ELSEVIER Gait & Posture 5 (I 997) 2 l-27

Gait study of patients with patellofemoral pain syndrome

Sylvie Nadeaua, Denis Gravel* a, Luc J. HCbertb, A. Bertrand Arsenaulta, Yves LepageC
Research Center, Montreal Rehabilitation Institute and School of Rehabilitation, Faculty of Medicine, University of Montreal,
6300 Darlington Ave., Montreal, Quebec, H3S 2J4. Cam&
bH6pital aes Forces Arm&es Canadiennes de Valcartier, Q&bee, Canaak
=Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada

ReceivedJune 12 1995;accepted3 January 1996

Abstract

Patellofemoral pain syndrome is a frequent knee impairment in young adults. This study investigated the kinematic and kinetic
gait patterns of individuals suffering from patellofemoral pain syndrome (PFPS). It was hypothesized that PFPS subjects modify
their gait pattern in order to reduce loading on the painful patellofemoral joint. To verify this, the gait pattern of five subjects
with right chronic PFPS was compared with that of five healthy subjects. Spatiotemporal, kinematic and kinetic data were collected
from five gait cycles. The joint moments at the hip, knee and ankle joints were calculated using an inverse dynamic approach and
the values were normalized to body weight (N-m/kg). Individual joint moments were expressed as a percentage of the support
moment in order to quantify possible compensatory strategies. The kinematic analysis revealed a significant reduction of the knee
flexion angle (ANOVAs, P < 0.01) occurring at lO%, 20% and 70% of the gait cycle. There were no significant differences between
the two groups of subjects (ANOVAs, P > 0.05) as far as the individual joint moments and their contribution to the support
moment were concerned. However, modifications were observed in the knee and hip moments between loo/oand 20% of the gait
cycle. These modifications may suggest that PFPS subjects alter their gait pattern in order to reduce loading of the patellofemoral
joint to avoid pain.

Keywords: Knee; Patellae; Gait; Moment of force

1. Iotmduction of these subjects. Dillon et al. [12] reported a decrease

Patellofemoral pain syndrome (PFPS) is a very fre-
quent impairment of the musculoskeletal system [l-4].
It is characterized essentially by pain over the anterior
aspect of the knee joint. The pain is sometimes elicited
by specific activities which increase the loading of the
patellofemoral joint such as squatting, ascending and
descending stairs and prolonged sitting [5-71. Although
many hypotheses have been proposed to explain the ori-
gin of the pain, the pathophysiology of this syndrome
still remains unclear. Patellar misalignment is a frequent
morphological finding and may be one of the possible
etiological factors [8- 111.
Objective gait studies of PFPS subjects have shown
kinematic and kinetic alterations of the gait parameters
* Corresponding author, Tel.: +I 5143402078;Fax: + 5143402154.
in knee flexion angles at the beginning of the stance
phase for chondromalacia patients. These authors
hypothesized that the PFPS subjects used less flexion at
the knee joint to decrease forces at the patellofemoral
joint and thus to avoid pain. In contrast, Chesworth et
al. [ 131 failed to reveal any modifications in the kinemat-
ics of the gait pattern in patients with PFPS following
improvement in their clinical symptoms. In a study of
the ground reaction forces in patients with anterior knee
pain, Callaghan and Baltzopoulos [ 141 reported that the
average vertical, anteroposterior and mediolateral
forces produced by their patients were lower than those
of the control group. To date, joint moments during
walking have not been reported for subjects with PFPS.
In other knee joint pathologies, joint moments at the
knee are often modified due to the presence of weakness
[15], pain [16,17] or instability [18]. Berchuck et al. [18]

