics.

49 Key words: Anterior knee pain, biomechanics, hip, patella.

50
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51 INTRODUCTION

52 Biomechanical abnormalities of the lower extremities have been associated with

53 a number of ankle, knee, hip, and lumbo-pelvic injuries.5,23,35,36,41,43 Women with

54 patellofemoral pain (PFP) commonly exhibit a medial collapse of the knee, also called

55 dynamic valgus.34,40 This dynamic valgus is characterized by a combination of

56 excessive hip adduction and internal rotation and knee valgus during weight-bearing

57 activities such as ascending and descending stairs, running, or jumping.6,38,50

58 Mechanically, this misalignment decreases patellofemoral joint contact area leading to

59 increased articular stress and potentially PFP.40,44

60 Powers still theorized knee varus moment.39 According to him, the hip abductor

61 weakness can cause a contralateral pelvic drop during single leg activities, which

62 distance the center of mass from the knee joint, increasing valgus internal moment of
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63 the joint.

64 A number of kinematic and kinetic studies have described poor hip alignment

65 often associated with excessive trunk lean in the frontal plane, as well as altered knee

66 and hip internal moments during low-impact activities in women with PFP.10,15,33,39 But

67 little data exist on high-impact activities which may add important information, such as

68 the timing and sequencing in which peak angles of movement occur. The single-leg

69 triple-hop test (SLTHT), which includes landing and propulsion phases, is widely used
J Orthop Sports Phys Ther

70 in clinical practice to assess the dynamic stability of the knee. A number of authors have

71 suggested that the hop test may be an important tool in identifying individuals who are

72 at risk for knee injuries and to quantify improvements during the rehabilitation of

73 individuals with PFP and those post anterior cruciate ligament reconstruction.17,19,20,29

74 The aim of the present study was to compare selected kinematics and kinetics of

75 the trunk and lower extremities of women with and without PFP during the transition
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76 period between the first and second hop of the SLTHT. We also aimed to describe the

77 time to peak joint angle for both groups during this task. We hypothesized that, in

78 comparison to the control group, women with PFP would exhibit greater ipsilateral

79 trunk lean, contralateral pelvic drop, and hip adduction and internal rotation, as well as a

80 different timing and sequencing of peak joint angles. We also hypothesized that those

81 with PFP would have higher hip and knee abductor internal moments.

82

83 METHODS

84 Participants

85 This cross-sectional study included 20 women with PFP (PFP group) and 20

86 age-matched pain-free women (control group). All volunteers were informed about the

87 study procedures and signed informed consent in accordance with National Health
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88 Council Resolution No. 196/96. The protocol for this study was approved by the

89 Universidade Nove de Julho Human Research Ethics Committee.

90 The sample size was calculated a priori based on peak knee flexion angle

91 reported in a previous study, which showed that maximal amplitudes of movement in

92 the sagittal plane were related to changes in knee valgus kinetic and kinematic values.35

93 Calculations were performed using α=.05, β=.10 (90% power), and a mean between-

94 group difference of 11° for knee flexion, assuming a standard deviation of 10°. Based
J Orthop Sports Phys Ther

95 on these parameters, 17 participants per group were required to adequately power the

96 study for this variable of interest.

97 All women in the study were between 18 and 35 years of age (TABLE 1),

98 corresponding to the age range when PFP is common.3,21,30 Women with PFP were

99 included if they had anterior knee pain for at least 3 months and reported increase pain

100 for 2 or more activities that commonly provoke PFP, as outlined by Thomee.47 These
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101 activities included ascending and descending stairs, squatting, kneeling, jumping, long

102 periods of sitting, resisted isometric knee extension at 60° of knee flexion, and pain on

103 palpation of the medial and/or lateral facet of the patella.

104 The women in the PFP group were recruited from an outpatient rehabilitation

105 program by a single physiotherapist with more than 10 years of clinical experience in

106 knee rehabilitation. Women of similar demographic characteristics, who came to the

107 clinic for treatment of upper extremity tendinopathies and did not have lower extremity

108 involvement were recruited from the same clinic at the time of discharge to serve as the

109 control group. All participants were considered physically active based on engaging in

110 physical activity on a weekly basis.6

111 Potential participants were excluded if they exhibited any of the following:

112 neurological disorder; injury to the hip, ankle, or lumbosacral region; rheumatoid
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113 arthritis; heart condition; previous surgery involving the lower extremities; or if they

114 were pregnant. Women who had other knee pathologies, such as patellar instability,

115 patellofemoral dysplasia, meniscal or ligament tears, osteoarthritis, or tendinopathies,

116 were also excluded, as were those who exhibited a leg length difference of more than 1

117 cm when measured in supine, from the anterior superior iliac spine to the medial

118 malleolus.

