Elsevier

Clinical Biomechanics

Volume 27, Issue 7, August 2012, Pages 702-705
Clinical Biomechanics

The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome

https://doi.org/10.1016/j.clinbiomech.2012.02.007Get rights and content

Abstract

Background

Excessive rearfoot eversion is thought to be a risk factor for patellofemoral pain syndrome development, based on theoretical rationale linking it to greater tibial internal rotation and hip adduction. This study aimed to establish the relationship of rearfoot eversion with tibial internal rotation and hip adduction during walking in individuals with and without patellofemoral pain syndrome.

Methods

Twenty-six individuals with patellofemoral pain syndrome and 20 controls (18–35 years) participated. Each underwent instrumented three-dimensional motion analysis during over-ground walking. Pearson's correlation coefficients (r) were calculated to establish the relationship of rearfoot eversion with tibial internal rotation and hip adduction (peak and range of motion).

Findings

Greater peak rearfoot eversion was associated with greater peak tibial internal rotation in the patellofemoral pain syndrome group (r = 0.394, P = 0.046). Greater rearfoot eversion range of motion was associated with greater hip adduction range of motion in the patellofemoral pain syndrome (r = 0.573, P = 0.002) and control (r = 0.460, P = 0.041) groups; and greater peak hip adduction in the control group (r = 0.477, P = 0.033).

Interpretation

Associations between greater rearfoot eversion and greater hip adduction indicate that interventions targeted at the foot or hip in individuals with patellofemoral pain syndrome may have similar overall effects on lower limb motion and clinical outcomes. The relationship between rearfoot eversion and tibial internal rotation identified in the patellofemoral pain syndrome group may be related to aetiology. However, additional prospective research is needed to confirm this.

Introduction

Despite the high frequency of patellofemoral pain syndrome (PFPS) presentations to health care practitioners (Feller et al., 2007, Ireland et al., 2003), the aetiology of this condition remains a contentious issue. There is common consensus that PFPS results from altered tracking or increased stress in the lateral patellofemoral joint (PFJ) (Dye, 2005, Feller et al., 2007). This has led to the proposal of various intrinsic and extrinsic factors which may lead to increased lateral PFJ stress (Brukner et al., 2007). Excessive rearfoot eversion is commonly considered to be a possible intrinsic risk factor for increasing lateral PFJ stress and subsequent PFPS development. Tiberio (1987) proposed that excessive rearfoot eversion during the stance phase of gait may result in increased tibial internal rotation. Due to associated joint coupling, the hip would internally rotate to a greater degree, thereby also increasing hip adduction and dynamic Q angle (Tiberio, 1987). These kinematic variations are thought to be detrimental to the PFJ due to reduced contact area and associated increased lateral PFJ compression (Wilson, 2007).

Many theoretical papers (Brukner et al., 2007, Gross, 2003, Mcconnell, 2002, Powers, 2003) have supported the association between rearfoot and hip kinematics in individuals with PFPS. However, there is currently no empirical evidence in a PFPS population to support this theory. Previous research evaluating dynamic pronation during walking indicates that individuals with PFPS do not possess greater rearfoot eversion magnitudes (Barton et al., 2011a; Callaghan and Baltzopoulos, 1994, Duffey et al., 2000, Levinger and Gilleard, 2007) or ranges (Barton et al., 2011a, Callaghan and Baltzopoulos, 1994) during walking compared to matched controls. However, the absence of a difference in these case–control studies does not refute the presence of an association between rearfoot and hip kinematics. It is possible that rearfoot eversion is reduced, in an attempt to compensate for pain in individuals with PFPS, a possibility which requires prospective research to adequately investigate. Additionally, it may reflect the multifactorial nature of PFPS, where only a sub-population will demonstrate excessive rearfoot eversion. This possibility is highlighted by a recent study, which found that those with greater peak rearfoot eversion during walking were more likely to report marked improvement 12 weeks after prefabricated foot orthosis provision (Barton et al., 2011b).

One possible explanation for improved efficacy of foot orthoses in individuals with PFPS possessing greater rearfoot eversion motion may be the presence of a relationship between rearfoot and tibial/hip kinematics. Although varying in methodology, previous studies investigating walking have consistently reported an absence (Bellchamber and Bogert, 2000, Nester, 2000, Reischl et al., 1999) or a weak (Pohl et al., 2007) relationship of rearfoot eversion with internal rotation at the tibia and hip. However, these findings are limited to healthy asymptomatic populations who may not accurately reflect individuals with PFPS. Additionally, previous research has focussed on transverse plane rotation at the hip, a variable often considered to possess poor accuracy due to large levels of soft tissue artefact (Schache et al., 2008). An alternative approach may be to evaluate the relationship of rearfoot eversion with hip adduction, since it is less affected by soft tissue artefact than rotation (Schache et al., 2008). Additionally, hip adduction is considered to be strongly coupled with rotation (Powers, 2010), and frequently found to be increased in individuals with PFPS (Barton et al., 2009).

Considering the theoretical link between excessive rearfoot eversion and tibial/femoral kinematics in individuals with PFPS currently lacks scientific validation, this study aimed to establish (i) the relationship between rearfoot eversion and proximal kinematics linked to PFPS development including tibial internal rotation and hip adduction; and (ii) if this relationship is similar between individuals with and without PFPS.

Section snippets

Participants

Participants were recruited from a previous case–control study investigating lower limb kinematics associated with PFPS (Barton et al., 2011a). Recruitment was achieved for both the PFPS and control groups via advertisements placed at La Trobe University, the University of Melbourne, and in the surrounding community. Patellofemoral pain syndrome participants consisted of 26 individuals (5 males and 21 females) with mean (SD) age, height and mass of 25 (5) years, 169 (9) cm, and 67 (14) kg

Results

Group means for gait velocity and kinematic variables evaluated have been previously reported (Barton et al., 2011a) and can be found in Table 1. No significant differences between the PFPS and control groups (P > 0.05) were indicated for any of these variables, although there was a trend towards reduced gait velocity in the PFPS group (P = 0.073). Correlation coefficients of rearfoot eversion with tibial internal rotation and hip adduction are shown in Table 2. Greater peak rearfoot eversion was

Discussion

Due to theoretical links with tibial and hip kinematics, excessive rearfoot eversion has been frequently hypothesised as a possible risk factor in the development of PFPS (Brukner et al., 2007, Gross, 2003, Mcconnell, 2002, Powers, 2003, Tiberio, 1987). However, associations between rearfoot eversion motion and kinematics of the tibia and hip considered to be related to PFPS have not previously been evaluated in a symptomatic population. Consistent with theoretical rationale, we found peak

Conclusions

This is the first study to evaluate the relationship of rearfoot eversion kinematics with tibial and hip kinematics theoretically linked to PFPS development in a symptomatic population. The most consistent and strongest associations were found between greater rearfoot eversion range of motion and greater hip adduction peak and range of motion. This indicates that interventions targeted at either end of the kinetic chain may have similar overall effects on lower limb motion and therefore,

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