OY66-6362/97/$17.00 0 1997 Elsevier Science B.V. All rights reserved

PIf SO966-6362(96)01078-8
22 S. Nudeau et (11. I Gair
demonstrated that 75% of patients presenting an ante-
rior cruciate ligament deficiency showed a reversed knee
joint moment (from extension to flexion) associated
with an increased hip extensor moment at the beginning
of the stance phase. These authors stated that in-
dividuals with an anterior cruciate ligament instability
reduce the utilization of the knee extensors to avoid
anterior displacement of the proximal end of the tibia on
the femur. Similarly, Winter [ 151 reported that patients
with a total knee replacement have a net flexor moment
at the knee joint during most of the stance phase. He
also noted a concomitant increase of the extensor
moments at both the hip and ankle joints.
The increase in the hip extensor moment reported in
the above studies can be interpreted as a muscular com-
pensation resulting from the underuse of the knee exten-
sor muscles. The support moment concept described by
Winter [ 151 provides a framework to demonstrate such
compensations carried out in this case by the hip exten-
sors. Within this concept, the collapse of the lower ex-
tremity during weight bearing is prevented by the
extensor muscles of the hip, knee and ankle joints.
Mathematically, the net support moment (MS) during
the stance phase is defined as Ms = Mx - MA - Mu
where M,, MA and MH represent the moments at the
knee, ankle and hip joints, respectively. Using the con-
vention that positive moments are created by the knee
extensors and negative ones are generated by the hip ex-
tensors and plantarflexors, these muscle groups would
contribute positively to Ms. Thus, according to the
above equation, a lower contribution of the knee exten-
sor muscles to the support moment could be compen-
sated by a larger participation of the hip extensor
muscles in order to produce the same support moment.
The objective of this study was to examine the gait
pattern of PFPS patients walking at a preferred speed in
order to determine if they presented kinematic and ki-
netic alterations during gait. We hypothesized that a
smaller knee flexion angle with a reduction in the knee
extension moment would be compensated by an increase
in the hip extensor and/or plantarflexor moments during
the stance phase in PFPS subjects.
2. Metbodology
2.1. Subjects
Two groups of subjects were evaluated during level
walking at preferred speed. The PFPS group included
two men and three women with a mean ( f S.D.) age of
28.4 (h7.5) years. They had a mean height and weight
of 1.72 ( f 0.06) m and 67.6 ( f 8.2) kg, respectively, and
presented chronic right PFPS diagnosed by an or-
thopaedic surgeon. The duration of the PFPS ranged
from l-7 years. These participants were selected accord-
ing to the following criteria: chronic anterior knee pain,
no previous knee surgery and/or traumatic injury, no
& Posture 5 (1997) 21-27
patellar subluxation and no systemic or orthopaedic
pathology. A control group of two healthy men and
three healthy women were also selected in order to
match the PFPS group on the basis of their anropo-
metric data. The mean age of this group was 25.5
(f 13.3) years. The groups mean height and weight
were 1.70 (~0.07) m and 67.0 (~8.6) kg, respectively.
All subjects gave their informed consent prior to partici-
pation in the study.
2.2. Assessment
Two types of assessments were performed: (I) a clini-
cal assessment performed on the involved and uninvolv-
ed limbs of the PFPS subjects and (II) a walking
assessment collected on the right lower limb for all
subjects.
(Z) Clinical assessment. Girth measurements were
taken at the knee joint level (interarticular line) as well
as at 5, 10 and 20 cm above the knee joint. Active range
of motion (ROM) was assessedby goniometry while the
subjects were asked to bend and extend their knees as
much as possible. The Q angle [5] was determined by
videography with markers placed on the anterior superi-
or iliac spinous process, patellar centre and anterior
tibial tuberosity. The Q angle is defined as the angle be-
tween the extension of a line from the anterior iliac spine
to the centre of the patella and a line joining the tibia1
tuberosity to the centre of the patella. The normal values
are C 15 in males and ~20 in females [a]. At the
beginning and at the end of the experimental session,
knee pain was evaluated using a visual analogue scale
(VAS;[ 191). Knee status of the involved limb was graded
using the Tegner and Lysholm questionnaire [20]. This
questionnaire includes items concerning activities of
daily living and knee symptoms (locking, swelling, insta-
bility and pain) and has a maximum score of 100, in-
dicating normal function.
(ZZ) Walking assessment. The subjects were instructed
to walk naturally on a 9-m walkway equipped with a
force platform (AMTI OR6-5-1). Five walking cycles
were collected on the right lower extremity for each sub-
ject using a Peak Performance videographic system.
Stride characteristics were recorded with three foot-
contacts located on the sole of the footwear, i.e. at the
heel, metatarsal heads and first toe. The force platform
was used to record vertical (Fz), anteroposterior (Fy)
and mediolateral (Fx) components of the external forces
and the corresponding moments.
Circular reflective markers were placed on the lateral
projection of the limbs axis. These markers identified
the fifth metatarsophalangeal joint, lateral malleolus,
knee joint flexionlextension axis (2.5 cm above the knee
joint line) and the hip joint flexion/extension axis (3.0
cm above greater trochanter). A marker was also posi-
tioned to identify the heel. The subjects position in the
sagittal plane was recorded by a video camera
 S. Nudcau et ~1. I Gait & Posture 5 (1997) 21-27 23

