Knee kinetic pattern during gait and anterior knee pain before and after rehabilitation in patients with patellofemoral pain syndrome
Highlights
► We analysed knee kinetics during gait in patients with patellofemoral pain syndrome. ► We analysed peak knee extension moment and pain before and after rehabilitation. ► Peak knee extension moment was reduced in patients with pain in stressful activities. ► Peak knee extension moment was normalised after pain reduction. ► Less knee kinetics demand acts as compensation to limit or avoid anterior knee pain.
Introduction
Patellofemoral pain syndrome (PFPS) is one of the most common causes of knee pain in athletes and non-athletes [1]. It can be defined as anterior knee pain involving the patella and retinaculum that excludes other intraarticular and peripatellar pathology [2]. Typical symptoms include pain behind and around the patella that occurs or is increased with running and activities that involve knee flexion and load the lower limbs. Several factors may create a predisposition for the development of PFPS via alterations in patellar tracking, increased patellofemoral joint forces, or combinations of these biomechanical features [2]. The most accepted hypothesis regarding the cause of patellofemoral pain is related to elevated patellofemoral joint (PFJ) reaction forces that lead to abnormal joint stress and subsequent articular cartilage wear [3], [4], [5]. The PFJ is typically modelled as a pulley system where the compressive force acting on the patella is created by the forces in the quadriceps tendon and the patellar ligament [6]. In activities that involve knee flexion and load the lower limbs, the PFJ reaction force value in sagittal plane is positively related to the internal knee extension moment (KEM) value [5], [7], [8]. Salsich et al. found in subjects with PFPS during stair ascent and descent that the peak KEM was reduced compared to controls [9] and was increased after patellar taping along with pain decrease [10]. The authors suggested the peak KEM reduction as a compensatory gait strategy to minimize pain and PFJ reaction force. During short-distance free level walking the PFJ is usually not painful [2], [5] but knee joint dynamic alteration may occur. Nadeau et al. [11] found that subjects with PFPS compared to controls had significantly reduced peak knee flexion but non-significant reduced peak KEM at the beginning of the stance phase during level walking. A small sample size (5 subjects in each group) may have contributed to this latter result. Although short-distance free level walking is usually not painful in subjects with PFPS, a peak KEM reduction may occur as a compensatory mechanism to avoid pain. To further investigate this assumption hypothesis the purpose of this study was (1) to confirm a reduced peak KEM during level walking in subjects with PFPS compared to controls and (2) to show an increase in peak KEM associated to post-rehabilitation pain reduction.
Section snippets
Subjects
Patients with PFPS were recruited from the Pierquin Rehabilitation Center in Nancy from September 2009 to August 2010. They were screened to rule out internal derangement or patellar tendinosis (pain at tendon's palpation) and were excluded in case of knee surgery or any neurological involvement that would influence gait. The inclusion criteria were (1) pain originating specifically from the patellofemoral articulation as assessed during patellar manipulation and (2) reproducible pain with at
Results
Twenty-three patients with PFPS and 22 controls were selected. They matched in genders, ages, leg lengths, physical activities but not in body mass and body mass index (BMI) since patients with PFPS were significantly heavier and overweight (Table 1). Among the 23 patients with PFPS, 2 patients were not present at the second session due to geographical relocations and 17 out of 21 patients had experienced significant post-rehabilitation pain reduction (see Table 2, Table 3 and Fig. 1 for the
Discussion
As expected, peak KEM at the beginning of the stance phase during level walking was significantly reduced in patients with PFPS compared to controls and significantly increased after therapeutic pain improvement.
This study bears some limits. The presence of femoral trochlear dysplasia that can create a predisposition for the development of PFPS [2] was not precisely described in the patients. However, the basic PFJ mechanical model, in which the compressive force is related to posteriorly
Acknowledgements
The authors acknowledge the financial support of the Institut Regional de Readaptation de Nancy and would like to express theirs thanks to Mrs. M.A. Haldric for her technical assistance.
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2020, Clinical BiomechanicsCitation Excerpt :Interestingly, following a therapeutic intervention to address knee flexion and extension strength and length, they found significant increases in KEM to be more similar to controls (Claudon et al., 2012). It is important to note that these prior studies (Besier et al., 2009; Cloudon et al. 2012) are in non ACL-R individuals; however, in our current study and in the study by Cloudon et al. (2012) KEMs improved over time. These findings indicate that while KEMs are decreased in both ACL-R and PFP patients, both seem to improve over the course of rehabilitation.
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