119
J Orthop Sports Phys Ther

120 Procedures

121 Individuals who met the inclusion and exclusion criteria and who were willing to

122 participate were scheduled for testing in the movement analysis laboratory. Women

123 who were symptomatic were first asked about the length of time they had experienced

124 symptoms and the intensity of their pain, using a visual analogue scale (VAS).12,13

125 Anthropometric assessment was subsequently performed and included measurements

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126 of: body mass, height, distance between anterior superior iliac spines, leg length, knee

127 and ankle width, and tibial torsion.15

128 Then, the volunteers walked on a treadmill for 10 minutes at a speed of 2 meters

129 per second. After this warm-up, they familiarized themselves with the SLTHT until they

130 felt comfortable with the activity. During these practice hops, the distance reached with

131 the first hop was measured and this distance was used to determine the starting location

132 of the participants so that they would land in the center of the concealed force platform

133 when performing the subsequent SLTHT.

134 Consistent with the conventional gait model (CGM),14,25 which has been used to

135 assess hop tasks in the literature,26-28,51-53 23 reflective spherical markers were placed on

136 the participants in the following locations: on the 2 anterior and posterior superior iliac
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137 spines; over the center of the patella; on the lateral femoral epicondyles; over the lower

138 1/3 of the surface of the shanks; on the lateral malleoli; over the second metatarsals; on

139 the calcanei; on the acromioclavicular joints; on the spinous process of the 7th cervical

140 vertebra; on the spinous process of the 10th thoracic vertebra; on the jugular notch where

141 the clavicles meet the sternum; on the xiphoid process of the sternum; and one offset

142 anywhere over the right scapula. For the CGM, the same markers are required during

143 static and dynamic trials.

J Orthop Sports Phys Ther

144 After all markers were attached, 1 static standing reference trial and 3 SLTHT

145 trials were performed for the symptomatic limb for those with PFP or the dominant limb

146 for those in the control group. Two minutes of rest was provided between each trial. As

147 it was not possible to standardize footwear, participants were barefoot during testing. In

148 addition, to standardize the position of the participants and to avoid compensatory

149 movements of the upper limbs, the participants were asked to cross their arms in front

150 of the thorax while performing the task.

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151 Instrumentation

152 An 8-camera SMART-D® BTS (Milan, Italy) system was used to capture the 3-

153 dimensional marker trajectories. The cameras were interfaced to a microcomputer and

154 placed around a force plate embedded in the floor (Kistler 9286, New York, USA). The

155 force plate was interfaced to the same microcomputer that was used for kinematic data

156 collection via an analog-to-digital converter, enabling the synchronization of kinematic

157 and kinetic data.

158 Based on the results of the pilot study, sampling frequencies of 100 Hz

159 (kinematic) and 400 Hz (kinetic) were used. These sampling rates have previously been

160 used in a number of studies to assess the kinematics4,11,24,45 and kinetics1,4,27,28,45 of jump

161 tasks.

162 Data Analysis

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163 Kinematic data were converted to the C3D format using Matlab software

164 (MathWorks, Inc, Natick, MA), applying the BTK 0.1.10 code (Biomechanical

165 ToolKit)2 and then labeled and processed in Vicon Nexus software (VICON, Oxford,

166 UK)48 using the Plug-in Gait model. As in previous studies assessing dynamic tasks, the

167 kinematic data were filtered using a fourth-order zero-lag Butterworth 12-Hz low-pass

168 filter.18 Joint kinematics were calculated using a joint coordinate system approach14,25

169 and were reported relative to a static standing trial to quantify the movement of one
J Orthop Sports Phys Ther

170 segment in relation to another or of one segment relative to the laboratory. Kinematics,

171 ground reaction forces, and anthropometric data were used to calculate articular internal

172 moments and power (scalar product of moment and angular velocity) of the hip, knee,

173 and ankle, using inverse dynamic equations in Vicon Nexus® software. Kinetic data

174 were normalized to body mass.

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175 Kinematic and kinetic data were obtained for the weight bearing period between

176 the first and second hop of the SLTHT. Therefore, the period of interest was from initial

177 foot contact with the force plate (0%) to toe-off (100%; FIGURE 1). Internal joint

178 moment for the lower extremity was recorded at peak knee flexion angle and

179 represented the end of the landing phase. The average power recorded during landing

180 phase was used to compare groups.

181 The peak joint angles, time to peak joint angles, and internal peak moments and

182 power of each joint studied were imported to Excel® for statistical analysis.

183 The time to peak joint angle analysis was performed to understand the timing

184 and sequencing with which the maximum amplitude of each joint was achieved during

185 the transition period between the first and second hop of the SLTHT.