(Panasonic, WV-DSlOO) placed 4.9 m from the [23] were applied to localize the sites of these differences
walkway. The video camera operated at a frequency of thus contrasting, at a given percentage of the gait cycle,
30 Hz. The force data and film sequences were syn- the data obtained for both groups. An a! level of signiti-
chronized by means of an electric impulse and a simulta- cance of 0.05 was selected for all statistical tests.
neous light which was captured on the film. The
foot-contacts and platform signals were sampled at a 3. Results
frequency of 120 Hz with a data-acquisition card (Data
Translation, model DT2821). 3.1. Clinical assessment
The Student t-tests did not reveal the presence of any
2.3. Data analysis significant differences between the involved and unin-
The Peak Performance system was used to digitize volved limbs of the PFPS subjects for any of the clinical
marker positions. The precision of the automatic variables assessed (Table 1). The average Q angle was
digitalization methods of this system is acceptable for slightly higher for the involved limbs than that of the
gait analysis, that is, l/38 18 mm horizontally and l/3 137 uninvolved limbs (30.7 vs. 24.1). None of the subjects
mm vertically for a marker of 38 mm in diameter [21]. reported the presence of pain during the session. Knee
The x and y coordinates obtained were smoothed, for- assessment, using the Tegner and Lysholm question-
ward and backward, with a second order digital Butter- naire, produced a mean result of 69.8 ( f 12.6).
worth filter, using a cut-off frequency between 2 and 8
Hz as determined by a residual analysis of each marker 3.2. Walking assessment
[22]. Following this, angular positions were determined Spatiotemporal parameters did not differ significantly
from proximal and distal coordinates and finite differen- between groups (Table 1). The average angular
tial procedures were applied to determine velocities and displacements for the hip, knee and ankle joints are
accelerations. The same procedures were applied to lin- shown in Fig. 1. The ANOVA revealed the presence of
ear displacements. A dynamic analysis was performed significant differences between groups in the angular
on body segments, and joint moments at the ankle, knee displacement of the knee joint (ANOVA, P = 0.0047).
and hip joints were calculated. Spatiotemporal, kin- According to the Tukeys test, the knee flexion was
ematic and kinetic calculations were carried out using significantly lower for the PFPS group as compared
computer programs developed at our Centre.
In order to compare the results between subjects and
groups, gait cycles were normalized (100%). All
moments were also normalized to body weight Table 1
(N . m/kg) [22]. The mean values were calculated at each Mean values (*SD.) of the clinical assessment and spatiotemporal
2% interval of the gait cycle and these values were used parameters
to estimate each moments contribution to the support Clinical assessment PFPS f-test P-value
moment. To quantify the compensation, moments at all
three joints were expressed in relation to their contribu- Uninvolved Involved
tion to the support moment. For example, the ankle (left) bh3m
joints contribution (CM,& in percentage, is given by: ROM knee
Flexion (9 141.0 (3.6) 143.0 (3.4) -1.00 0.35
Extension () 3.2 (4.1) 3.4 (3.7) -0.08 0.94
MS-WK-MH) x 1oo
CM, = Girth measures (cm)s 51.4 (3.0) 49.6 (2.8) 0.41 0.60
MS Q angle 24.1 (8.2) 30.7 (8.4) -1.27 0.24
TLb 69.8 (12.6)
2.4. Statistical analysis Spatiotemporal Groups t-test P-value
Students t-tests were used to determine between- parameters
group differences for the values of spatiotemporal vari- Control PFPS
ables of the gait cycle and to detect differences in the (n = 5) (?I = 5)
clinical variables between the involved and uninvolved Cadence (step/mitt) 103.7 (6.9) 101.3 (8.3) 0.50 0.63
limbs of the PFPS subjects. PFPS and control group dif- Stride length (m) 1.4 (0.1) 1.5 (0.2) -0.04 0.97
ferences were evaluated by two-way ANOVAs with re- speed Ws) 1.3 (0.2) 1.2 (0.2) 0.21 0.84
peated measures using results obtained at each 10% of Single support (%) 59.0 (2.2) 58.7 (2.2) 0.52 0.61
the gait cycle as the repeated measure factor. This Swing (%) 40.7 (1.9) 41.5 (2.2) -0.62 0.63
Double support (%) 19.6 (3.8) 18.8 (3.6) 0.33 0.75
statistical procedure was applied to the joint angles, the
ground reaction forces, the muscular moments and to Girth measures: the values reported are those taken at 20 cm above
their respective contribution to the support moment. the knee joint level.
When significant differences were found, Tukeys tests ?L: Tegner and Lyshom questionnaire.
24 S. Nudrtiu et al. I Gait & Posture 5 (1997) 21-27

