Gait & Posture 37 (2013) 440444

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Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Gait biomechanics and hip muscular strength in patients with

patellofemoral osteoarthritis
Michael B. Pohl a,*, Chirag Patel b, J. Preston Wiley c, Reed Ferber d,e
a

Department of Kinesiology and Health Promotion, University of Kentucky, Lexington, KY, USA
Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
c
Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
d
Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
e
Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 22 January 2012
Received in revised form 25 August 2012
Accepted 30 August 2012

A signicant number of patients with patellofemoral osteoarthritis (PFOA) have described a history of
patellofemoral pain syndrome (PFPS). This leads to speculation that the underpinning mechanical causes
of PFPS and PFOA may be similar. Although alterations in gait biomechanics and hip strength have been
reported in PFPS, this relationship has not yet been explored in PFOA. Therefore the purpose of this study
was compare gait biomechanics and hip muscular strength between PFOA patients and a healthy control
group. Fifteen patients with symptomatic, radiographic PFOA and 15 controls participated. All patients
underwent a walking gait analysis and maximal hip strength testing. Biomechanical variables of interest
included the peak angular values of contra-lateral pelvic drop, hip adduction and hip internal rotation
during the stance phase. Hip abduction and external rotation strength were assessed using maximal
voluntary isometric contractions. The PFOA group demonstrated signicantly lower hip abduction
strength compared to controls but no difference in hip external rotation strength. There were no
statistical differences between the PFOA and control groups for contra-lateral pelvic drop, hip adduction
and hip internal rotation angles during walking. Despite patients with PFOA exhibiting weaker hip
abductor muscle strength compared to their healthy counterparts they did not demonstrate alterations
in pelvis or hip biomechanics during gait. These preliminary data suggests that weaker hip abductor
strength does not result in biomechanical alterations during gait in this population.
2012 Elsevier B.V. All rights reserved.

Keywords:
Patellofemoral
Osteoarthritis
Knee
Gait
Strength
Biomechanics

1. Introduction
Osteoarthritis (OA) is the most common joint disease in the
world [1]. However, the aetiology of this disease remains unclear
and there are currently no known treatments that have been
proven to slow its progression. The knee is one of the most
commonly affected joints and represents a major cause of pain and
disability [2]. Traditionally, knee OA has been viewed as a disorder
of the tibiofemoral joint, particularly of the medial compartment.
However, studies have shown that 2233% of knee OA patients
exhibit osteoarthritic changes in the patellofemoral joint [35].
Additionally, compared with medial compartment OA, PFOA
patients are more likely to report disability [4,5] and suffer an
earlier onset of chronic symptoms [4,6].
Due to a current lack of literature investigating the biomechanical gait patterns associated with PFOA, it is pertinent to examine

* Corresponding author at: Seaton Building 222, University of Kentucky,

Lexington, Kentucky 40506, USA. Tel.: +1 859 257 2706; fax: +1 859 323 1090.
E-mail address: michael.pohl@uky.edu (M.B. Pohl).
0966-6362/$ see front matter 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.gaitpost.2012.08.017

other patellofemoral disorders to help elucidate potential mechanisms. A study of PFOA patients waiting to undergo an arthroplasty
showed that 22% of them described preceding patellofemoral pain
syndrome (PFPS) in their adolescence and early adult years [6].
This nding is perhaps not surprising since up to 78% of PFPS
patients still report chronic pain 520 years after rehabilitation
[79]. The longevity of PFPS along with the low success rate
following rehabilitation, leads to the hypothesis that the underpinning mechanical causes of PFPS and PFOA may be similar. This
hypothesis is based on the premise that abnormal biomechanical
patterns associated with the aetiology of PFPS may also contribute
to degenerative changes at the patellofemoral joint over time.
Although the exact aetiology of PFPS remains unknown, some
studies have shown excessive hip adduction and internal rotation
during gait to be present in PFPS patients [1012]. It is possible that
abnormal hip mechanics are responsible for symptoms since
several cadaveric studies have provided evidence for a link
between abnormal lower extremity alignment and altered loading
at the patellofemoral joint [13,14]. Excessive hip adduction may
result in a medial collapse of the supporting limb and a theoretical
increase in the quadriceps angle during stance (knee abduction).