186 Statistical Analysis

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187 The Kolmogorov-Smirnov test (with the Lilliefors correction factor) was used to

188 test the normality of the kinematic and kinetic data. Descriptive statistics, means and

189 standard deviations (SD), were calculated for all variables. The average of 3 trials was

190 used for all statistical analyses of the kinematic and kinetic data. The kinematic and

191 kinetic variables were compared between groups using 2 separate multivariate analyses

192 of variance (MANOVA). If there were significant multivariate effects, univariate effects

193 were tested for all relevant variables. The significance level was set at P<.05. Cohen’s d
J Orthop Sports Phys Ther

194 effect size were calculated and defined as trivial if the value was between 0.0 and 0.2;

195 small if 0.3 to 0.5; medium if 0.6 to 0.8; and large if 0.9 or higher.37 All statistical

196 comparisons were performed with SPSS version 15.0 (SPSS Inc., Chicago, IL).

197

198 RESULTS
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199 The MANOVAs indicated significant differences for kinematic variables

200 (Wilk’sλ=.52; P<.001), joint internal moments (Wilk’s λ=.16; P<.001), and joint powers

201 (Wilk’s λ= .23; P<.001).

202 Performance

203 The mean ± SD distance for the first jump of the SLTHT for the women in the

204 control group was 1.05 ± 0.17 m compared to 0.96 ± 0.11 m for the women in the PFP

205 group (P = .091).

206 Kinematics

207 TABLE 2 provides the descriptive peak joint angles data, as well as the results

208 of statistical analysis for between group comparisons.

209 Trunk

210 When compared to the control group, the women in the PFP group exhibited
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211 greater anterior (P=.038) and ipsilateral (P=.001) trunk lean, but less ipsilateral trunk

212 rotation (P=.003).

213 Pelvis

214 When compared to the control group, the women in the PFP group exhibited

215 greater contralateral pelvic drop (P=.001) and less ipsilateral rotation (P=.001). There

216 was no significant difference between groups for anterior pelvic tilt (P=.299).

217 Hip
J Orthop Sports Phys Ther

218 Women in the PFP group exhibited greater hip adduction (P=.002) and internal

219 rotation (P=.002). However, they exhibited less hip flexion (P=.029).

220 Knee

221 When compared to the control group, the women in the PFP group exhibited less

222 knee flexion (P=.001). No significant difference was found for knee adduction (P=.614).

223 Ankle
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224 Women with PFPS exhibited greater ankle eversion (P=.019) and less

225 dorsiflexion (P=.003) than those in the control group.

226 Time to Peak

227 Data on the time to peak joint angle as a percentage of contact time are provided

228 in FIGURE 2 and TABLE 3. The women in the PFP group exhibited a significantly

229 (P<.05) faster time to peak joint angle for the following variables: ipsilateral trunk

230 rotation, ipsilateral pelvic rotation, hip internal rotation, knee flexion, knee adduction,

231 ankle dorsiflexion, and ankle eversion. They conversely exhibited a significantly

232 (P<.05) slower time to peak joint angle for the following variables: anterior trunk lean,

233 ipsilateral trunk lean, contralateral pelvic drop, and hip adduction. There were no

234 significant between group differences (P>.05) for time to peak joint angle for hip

235 flexion and anterior pelvic tilt.

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236 Kinetics

237 TABLE 4 provides the descriptive statistics for all kinetic variables as well as

238 the results of the between group comparisons.

239 Hip

240 Women with PFP exhibited a greater internal hip abductor moment than those in

241 the control group (P=.017) but less hip power absorption in the frontal plane (P=.006).

242 No statistically significant differences were found between groups for internal hip
J Orthop Sports Phys Ther

243 extensor moment (P=.679) and hip power absorption in the sagittal plane (P=.931).

244 Knee

245 Women with PFP exhibited a greater internal knee abductor moment than those

246 in the control group (P=.001) and greater knee power absorption in the frontal plane

247 (P=.001). Conversely, they exhibited a lower internal knee extensor moment (P=.001)

248 and less knee power absorption in the sagittal plane (P=.006).
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249 Ankle

250 Women with PFP exhibited a lower internal ankle plantar flexor moment than

251 those in the control group (P=.035) and less ankle power absorption in the sagittal plane

252 (P=.018). No significant differences were found between groups for the internal ankle

253 inverter moment (P=.051) and ankle power absorption in the frontal plane (P=.420).