40 all the moment curves obtained, no significant differ-

20 ences were found between groups (ANOVA, P > 0.05).
Nevertheless, at the beginning of the stance phase,
G 0
- 15% of the gait cycle, the knee extensor moment was
Q -20 slightly lower (0.104 N. m/kg or 16%) for the PFPS
9 60 group than for the control group. At the same period of
0 the gait cycle, the hip extensor moment was slightly
z 40
higher (0.064 N-m/kg or 56%) for the PFPS subjects.
; 20 These non-significant changes were reflected in the con-
5 0 c tribution of each joint moment to the support moment.
- 40 3 ANKLE
ii!r For example, in Fig. 3 it can be observed that the con-
tribution of knee extensors was lower for PFPS subjects
between 10% and 22% of the gait cycle as compared with
the control group. At the same period of the gait cycle,
20 40 60 80 100 the hip extensor moment contribution appeared to be
0
% OF STRIDE higher for the PFPS group.
The ground reaction force patterns were statistically
Fig. I. Joint angular displacements at the hip, knee and ankle for the similar for both groups as seen in Fig. 4 (ANOVA, P >
control (-) and the PFPS (-C) groups. *: P < 0.05. 0.05). However, the data from the PFPS group revealed
a lower first peak of the vertical (Fz) and antero-
posterior (Fv) forces in comparison with the control
with the control group at 10% (1314( h4.0) vs. 21.8 group. The negative components of the mediolateral
(*4.6)), 20% (14 . 4 (~3.0) vs. 19.8 (h4.0)) and 70% forces (Fx) were also reduced in the pathological group.
(63.1 (k3.8) vs. 71.0 (h2.6)) of the gait cycle. In addi-
tion, the same trend was seen at the hip, where a lesser 4. Diseussion
flexion was observed in the PFPS subjects.
Fig. 2 shows the support moment as well as the 4. I. Clinical assessment
moment calculated at the hip, knee and ankle joints. For The clinical assessments disclosed a relatively homo-
genous group of PFPS subjects with minimal patellar
symptoms at the time of the experimental evaluation. In
the present study, the absence of pain was not an unex-
pected finding because our testing protocol involved a
short walking distance. All subjects presented good mo-
bility at all three joints and no differences between the
involved and uninvolved legs could be observed in girth
measurements despite the long lasting presence of inter-
mittent pain (> 1 year). However, the Tegner and