M.B. Pohl et al. / Gait & Posture 37 (2013) 440444

In turn, an increased quadriceps angle has been shown to result in

elevated patellofemoral contact pressure [14]. Similarly, greater
internal rotation of the femur was reported to also lead to
increased patellofemoral contact pressure [13]. Therefore, alterations in gait kinematics could theoretically alter the contact
pressure experienced in the patellofemoral joint, thus placing
the underlying cartilage at risk for subsequent damage and
degeneration.
Hip muscular strength has also received attention in the
literature with respect to its association with PFPS. In particular,
PFPS patients demonstrated decrements of 1521% and 1536% in
hip abductor and hip external rotator strength respectively when
compared to a healthy control group [1517]. Moreover, reduced
hip abductor and external rotator muscle strength has been
associated with excessive hip abduction [16] and internal rotation
[12] during gait respectively, suggesting that reduced hip muscle
force output may be partly responsible for the atypical hip
biomechanics.
Considering the epidemiological link between PFPS and PFOA, it
is possible that the abnormal hip biomechanics and weakness of
the hip musculature found in PFPS patients may also be
contributing factors to PFOA. However, there is a dearth of
literature examining muscular strength and gait biomechanics in
patients with knee osteoarthritis whose symptoms originate
primarily in the patellofemoral joint. Therefore, the purpose of
this study was to investigate differences in hip strength and gait
biomechanics between patients with mild to moderate PFOA and
asymptomatic controls. It was hypothesised that compared to
controls, PFOA patients would demonstrate greater hip adduction,
hip internal rotation and contralateral pelvic drop during walking
together with reduced hip abduction and external rotation
muscular strength.
2. Methods
2.1. Subjects
Fifteen male and female subjects diagnosed with PFOA were
recruited for the study. Fifteen gender matched asymptomatic
subjects served as a control group (CON). Demographic data for all
subjects can be found in Table 1. There were no signicant
differences between the PFOA and CON group in terms of age, mass
or BMI. The sample size was selected following an a priori power
analysis on the variable with the largest standard deviation (SD)
noted in previous literature, peak hip internal rotation [12]. Using a
within-group SD of 5.48 and expected difference between groups of
Table 1
Mean (SD) average subject demographics, knee injury and osteoarthritis outcome
score, and the frequency of compartmental OA radiographic scores.

Demographics
Gender distribution
(female:male)
Age (years)
Mass (kg)
BMI (kg/m2)
KOOS
Pain (/100)
Symptoms (/100)
ADL (/100)
Sports (/100)
QOL (/100)
OA grade (KL)
Grade 1
Grade 2
Grade 3
Grade 4

PFOA

CON

12:3

12:3

55 (9)
75.6 (10.5)
26.4 (3.7)

51 (9)
69.9 (13.3)
25.0 (3.5)

0.32
0.19
0.30

61.6 (12.5)
60.7 (19.5)
75.9 (13.4)
49.5 (26.9)
37.5 (19.4)
PF compartment
5
5
3
2