254

255 DISCUSSION

256 This study compared selected trunk and lower extremity kinematic and kinetic

257 variables between women with and without PFP for the weight bearing period between

258 the first and second hop of the SLTHT. In comparison to women in the control group,

259 those with anterior knee pain exhibited greater anterior and ipsilateral trunk lean,

260 contralateral pelvic drop, hip adduction and internal rotation, and ankle eversion but less
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261 ipsilateral trunk and pelvis rotation, hip and knee flexion, and ankle dorsiflexion.

262 Furthermore, women with PFP exhibited greater hip and knee internal abductor

263 moment, less hip power absorption and greater knee power absorption in the frontal

264 plane but less knee extensor and ankle plantar flexor internal moments with less knee

265 and ankle power absorption in the sagittal plane.

266 Compared to the control group, time to peak joint angle for women with PFP

267 occurred earlier for ipsilateral trunk and pelvis rotation, hip internal rotation, knee
J Orthop Sports Phys Ther

268 adduction, knee flexion, and ankle dorsiflexion and eversion, whereas it occurred later

269 for anterior and ipsilateral trunk lean, contralateral pelvic drop, and hip adduction.

270 Some of our findings (specially trunk and hip variables) were found in the

271 literature, as the higher ipsilateral trunk lean;33 contralateral pelvic drop;33 hip

272 adduction;15,31,33 and internal rotation31,33 presented in PFP group when compared to

273 pain free controls. By the other side, in relation to the knee adduction presented in our
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274 volunteers, we didn’t find data in literature to confirm this finding, except theory made

275 by Powers 201039

276 We believe that this finding is consistent with the high demands placed on the

277 hip abductors during SLTHT, which leads to the contralateral pelvic drop and ipsilateral

278 trunk lean, potentially reflecting hip abductor weakness.7,9,33,40,44 The contralateral

279 pelvic drop increases the medial distance of the center of mass to the knee joint,

280 increasing knee internal valgus moment.39 Moreover, the contralateral pelvis drop

281 explain the uncommon combination of hip adduction and knee adduction presented in

282 our study. While both groups who participated in this study exhibited a similar

283 movement pattern, the pattern was more pronounced in those with PFP.

284 In the transverse plane, women with anterior knee pain exhibited a greater

285 amount of hip internal rotation and reached peak hip internal rotation earlier.
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286 Theoretically, this excessive and early internal rotation could be attributed to weakness

287 or a deficit of activation of the hip external rotators.22,31,33,42

288 In the frontal plane, women with PFP exhibited a greater amount of hip

289 adduction, which was reached later during the movement. Furthermore, those with PFP

290 exhibited greater ipsilateral trunk lean and contralateral pelvic drop, associated with

291 greater hip internal abductor moment and less hip power absorption than individuals in

292 the control group (FIGURE 3).

J Orthop Sports Phys Ther

293 Similar to hip adduction, both contralateral pelvic drop and ipsilateral trunk lean

294 occurred later in the PFP group than in the control group. Consistent with others, we

295 believe that these findings may be explained by a deficit in torque produced by the hip

296 abductor muscles.33,38 In our opinion, weak hip abductors may initially be able to

297 control the pelvis, but they cannot sustain this position during the entire movement.

298 Because contralateral pelvic drop occurs in association with an internal hip abductor
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299 moment and power absorption in the hip joint, ipsilateral trunk lean is expected as a

300 compensatory adjustment to promote lateral displacement of the ground reaction

301 forces.36,38,49

302 In the sagittal plane, women from the symptomatic group exhibited less hip and

303 knee flexion, less ankle dorsiflexion, less internal knee extensor and ankle plantar

304 flexion moment, as well as less knee and ankle power absorption. A greater knee

305 flexion angle and greater internal knee extensor moment and power absorption, lead to

306 increased compressive force of the patellofemoral joint.16,17,32 We believe that women in

307 the PFP group limited their sagittal plane movement during the SLTHT in an attempt to

308 reduce the demand on the quadriceps and consequently decrease patellofemoral joint

309 stress. The symptomatic women also exhibited exaggerated movements in terms of

310 anterior trunk lean, which peaked later than it did in the control group. This may have
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311 occurred as a compensatory mechanism of the trunk, moving the center of mass of the

312 trunk more directly above the knee joint, to reduce load absorption demands on the

313 lower extremity.46

314 A number of studies have assessed the biomechanical behavior of patients with

315 PFP while performing less demanding tasks.7,8,25,31,42 The present study used 3-

316 dimensional analysis of proximal (trunk, pelvis, and hip), local (knee), and distal joints

317 (ankle) to study a more challenging task (SLTHT), requiring greater neuromuscular
J Orthop Sports Phys Ther

318 control. We believe that this knowledge can play an important role in clinical decision-

319 making aimed at intervening to prevent abnormal movements in lower limb during

320 functional activities.