-100 4
-2 1 4 10 16 22 28 34
0 20 40 60 80 100 % OF STRIDE
% OF STRIDE
Fig. 3. Contribution of the hip (CM), knee (CMK) and ankle (CM,)
Fig. 2. Support moment and muscular moments at the hip, knee and to the support moment for the control (-) and the PFPS (-C)
ankle for the control (-) and the PFPS (-C) groups. groups.
 S. Nudeuu
8
VERTICALE (Fz)
6
-0.2
-0.4
-0.6
0 20 80 100
Fig. 4. Vertical (Fz), anteroposterior (Fy) and mediolateral
ponents of the ground reaction forces for the control (-)
PFPS (-C) groups.
Lysholm questionnaire revealed chronic impairment
scores ranging from 56/100-85/100. Such findings could
be related to the fact that this questionnaire inquires
about stressful activities that cause anterior knee pain.
The Q angle is frequently used to describe a lower limbs
frontal alignment [5]. In the present study, all Q angles
were more pronounced in the involved leg when com-
pared with the uninvolved one. However, mean Q angle
values reported in the present study are higher (3: 20)
than those frequently reported in the literature [6]. This
may have been due to the fact that the measures were
taken with the videographic system used in this study.
Results of the clinical assessment were compatible
with characteristics reported in other studies. Wilson
[24] and Amoldi [25] reported that PFPS patients rarely
present limited knee joint ROM. An increased Q angle
is a frequent finding in PFPS subjects [6,26-281 and
even if pain is one of the most important clinical lind-
ings, it is not always present, specifically during short
distance walking [ 131.
4.2. Walking assessment
In the present study, spatiotemporal parameters were
considered because different walking speeds affect mus-
cular moments [29]. No differences could be found in
these parameters between groups, a result which is in
agreement with those of Chesworth et al. [13] and
Dillon et al. [12]. The absence of pain could potentially
explain this similarity in spatiotemporal parameters.
et ul. I Gait & Posture 5 (1997) 21-27 25
Measured angular displacements at the knee joint
significantly differed between PFPS and control groups.
This is consistent with our expectation related to the
modifications in the kinematic gait pattern in PFPS sub-
jects. These results support those of Dillon et al. [ 121 for
subjects suffering from chondromalacia of the patella.
Similar to these authors, we found reduced knee flexion
at the beginning of the stance phase (10% and 20% of the
gait cycle). The reduction in knee stance flexion can be
considered as a strategy used by PFPS subjects to avoid
quadriceps contraction in order to decrease the loading
on the patellofemoral joint. With a lesser knee flexion,
the lever arm of the ground reaction force is shortened
and consequently the external knee extensor moment is
reduced. In such a way, equilibrium is achieved by fewer
quadriceps contractions. In the present study, the aver-
age knee extensor moment was effectively lower (0.104
N-m/kg or 16%) in PFPS subjects than in normal sub-
jects; however, this difference was not statistically sig-
nificant.
PFPS subjects also showed smaller knee flexion dur-
ing the swing phase. This kinematic change is probably
related to the fact that the forces generated at the
(Fx) com- patellofemoral joint increase with the knee flexion angle.
and the
The reason behind this effect is that the decrease of the
angle between the quadriceps attachment to the patella
and patellar tendon with knee flexion results in larger
joint compression for the same force in the quadriceps
muscle [30,31].
Individual joint moments and contributions to the
support moment were similar for both groups. Thus, the
hypothesis that PFPS subjects develop compensatory
muscular strategies was not supported. However, it can
be mentioned that the slight increase of the hip extensor
moment in conjunction with the decrease in the knee ex-
tensor moment found in the present results represent
one type of the expected compensations.
Ground reaction forces did not differ between groups.
Again, a tendency toward decreased forces at the begin-
ning of the stance phase was observed which was in
agreement with the significant decrease reported by
Callaghan and Baltzopoulos [ 141. These modifications
might reflect an apprehension on the part of the PFPS
subjects to load the knee joint at the beginning of the
stance phase. The reductions in reaction forces could
also explain the change in the knee extension moment.
Moreover, the modifications in the mediolateral force
are possibly indicative of some other changes occurring
in the frontal plane. For example Dillon et al. [ 121 have
demonstrated that subjects with chondromalacia pres-
ent an increased medial hip rotation at the beginning of
the stance phase. Three-dimensional studies are thus
needed to assess more thoroughly the gait pattern of
PFPS subjects.
The severity of the disease of our subjects is one factor
that could explain the fact that, in the present study,
26 S. Nadeau et al. I Gait
muscular compensations were not depicted. The patient