TF compartment
6
4
3
0

441

6.48, a minimum of 12 subjects in each group were required to

adequately power the study (a = 0.05, b = 0.8). Prior to participation, all subjects provided written informed consent that had been
approved by the Institutional Review Board.
The PFOA participants were recruited through the university
sports medicine centre while attending a knee OA clinic conducted
by a sports medicine physician. Potential candidates that
volunteered to participate in the study were evaluated by a
certied Athletic Therapist and had to meet the following inclusion
criteria: aged 40 years; knee pain originating primarily from the
peri- or retro-patellar region; patellofemoral pain that was
aggravated by at least two activities including stair ambulation,
squatting, prolonged sitting, rising from seating, kneeling or
exercise; radiographic evidence of OA (KellgrenLawrence grade
1) in the patellofemoral joint [18,19]; ability to walk without a
cane or assistive device; familiar and comfortable with treadmill
walking. Participants with unilateral or bilateral symptoms were
included in the study. Exclusion criteria for the PFOA group
included: prior history of patella fracture or recurrent subluxation;
bony abnormalities including bone fracture, osteochondritis
dissecans, or bi-partite patella; concomitant OA of the tibiofemoral
joint that was more severe (greater KL grade) than the
patellofemoral joint; known OA of other lower extremity weight
bearing joints (including the spine); knee, hip or ankle arthroplasty, osteotomy; arthroscopic surgery or knee injections within
the last 3 months; currently undergoing (or within the last 6
weeks) physiotherapy for knee pain; any physical or medical
problems for which strength testing/exercise would be contraindicated. A total of 19 volunteers were screened resulting in 4
being excluded from the study. The reasons for exclusion were
tibiofemoral OA that was more severe than the patellofemoral joint
(n = 2), evidence of hip OA (n = 1) and history of patellar fracture
(n = 1).
The same exclusion criteria that was applied to the PFOA group
was also used for the control group. In addition, all asymptomatic
control subjects were required to meet the following inclusion
criteria: aged 40 years; have no known OA in any lower extremity
joint (including the spine); been free of any lower extremity
musculoskeletal pain for the previous 6 months; were familiar and
comfortable with treadmill walking.
2.2. Biomechanical measures
Biomechanical data were collected using an eight camera Vicon
MX3 (Vicon Motion Systems, Oxford, UK) motion analysis. Twentyone anatomical and 27 tracking markers placed bilaterally on the
skin of the pelvis, thigh, shank and shoe of the participant (Fig. 1).
Following a standing calibration trial the anatomical markers were
removed and subjects walked on a treadmill for 3 min at a speed of
1.1 m/s while wearing standard, neutral, laboratory shoes (Nike Air
Pegasus, Nike, Portland, OR). Treadmill walking was conducted due
to space and setup restrictions imposed by the laboratory. The
walking speed was selected to be similar to mean average
treadmill walking speeds of knee OA patients in previous studies
[20,21].
Following the 3-min treadmill accommodation period, kinematic data for ten footfalls were collected. Raw marker trajectory
data were ltered using a fourth order low-pass Butterworth lter
with cut-off frequency of 8 Hz [22]. Three-dimensional hip, knee
and ankle joint angles were calculated using cardan angles with
the distal segment expressed relative the proximal segment. Pelvic
angles were dened as the pelvis segment relative to the
laboratory. Visual 3D software (C-motion Inc, Germantown, MD)
was used to lter all the marker data and calculate joint angles.
Good reliability of this kinematic gait model has been documented
previously [23]. Joint angle kinematics were analysed for the

M.B. Pohl et al. / Gait & Posture 37 (2013) 440444

442

Right

Left

All
symptoms in
left knee

All
symptoms in
right knee

Symptoms
equal between
knees

Fig. 2. Between-side visual analog scale. Participants were asked to place a single
mark on the horizontal line to represent which knee they experienced greater
symptoms in. For example, a mark placed on the extreme left indicated that
symptoms were completely restricted to the left knee. A mark placed in the middle
of the scale indicted that symptoms were of a similar severity for both knees.