321 The present study also has a number of potential limitations. First, we only

322 assessed the transition between the first and second jump based on data from a pilot

323 study indicating that greater kinetic and kinematic peak values occurred between the
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324 first and second jump. Because the participants in the study were not aware that data

325 were collected for only this transition phase, the potential “lab-effect” (ie, Hawthorne

326 effect) that may occur during data collection may have been minimized, but likely not

327 completely eliminated. Second, soft tissue movement and other technical limitations

328 may have affected the measurement of the small amount of motion that take place in the

329 frontal and transverse plane, especially at the ankle. However, given the low standard

330 deviation found in both groups, these limitations probably did not affect the results of

331 the present study. Third, because it was difficult to standardize footwear used during

332 data collection, we decided to test all participants barefoot, which is not typical for a

333 jumping task. Finally, participants crossed their arms during testing, which may have

334 influenced the performance of the task. However, this position was used to avoid

335 compensatory movements of the upper limbs.

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336 The primary clinical implication of these findings is that may be beneficial to

337 consider highly challenging activities when assessing patients with PFP, once that

338 biomechanical disorder are present. Future studies should consider incorporating

339 electromyographic assessment of the trunk, hip, and knee musculature.

340

341 CONCLUSION

342 Compared to the control group, women with PFP exhibited altered kinematics
J Orthop Sports Phys Ther

343 and kinetics of the trunk, hip, knee, and ankle in all 3 planes of motion during the

344 weight bearing transition period between the first and second hop of the SLTHT.

345

346 KEY POINTS

347 Findings: Compared to the control group, women with PFP exhibited altered

348 kinematics and kinetics of the trunk, hip, knee, and ankle in all 3 planes of motion
 15

349 during the weight bearing transition period between the first and second hop of the

350 SLTHT.

351 Implications: These biomechanical alterations are different with what has been

352 identified for other weight bearing functional movements in this population.

353 Caution: These data are limited to young women during a specific high-impact activity

354 (SLTHT) and do not establish cause-and-effect.

355

356 AKNOWLEDGEMENTS

357 This study was in part supported by Grant 2012/08909-5 from the São Paulo Research

358 Foundation (FAPESP).

359
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420 19. Fukuda TY, Melo WP, Zaffalon BM, et al. Hip posterolateral musculature
421 strengthening in sedentary women with patellofemoral pain syndrome: a
422 randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys
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424 20. Fukuda TY, Rossetto FM, Magalhães E, Bryk FF, Lucareli PR, de Almeida
425 Aparecida Carvalho N. Short-term effects of hip abductors and lateral rotators
426 strengthening in females with patellofemoral pain syndrome: a randomized
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429 21. Hains G, Hains F. Patellofemoral pain syndrome managed by ischemic
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430 compression to the trigger points located in the peri-patellar and retropatellar
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436 Orthop Sports Phys Ther. 2010;40(2):39-41. doi: 10.2519/jospt.2010.0102
437 24. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor
438 function and lower extremity landing kinematics: sex differences. J Athl Train.
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440 25. Kadaba MP, Ramakrishnan HK, Wootten ME. Measurement of lower extremity
441 kinematics during level walking. J Orthop Res. 1990;8(3):383-392.
442 26. Kernozek TW, Torry MR, Iwasaki M. Gender differences in lower extremity
443 landing mechanics caused by neuromuscular fatigue. Am J Sports Med.
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444 2008;36(3):554-565.
445 27. Mackala K, Stodółka J, Siemienski A, Coh M. Biomechanical analysis of squat
446 jump and countermovement jump from varying starting positions. J Strength
447 Cond Res. 2013;27(10):2650-2661. doi: 10.1519/JSC.0b013e31828909ec
448 28. Mackala K, Stodółka J, Siemienski A, Coh M. Biomechanical analysis of
449 standing long jump from varying starting positions. J Strength Cond Res.
450 2013;27(10):2674-2684. doi: 10.1519/JSC.0b013e31825fce65
451 29. Magalhães E, Fukuda TY, Sacramento SN, Forgas A, Cohen M, Abdalla RJ. A
452 comparison of hip strength between sedentary females with and without
453 patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2010;40(10):641-
454 647. doi: 10.2519/jospt.2010.3120.
455 30. Magalhães E, Silva AP, Sacramento SN, Martin RL, Fukuda TY. Isometric
456 strength ratios of the hip musculature in females with patellofemoral pain: a
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457 comparison to pain-free controls. J Strength Cond Res. 2013;27(8):2165-2170.