assessed in Winters study [ 151 had a IO-year history of
pathology and the patients with unstable anterior
cruciate ligaments observed by Berchuck et al. [ 181were
candidates for surgery. In contrast to those subjects, our
PFPS subjects did not experience any pain during expcr-
imentation and were not candidates for surgery. Thus,
it is possible that PFPS patients use muscular compensa-
tions only when the task is more demanding.
Since the statistical analyses indicated that knee flex-
ion angle is the important variable characterizing PFPS
subjects, it is relevant to discuss its significance. In other
knee pathologies, authors have reported that knee flex-
ion during the stance phase in gait is related to clinical
findings. In general, greater knee flexion during stance
is observed in patients having more involvement of the
affected knee. With a greater stance knee flexion, it is
impossible to have a low extensor moment at the knee
during gait [32]. In studies of patients following knee ar-
throplasty, it was found that subjects having a good
range of motion in extension actually reverse the exten-
sor knee moment to a flexor one during the stance phase
[32]. Furthermore, some studies [ 15,181 which have
reported a reversed knee moment, also revealed a larger
hip extensor moment; probably to provide a more nor-
mal support moment. In the present study, at the begin-
ning of the stance phase, we found a significant decrease
in knee flexion in PFPS subjects. This decrease was
associated with a concomitant decrease in the average
knee extensor moment and a small increase in the aver-
age hip extensor moment. These results could support
the fact that a smaller knee flexion, in addition to reduc-
ing the mechanical demand on the knee extensor mus-
cles, promotes the compensations noted in the hip
extensor moment. These findings could be considered as
a possible strategy used by the PFPS subjects to reduce
loading on the painful patellofemoral joint. This could
be an alternative explanation to the lack of pain: PFPS
subjects may have learned to compensate to avoid the
onset of pain. However, further studies with a larger
amount of subjects are needed before definitive conclu-
sions can be made.
The results of the knee joint angle were statistically
significant while those of the knee joint moment were
not. A possible explanation of this finding could be the
large between-subjects variability. Winter [29] reported
that joint moments are more variable between subjects
than joint an.gles. This was associated with the multiple
combinations of moments at the hip, knee and ankle
which could be used to produce the final typical
kinematic gait pattern. Such combinations are necessary
to control balance of the body and to prevent collapse
of the limb. In the present study, the coefficients of vari-
ation at the knee were 15.7% and 78.3% for the joint
angle and joint moment, respectively, and are similar to
those reported in other studies [29]. Consequently, given
& Po.srure 5 (1997) 21-27
the variability in the data, greater differences between
groups are required to observe statistically significant
results in the joint moments as compared with joint
angles. An additional reason, which could explain the
lack of statistical differences in knee and hip extensor
moments, is the possibility that the initial compensatory
strategy used by most PFPS subjects, is a modification
of their kinematic patterns. The changes in joint
moments could appear later on within the illness process
and/or only in a few subjects because kinematic changes
fail to relieve pain.
5. Conclusion
The present study compared the gait patterns of five
PFPS subjects with those of five normal subjects. The
objectives of the study were to evaluate the changes in
kinematic and kinetic parameters of gait in subjects suf-
fering from chronic PFPS and also to determine if PFPS
subjects had developed muscular compensations. Re-
sults revealed a decrease in the knee tlexion angle but
failed to reveal significant kinetic changes in the gait
pattern. Nevertheless, considering the limited number of
subjects and the wide between-subjects variability, we
believe that the trends observed in the knee moment, hip
moment compensations and ground reaction forces fur-
ther support the presence of gait adaptation to the
underlying knee pathology in individuals with
patellofemoral pain syndrome.
Acknowledgments
This research was supported by grants from the
Fonds de la Recherche en Sante du Quebec and the Na-
tional Defense of Canada. The authors would like to
thank Mr. Michel Goyette for his participation in data
collection and processing. During the course of the pres-
ent study, S. Nadeau was supported by a M.Sc. scholar-
ship from the Fonds pour la Formation de Chercheurs
et 1Aide a la Recherche. D. Gravel is a research fellow
from the Fonds de la Recherche en Sante du Quebec.
This work was also supported by the National Defence
of Canada.
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