(Sports), and knee-related quality of life (QOL) using subscale

scores from the Knee Osteoarthritis Outcome Score (KOOS)
questionnaire [27]. All radiographs were assessed by a single
musculoskeletal radiologist with 6 years of experience. Good intraobserver reliability in terms of assessing the tibiofemoral and
patellofemoral joints of the knee has been documented previously
with unweighted k-coefcients between 0.81 and 0.99 [4,19].
2.5. Data analysis

Fig. 1. Marker setup for the biomechanical gait analysis.

stance phase and normalised to 101 data points. To determine the

stance phase, initial contact (IC) and toe off (TO) were identied
using a velocity-based algorithm applied to the posterior distal
heel and toe marker respectively [24]. A custom Labview program
(National Instruments, Austin, USA) was used to extract the
kinematic variables of interest for each subject. These included the
peak angle and the angular excursion (displacement between IC
and the peak value) for contralateral pelvic drop, hip adduction, hip
internal rotation and knee abduction.

In PFOA patients, the most symptomatic limb was selected for

data analysis in terms of both gait biomechanics and strength. The
most symptomatic limb was identied using a between-side visual
analog scale that was completed by the patient (Fig. 2). In the CON
group, the distribution of limbs to be analysed was selected using
random assignment to match the distribution of right and left
limbs in the PFOA group. For instance, the right limb was the most
symptomatic in 7 PFOA participants. Therefore, 7 right limbs and 8
left limbs were selected for analysis in the CON group. Descriptive
statistics including ensemble mean and standard deviation values
of all biomechanical and strength measurements were calculated
for both the PFOA and CON groups. Independent t-tests were
performed for between-group statistical comparisons for all
variables of interest. Signicance was set at an alpha level of
P < 0.05 and all statistical analysis was undertaken using SPSS 17.0
(SPSS Inc, Chicago, USA).

2.3. Strength measures

3. Results
Following the walking trials, maximal voluntary isometric
strength testing was performed on the hip abductors and hip
external rotators. Muscle force was measured using a force
dynamometer (Nicholas MMT, Lafayette Instruments, Lafayette,
USA) and non-elastic adjustable straps as described and illustrated
by Snyder et al. [25]. Once in the testing position, each participant
performed one practice trial. Three isometric maximal voluntary
contractions (MVC) were then performed (each of 5 s duration)
with 15 s of rest in between each trial. The mean of the three MVC
trials was then normalised as a percentage of body weight [16,26].
The mean force of the three MVC trials was also converted to
torque by multiplying the mean force output by the resistance
lever arm and then normalised by dividing by body mass. A
between-session reliability analysis of both strength-testing
procedures was conducted on ve participants using a single
experienced tester (certied Athletic Therapist). Intra-class
correlation coefcient (ICC 3,1) values of 0.90 and 0.89 for hip
abduction and hip external rotation strength measurements
respectively demonstrated good reliability which was also in
agreement with previous literature [16,25].
2.4. Pain, function and radiographic measures
Subjects in the PFOA group were asked to complete selfadministered questionnaires assessing pain, symptoms, activities
of daily living function (ADL), sport and recreation function

The PFOA and CON groups were well matched in terms of mass
and BMI (Table 1). There were no signicant between-group
differences in either peak angle or angular excursion variables for
pelvic drop, hip adduction, hip internal rotation and knee
abduction (Table 2). Effect sizes for all kinematic variables were
Table 2
Mean (SD) average kinematic and strength variables of interest for the experimental
groups.
PFOA
Kinematics
Peak pelvic drop (8)
Pelvic drop
excursion (8)
Peak hip adduction (8)
Hip adduction excursion (8)
Peak hip internal rotation (8)
Hip internal rotation
excursion (8)
Peak knee abduction (8)
Knee abduction excursion (8)
Strength
Hip abduction (%BW)
Hip abduction (Nm/kg)
Hip external rotation (%BW)
Hip external rotation (Nm/kg)

CON

Effect
size

3.0 (1.3)
4.6 (2.4)

2.5 (2.2)
4.2 (2.8)

0.42
0.64

0.31
0.17

9.0
6.2
6.9
4.3

8.6
6.5
6.2
3.6

(3.4)
(2.6)
(6.6)
(2.3)

0.74
0.77
0.74
0.58

0.07
0.24
0.12
0.11

2.7 (2.9)
0.4 (0.5)