458 doi: 10.1519/JSC.0b013e318279793d
459 31. McKenzie K, Galea V, Wessel J, Pierrynowski M. Lower extremity kinematics
460 of females with patellofemoral pain syndrome while stair stepping. J Orthop
461 Sports Phys Ther. 2010;40(10):625-632. doi: 10.2519/jospt.2010.3185
462 32. Mostamand J, Bader DL, Hudson Z. Reliability testing of the patellofemoral
463 joint reaction force (PFJRF) measurement during double-legged squatting in
464 healthy subjects: a pilot study. J Bodyw Mov Ther. 2012;16(2):217-223. doi:
465 10.1016/j.jbmt.2011.03.003
466 33. Nakagawa TH, Moriya ET, Maciel CD, Serrão FV. Trunk, pelvis, hip, and knee
467 kinematics, hip strength, and gluteal muscle activation during a single-leg squat
468 in males and females with and without patellofemoral pain syndrome. J Orthop
469 Sports Phys Ther. 2012;42(6):491-501. doi: 10.2519/jospt.2012.3987
470 34. Nguyen AD, Shultz SJ, Schmitz RJ, Luecht RM, Perrin DH. A preliminary
471 multifactorial approach describing the relationships among lower extremity
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474 35. Petschnig R, Baron R, Albrecht M. The relationship between isokinetic
475 quadriceps strength test and hop tests for distance and one-legged vertical jump
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477 Ther. 1998;28(1):23-31.
478 36. Pollard CD, Sigward SM, Powers CM. Limited hip and knee flexion during
479 landing is associated with increased frontal plane knee motion and moments.
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480 Clin Biomech (Bristol, Avon). 2010;25(2):142-146. doi:

481 10.1016/j.clinbiomech.2009.10.005.
482 37. Portney L, Watkins M. Foundations of clinical research: applications to
483 practice. 2 ed. Upper Saddle River, NJ; 2000.
484 38. Powers CM. The influence of altered lower-extremity kinematics on
485 patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys
486 Ther. 2003;33(11):639-646.
487 39. Powers CM. The influence of abnormal hip mechanics on knee injury: a
488 biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42-51. doi:
489 10.2519/jospt.2010.3337
490 40. Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have
491 weak hip muscles: a systematic review. Aust J Physiother. 2009;55(1):9-15.
492 41. Salsich GB, Graci V, Maxam DE. The effects of movement pattern modification
493 on lower extremity kinematics and pain in women with patellofemoral pain. J
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494 Orthop Sports Phys Ther. 2012;42(12):1017-1024. doi: 10.2519/jospt.2012.4231

495 42. Salsich GB, Long-Rossi F. Do females with patellofemoral pain have abnormal
496 hip and knee kinematics during gait? Physiother Theory Pract. 2010;26(3):150-
497 159. doi: 10.3109/09593980903423111
498 43. Selfe J, Richards J, Thewlis D, Kilmurray S. The biomechanics of step descent
499 under different treatment modalities used in patellofemoral pain. Gait Posture.
500 2008;27(2):258-263. http://dx.doi.org/10.1016/j.gaitpost.2007.03.017
501 44. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and
502 muscle activation between subjects with and without patellofemoral pain. J
503 Orthop Sports Phys Ther. 2009;39(1):12-19. doi: 10.2519/jospt.2009.2885
504 45. Struzik A, Zawadzki J. Leg stiffness during phases of countermovement and
505 take-off in vertical jump. Acta Bioeng Biomech. 2013;15(2):113-118.
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506 46. Teng HL, Powers CM. Sagittal plane trunk posture influences patellofemoral
507 joint stress during running. J Orthop Sports Phys Ther. 2014;44(10):785-792.
508 doi: 10.2519/jospt.2014.5249
509 47. Thomeé R, Augustsson J, Karlsson J. Patellofemoral pain syndrome: a review of
510 current issues. Sports Med. 1999;28(4):245-262.
511 48. VICON®. Plug-in-Gait modelling instructions. Manual, Vicon® 612 Motion
512 Systems; 2002.
513 49. Willson JD, Binder-Macleod S, Davis IS. Lower extremity jumping mechanics
514 of female athletes with and without patellofemoral pain before and after
515 exertion. Am J Sports Med. 2008;36(8):1587-1596. doi:
516 10.1177/0363546508315592
517 50. Willson JD, Davis IS. Lower extremity mechanics of females with and without
518 patellofemoral pain across activities with progressively greater task demands.
519 Clin Biomech (Bristol, Avon). 2008;23(2):203-211.
520 http://dx.doi.org/10.1016/j.clinbiomech.2007.08.025
521 51. Yeow CH, Lee PV, Goh JC. Effect of landing height on frontal plane
522 kinematics, kinetics and energy dissipation at lower extremity joints. J Biomech.
523 2009;42(12):1967-1973. doi: 10.1016/j.jbiomech.2009.05.017
524 52. Yeow CH, Lee PV, Goh JC. Sagittal knee joint kinematics and energetics in
525 response to different landing heights and techniques. Knee. 2010;17(2):127-131.
526 doi: 10.1016/j.knee.2009.07.015
527 53. Yeow CH, Lee PV, Goh JC. An investigation of lower extremity energy
528 dissipation strategies during single-leg and double-leg landing based on sagittal
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529 and frontal plane biomechanics. Hum Mov Sci. 2011;30(3):624-635. doi:
530 10.1016/j.humov.2010.11.010
531

