Elsevier

Gait & Posture

Volume 30, Issue 4, November 2009, Pages 405-416
Gait & Posture

Review
Kinematic gait characteristics associated with patellofemoral pain syndrome: A systematic review

https://doi.org/10.1016/j.gaitpost.2009.07.109Get rights and content

Abstract

Development of patellofemoral pain syndrome (PFPS) is considered to be multifactorial. The aims of this systematic review were to (i) summarise and critique the body of literature addressing kinematic gait characteristics associated with PFPS; and (ii) provide recommendations for future research addressing kinematic gait characteristics associated with PFPS. A comprehensive search of MEDLINE, EMBASE, CINAHL, and Current Contents revealed 561 citations for review. Each citation was assessed for inclusion and quality using a modified version of the ‘Quality Index’ and a novel inclusion/exclusion criteria checklist by two independent reviewers. A total of 24 studies were identified. No prospective studies with adequate data to complete effect size calculations were found. Quality of included case–control studies varied, with a number of methodological issues identified. Heterogeneity between studies made meta-analysis inappropriate. Reductions in gait velocity were indicated during walking, ramp negotiation, and stair negotiation in individuals with PFPS. Findings indicated delayed timing of peak rearfoot eversion and increased rearfoot eversion at heel strike transient during walking; and delayed timing of peak rearfoot eversion, increased rearfoot eversion at heel strike, reduced rearfoot eversion range, greater knee external rotation at peak knee extension moment, and greater hip adduction during running in individuals with PFPS. There is a clear need for prospective evaluation of kinematic gait characteristics in a PFPS population to distinguish between cause and effect. Where possible, future PFPS case–control studies should consider evaluating kinematics of the knee, hip and foot/ankle simultaneously with larger participant numbers. Completing between sex comparisons when practical and considering spatiotemporal gait characteristics during methodological design and data analysis is also recommended.

Introduction

Patellofemoral pain syndrome (PFPS) is one of the most common musculoskeletal presentations to orthopaedic [1], [2], general practice [3], and sports medicine clinics [4], [5], [6]. The condition is highly prevalent in adolescents and young adults [7], [8], and has been reported to be more common in females than males [5], [9], [10]. Patellofemoral pain syndrome can be defined as anterior knee pain or retro-patellar pain in the absence of other specific pathology [11]. The anatomical source of the pain remains a highly debated issue but is commonly believed to be the result of elevated lateral patellofemoral joint (PFJ) stress [2], [7], [8].

The aetiology of elevated lateral PFJ stress and subsequent PFPS development is considered to be multifactorial. Many abnormal kinematic gait characteristics have been hypothesised to contribute to pain development. At the knee joint, altered tibiofemoral rotation and an increase in knee adduction during the stance phase of gait have been proposed to result in lateral patellar tracking and increase lateral PFJ compression [8], [12], [13]. These kinematic differences could result from structural abnormalities [2], or altered kinematics at the hip or foot and ankle [8], [12]. Altered or excessive foot pronation has been hypothesised to increase tibial and femoral internal rotation and lead to greater adduction or medial collapse of the knee [8], [12]. Recent research has indicated the presence of decreased hip muscle strength (abductors and external rotators) in individuals with PFPS [1], [14], [15]. These findings support the theory that increased hip internal rotation and adduction during gait may be a risk factor for PFPS development [8], [12], [16].

Knowledge of kinematic differences between individuals with and without PFPS is important to health professionals and researchers. This knowledge is needed to develop and optimise valid treatment and prevention strategies for PFPS. A number of research teams have evaluated kinematic variables in individuals with and without PFPS. This has led to a large body of literature using various research designs and methods of kinematic analysis to test proposed hypotheses. Therefore, the aims of this systematic review were to (i) summarise and critique the body of literature addressing kinematic gait characteristics associated with PFPS; and (ii) provide methodological recommendations for future research investigating kinematic gait characteristics associated with PFPS.

Section snippets

Inclusion and exclusion criteria

Prospective and case–control studies published in English evaluating kinematic variables during walking, running, stair negotiation, and ramp negotiation in individuals with PFPS were considered for inclusion. The inclusion criteria required participants to be described as having: patellofemoral pain syndrome; retropatellar, peripatellar, or patellofemoral pain; anterior knee pain; patella or patellofemoral dysfunction; chondropathy; or chondromalacia patellae.

Search strategy

MEDLINE, EMBASE, CINAHL, and

Review selection and identification

The initial search yielded 596 citations. Following application of the inclusion/exclusion criteria to each citation's title, abstract and subsequent full text, and a consensus meeting between the two reviewers, the number of citations was reduced to 24 [15], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43]. Prior to consensus, reviewer one had failed to include one study [36], and reviewer two had included

Discussion

The review identified 24 published studies evaluating kinematic gait characteristics associated with PFPS. Various methodological issues were identified in the review, which have implications for interpretation of included findings. These included identification of potential methodological bias, lack of control of or accounting for spatiotemporal gait characteristics which may alter kinematics, different study population definitions and demographics, including participants greater than 40 years

Conclusion

Evidence for kinematic gait characteristic associated with PFPS is currently limited by a paucity of published prospective studies, and methodological weaknesses in existing case–control studies. Prospective evaluation of kinematic gait characteristics in a PFPS population to determine which variables are possible risk factors for the condition is needed. Evaluation of knee, hip and foot and ankle kinematics simultaneously with larger participant numbers, consideration to spatiotemporal gait

Acknowledgement

A/Prof. Menz is currently a National Health and Medical Research Council fellow (Clinical Career Development Award, ID: 433049).
Conflict of interest

The authors state that there are no conflicts of interest which might have influenced the preparation of this manuscript.

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