0.84
0.53

0.07
0.24

37.4 (8.7)
1.30 (0.35)
13.7 (5.1)
0.41 (0.16)

0.01
0.01
0.42
0.49

0.97
0.98
0.34
0.30

(2.5)
(3.4)
(5.0)
(3.8)

2.5 (4.0)
0.6 (0.9)
28.1 (10.6)
0.96 (0.35)
12.3 (3.2)
0.38 (0.10)

M.B. Pohl et al. / Gait & Posture 37 (2013) 440444

a) Pelvis Frontal Plane

3

Contralateral (+)

Angle ()

2
1
0

PFOA

-1 0

20

40

60

80

100

CON

-2
-3
Ipsilateral (-)

-4

b) Hip Frontal Plane

10

Adduction (+)

Angle ()

8
6
4

PFOA

CON

0
-2 0

20

40

60

80

100

Abduction (-)

-4

c) Hip Transverse Plane

8

Internal Rotation (+)

Angle ()

4
0
0

20

40

60

80

100

-4

PFOA
CON

-8
External Rotation (-)

-12
IC

% Stance

TO

Fig. 3. Mean ensemble angular displacement curves of pelvis frontal plane (a), hip
frontal plane (b) and hip transverse plane (c) for patellofemoral osteoarthritis
(PFOA) and control (CON) groups. IC, initial contact; TO, toe-off.

also generally low. A post hoc analysis was conducted comparing

the biomechanical variables of interest between the two groups
when only the female subjects were included (N = 12). There were
still no signicant differences between the PFOA and CON group in
peak angles or angular excursions for pelvic drop, hip adduction
and hip internal rotation (0.48  P  0.90). Ensemble mean group
kinematic curves are presented in Fig. 3.
The PFOA group demonstrated signicantly lower hip abduction MVC strength compared to the CON group (Table 2). However,
there were no differences between the PFOA and CON groups in hip
external rotation MVC strength.
4. Discussion
The goal of this study was to investigate differences in hip
strength and gait biomechanics between patients with mild to
moderate patellofemoral osteoarthritis and asymptomatic controls. Contrary to the hypothesis, no differences in hip biomechanics during walking were found between the two groups. However,
evidence for a hip muscle strength discrepancy was partially
supported with the PFOA group demonstrating signicantly
decreased hip abduction strength.