532
533
534
J Orthop Sports Phys Ther
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535
536
537 FIGURE 1: Landing and propulsion during the transition between the first and second
538 hop of the single-leg triple hop test (SLTHT). The graph shows from initial contact
539 (0%) to toe off (100%) with the transition from landing to propulsion, occurring at 60%,
540 being defined based on the peak knee flexion angle.
541
542
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J Orthop Sports Phys Ther
 21

543
544
545
546 FIGURE 2: Time to peak joint angle as a percent of the weight bearing phase. *There
547 was a significant group-difference (P<.05) for all variables except for anterior pelvic tilt
548 and hip flexion. Abbreviations: ABD, abduction; ADD, adduction; Ant, anterior; Dor,
549 dorsiflexion; Flex, flexion; IL, ipsilateral; IR, internal rotation; Ever, eversion; Rot,
550 rotation.
551
552
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J Orthop Sports Phys Ther
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J Orthop Sports Phys Ther

553
554
555 FIGURE 3: Frontal plane alignment of the lower extremity and trunk at 60% of the
556 weight bearing phase between hop 1 and 2 for a representative woman in the control (A)
557 and patellofemoral pain (B) group. The red line indicates the ground reaction forces at
558 that same moment.
 TABLE 1: Demographic data

Control (n = 20)* PFP (n = 20)*

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Age (y) 23.1 ± 3.3 23.5 ± 2.1

Body mass (kg) 55.9 ± 7.1 55.3 ± 4.8
Height (m) 1.65 ± 0.12 1.71 ± 0.13
2
BMI (kg/m ) 21.3 ± 2.7 20.2 ± 1.8
ƚ
VAS (0-10) 0 4.9 ± 1.6
Abbreviations: BMI, body mass index; PFP, patellofemoral pain; VAS, visual analogue scale
* Data are mean ± SD
ƚ
Scored from 0 to 10, where 0 is no pain and 10 is the worst imaginable pain. Score is for the average amount of pain
during the last 2 weeks.
 
J Orthop Sports Phys Ther
 TABLE 2: Peak Joint Angle for the Trunk, Pelvis, Hip, Knee, and Ankle in Women With and Without PFP  

 
Between-group §
Control (n = 20)* PFP (n = 20)* ǂ Effect Size P Value
differences
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Anterior trunk lean 31.2 ± 6.0 35.9 ± 5.1 4.7 (1.1, 8.3) 0.8 0.038
Ipsilateral trunk lean 3.5 ± 2.4 9.2 ± 2.4 5.7 (4.2, 7.2) 2.3 0.001
Ipsilteral trunk rotation 17.1 ± 5.3 11.5 ± 3.2 -5.6 (-8.4, -2.8) 1.2 0.003
Anterior pelvic tilt 35.0 ± 5.1 33.2 ± 3.3 -1.8 (-4.8, 1.2) 0.4 0.299
Contralateral pelvic drop 4.1 ± 1.6 7.3 ± 2.0 3.2 (2.0, 4.4) 1.7 0.001
Ipsilateral pelvic rotation 14.0 ± 3.0 10.9 ± 1.6 -3.1 (-4.6, -1.6) 1.2 0.001
Hip flexion 58.6 ± 3.7 54.4 ± 5.4 -4.2 (-7.2, -1.2) 0.9 0.029
Hip adduction 6.9 ± 0.6 10.3 ± 0.6 3.4 (3.0, 3.8) 0.9 0.002
Hip internal rotation 8.9 ± 0.9 12.5 ± 3.3 3.6 (2.1, 5.2) 1.4 0.002
Knee flexion 56.7 ± 4.9 47.8 ± 2.8 -8.9 (-11.5, -6.4) 1.4 0.001
J Orthop Sports Phys Ther

Knee adduction 7.8 ± 3.0 8.4 ± 2.2 0.6 (-1.1, 2.3) 0.2 0.614
Ankle dorsiflexion 32.5 ± 1.5 26.7 ± 0.8 -5.8 (-6.6, -5.0) 4.8 0.003
Ankle eversion 6.7 ± 2.2 10.6 ± 4.3 3.9 (1.7, 6.1) 0.9 0.019
Abbreviation: PFP, patellofemoral pain
* Data are mean ± SD in degrees
§
Effect size determined using Cohen d (0.0 to 0.2 - trivial, 0.3 to 0.5 - small, 0.6 to 0.8 - medium, and 0.9 or higher - large)
ǂ
Mean between-group difference (95% confidence interval)
   TABLE 3: Time to peak joint angle as a percent of the weight bearing phase

  ǂ § P
Control (n = 20)* PFP (n = 20)* Between-group differences Effect Size
Value
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Anterior trunk lean 61 ± 3 69 ± 3 8 (6, 10) 2.3 0.001
  Ipsilateral trunk lean 28 ± 2 38 ± 1 10 (9, 11) 5.9 0.001
Ipsilteral trunk rotation 17 ± 5 12 ± 1 -5 (-8, -2) 1.2 0.003
  Anterior pelvic tilt 37 ± 2 38 ± 2 1 (0, 2) 0.5 0.100
Contralateral pelvic drop 28 ± 1 38 ± 1 10 (9, 11) 7.3 0.001
 
Ipsilateral pelvic rotation 24 ± 2 14 ± 1 -10 (-11, -9) 5.3 0.001
Hip flexion 35 ± 3 36 ± 3 1 (1, 3) 0.3 0.540
 
Hip adduction 23 ± 3 33 ± 3 10 (8, 12) 3.3 0.001
  Hip internal rotation 22 ± 1 12 ± 2 -10 (-11, -10) 7.4 0.001
Knee flexion 62 ± 3 60 ± 3 -2 (- 4, 0) 0.6 0.032
  Knee adduction 15 ± 2 12 ± 3 -3 (-5, -1) 1.1 0.003
Ankle dorsiflexion 62 ± 4 58 ± 3 -4 (-6, -2) 1.1 0.032
 
Ankle eversion 62 ± 4 58 ± 3 -4 (-6, -2) 1.1 0.019
J Orthop Sports Phys Ther

  Abbreviations: PFP, patellofemoral pain

* Data are mean ± SD in %
§
Effect size determined using Cohen d (0.0 to 0.2 - trivial, 0.3 to 0.5 - small, 0.6 to 0.8 - medium, and 0.9 or higher -
large)
ǂ
Mean between-group difference (95% confidence interval)
 TABLE 4: Power and internal moment for the Hip, Knee,and Ankle in Women With and Without PFP

ǂ §
Control (n = 20)* PFP (n = 20)* Between-group differences Effect Size P Value
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Joint Moment (Nm/kg)

Hip abductor 1.8 ± 0.5 2.2 ± 0.2 0.4 (0.2, 0.6) 1.0 0.017
Hip extensor 2.9 ± 0.5 2.8 ± 0.5 -0.1 (-0.4, 0.2) 0.2 0.679
Knee abductor 0.9 ± 0.3 2.1 ± 0.4 1.2 (1.0, 1.4) 3.3 0.001
Knee extensor 2.8 ± 0.4 1.9 ± 0.3 -0.9 (-1.1, -0.7) 2.5 0.001
Ankle plantar flexor 2.4 ± 0.4 2.0 ± 0.3 -0.4 (-0.6, -0.2) 1.1 0.035
Ankle invertor 0.4 ± 0.2 0.6 ± 0.3 0.2 (0.0, 0.4) 0.7 0.051
Joint Power Absorption (W/Kg)
Hip in the sagittal plane 6.0 ± 1.0 6.0 ± 1.1 0.0 (-0.6, 0.6) 0.0 0.931
Hip in the frontal plane 1.1 ± 0.3 0.8 ± 0.2 -0.3 (-0.4, -0.1) 0.7 0.006
J Orthop Sports Phys Ther

Knee in the sagittal plane 1.1 ± 0.2 0.9 ± 0.2 -0.2 (-0.3, -0.1) 0.7 0.006
Knee in the frontal plane 1.0 ± 0.2 1.9 ± 0.6 0.9 (0.6, 1.2) 1.9 0.001
Ankle in the sagittal plane 1.1 ± 0.2 0.9 ± 0.2 -0.2 (-0.3, -0.1) 0.6 0.018
Ankle in the frontal plane 0.4 ± 0.1 0.3 ± 0.1 -0.1 (-0.2, 0.0) 1.0 0.420
Abbreviations: PFP, patellofemoral pain
* Data are mean ± SD
ǂ
Mean between-group difference (95% confidence interval)
§
Effect size determined using Cohen d (0.0 to 0.2 - trivial, 0.3 to 0.5 - small, 0.6 to 0.8 - medium, and 0.9 or higher - large)