443

The lack of pelvis and hip kinematic differences between PFOA

and CON contradicted the hypotheses of the study. The hypotheses
were based on several studies that reported greater hip adduction,
hip internal rotation or contralateral pelvic drop in patients with
PFPS [1012]. It was speculated that PFOA patients would exhibit
similar kinematic patterns based on the assumption that the
underlying causes of PFOA and PFPS would be similar. However,
the kinematic differences for PFPS patients cited in the literature
were investigated during a running gait. Although Souza et al. [12]
and Willson and Davis [10] found that kinematic differences
between PFPS and control subjects during running carried over to
other movement tasks, walking was not investigated.
Patients with PFOA demonstrated 25% less hip abduction
strength compared to the control group. To the authors
knowledge, there is limited strength data on PFOA patients to
compare the ndings with. The magnitude of this strength
discrepancy corresponds well with the decrements of 1521%
that have been reported for hip abduction strength in PFPS patients
[15,16,28]. It has been speculated that weakness of the hip
abductor muscles in PFPS patients may lead to poor frontal plane
hip control and hence greater hip adduction angles during gait
[29]. However, the ndings of the present study revealed that the
hip abductor weakness in the PFOA group was not associated with
greater hip adduction or pelvic drop. Walking requires signicantly
less hip abductor activation than a maximal isometric contraction
[30]. Further, an experimentally induced 24% reduction in maximal
hip abductor strength was found to be insufcient to produce
changes in hip adduction or contralateral pelvic drop during
walking [31]. Therefore, it is possible that the decrement in
isometric hip abduction strength in PFOA subjects was not large
enough to result in altered hip and pelvis biomechanics during
walking. However, reductions in hip abductor strength may have
biomechanical implications for more dynamic movement tasks
such as running and jumping that place the muscles under greater
demand.
An alternative explanation for why differences in lower
extremity kinematics were not found in the PFOA group despite
having lower hip abductor strength, may reside in the fact that
strength measurements were conducted in a sidelying position.
While the sidelying position was selected to ensure both good
reliability and enable comparison with previous literature, it does
not necessarily represent the functional demands placed on the hip
abductors during an upright task such as walking. Therefore, it
would be of interest to investigate the relationship between
strength and gait kinematics in PFOA patients using a more
functionally relevant measure of hip abductor strength/control.
Although slower self-selected walking speeds have been
documented in patients with knee OA [21], a xed walking speed
was used in the present study. The xed walking speed of 1.1 m/s
was chosen to be similar to the mean self-selected treadmill walking
speed of persons with knee OA [20,21]. It could be argued that
constraining gait speed would force each study participant to
produce similar forces for propulsion, thereby requiring similar
muscle activation proles and joint kinematic proles. Indeed, it has
been documented that walking speed can alter lower extremity joint
kinematics in knee OA patients [20]. However, differences in hip
biomechanics have been demonstrated between PFPS and control
subjects during running when speed was controlled for [11,12]. This
suggests that biomechanical differences in gait can be observed in
patients with patellofemoral disorders when speed is held constant.
Therefore, a xed walking speed was used to determine whether gait
kinematic differences were truly present in PFOA patients when
speed was controlled for. However, there is the potential that a faster
walking speed could place greater demand on the musculoskeletal
system and induce kinematic differences between the PFOA and
control groups that were not present during the slower walking

M.B. Pohl et al. / Gait & Posture 37 (2013) 440444

444

speed. Further research is needed to clarify whether walking

speed inuences the association of gait biomechanical variables
with PFOA.
There is the possibility that the conclusions of this study were
limited by the small sample size. The a priori power analysis was
conducting using published data that involved runners with PFPS
[12]. As mentioned earlier, the kinematic differences between
groups may be smaller during walking compared to running and
thus a larger sample size might have been required to detect
between-group differences during a walking task. Therefore, a post
hoc sample size calculation was conducted using the preliminary
data presented in this study. It was determined that group sample
sizes of 206, 875 and 1099 would have been required to detect
statistical differences in peak pelvic drop, hip adduction and hip
internal rotation respectively (a = 0.05, b = 0.2). Thus, having to
collect such a large sample would question the clinical applicability
of any between-group signicant differences that may have arisen.
Another limitation was that a large scale study concerning the
reliability of the individual compartment (patellofemoral and
tibiofemoral) radiographic scoring was not conducted as part of
this investigation. However, the purpose of this study was not to
investigate the association of gait biomechanics with OA radiographic severity. Rather, the key issue was to include patients with
symptoms consistent with PFOA which included not only radiographs, but also pain and symptoms. However, given that future
investigations are needed to compare the gait biomechanics of
PFOA patients with varying levels of severity, more studies are also
needed to evaluate the intra- and inter-observer reliability of
grading the separate compartments of the knee joint.
In summary, the PFOA group demonstrated signicantly lower
hip abduction strength than the healthy control group. This provides
evidence that some of the strength discrepancies reported in the
PFPS literature may also be present in those with PFOA. However, no
between-group differences in hip and pelvis biomechanics were
found during walking. These preliminary ndings suggest that
abnormal hip and pelvis biomechanics may not be associated with
osteoarthritic changes in the patellofemoral joint.
Acknowledgements
This study was funded by Alberta Innovates: Health Solutions
and Alberta Innovates: Technology Futures. The authors gratefully
acknowledge the assistance of Kimber Thornton, Jill Baxter,
Chandra Lloyd, Sang-Kyoon Park and Lindsay Farr.
Conict of interest
There are no conicts of interest for any of the authors.
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