Does Gender Differences and Biomechanics Explain

Why More Females Develop Patellofemoral Pain

Syndrome?

Research Team
Catherine Martin ATS
Matthew Harris PT, ATC
Hannah Clementson LAT, ATC
Beth Funkhouser LAT, ATC

12/01/2018
 Table of Contents
CLINICAL SCENARIO .............................................................................................................................................. 2
FOCUSED CLINICAL QUESTION: ............................................................................................................................................ 2
KEYWORDS:.............................................................................................................................................................................. 2
SUMMARY OF SEARCH METHODOLOGY ........................................................................................................ 3
SEARCH STRATEGY: ................................................................................................................................................................ 3
SOURCES OF EVIDENCE SEARCHED: ..................................................................................................................................... 3
BEST EVIDENCE REVIEWED: ................................................................................................................................................. 3
CLINICAL BOTTOM LINE ...................................................................................................................................... 6
IMPLICATIONS FOR CLINICAL PRACTICE ............................................................................................................................. 7
RECOMMENDATIONS FOR FUTURE RESEARCH .................................................................................................................. 7
REFERENCES: ........................................................................................................................................................... 7

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CLINICAL SCENARIO
The problem was the there is a lot of females that I have come into contact with at
school with patellofemoral pain syndrome and there is a lacking number of males with
this development. After looking into it, females were always more prone to have PFPS
than males and it was not really understood as to why. Up until this semester, I have
focused on ACL related research and I wanted to go into more chronic knee
pathologies. In classes related to my major, it has always just been taught that females
develop PFPS more than males and no one has ever asked why. This is how I got to the
development of my question.

Development of Clinical Question:

After speaking with athletes that have had PFPS and preceptors about how many
times they have had female athletes with PFPS, I wanted to look into the data. I have
previously been educated on Q angle and proper running mechanics so those were
going to help me with coming to an answer of why females are more likely to get PFPS
than males. Gender differences and biomechanics are important for this question.

Development of Investigation Committee:

I wanted Beth Funkhouser to be on my committee because she has a broad
understanding of the body and specific injuries. Beth Funkhouser helped me with
making my question in a better format and not be broad. Hannah Clementson was also
important to have on my committee because she had a sport that involved females and
jumping and she had some athletes with anterior knee pain. Matt Harris was a good
addition to the committee because he sees injuries from and rehabilitation perspective
so he deals with the strengthening and preventing of any type of injuries. Previously in
my time at Emory & Henry College, I was observing Matt Harris at his clinic and he had
a patient with anterior knee pain that was from osteoarthritis and they were a runner
earlier in their life. Having that experience helped me understand the development of
PFPS to osteoarthritis and why that happens.

Focused Clinical Question:

Do gender differences and biomechanics(I) make female athletes(P) more susceptible
to PFPS(O) than male athletes(C)?

Keywords:
The key words used were PFPS, biomechanics, female, male, and gender.

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SUMMARY OF SEARCH METHODOLOGY
Beth Funkhouser initially got me started on answering my question when we sat down
and narrowed down what exactly I needed to look into to answering my question.
Hannah Clementson helped me some with just discussing symptomology of PFPS and
how to diagnose and also how she went about treating this as well. Besides those
encounters, most of the time, I read published studies about PFPS with gender
involvement and biomechanics. Specific studies that were accessible to me were slim so
I had to take what I had access to and run with that information to help me look into
other sections of PFPS and then I finally found a handful of published journals with
good information about gender differences and biomechanics.

Search Strategy:
PICO
P-female athletes
I-gender differences and biomechanics
C- male athletes
O- PFPS

Sources of Evidence Searched:

I used Academic Search Complete for my database to gather information. All of
my resources are medical journals. I used the Journal of Sport Rehabilitation,
Orthopedic Reviews, Clinical Biomechanics, and the Journal of Biomechanics
specifically.

Best Evidence Reviewed:

1. Lower Extremity mechanics of females with and without patellofemoral pain

across activities with progressively greater task demands By: John D. Wilson and
Irene s. Davis
a. This journal analyzed the mechanics in females with and without
patellofemoral pain. Patellofemoral pain syndrome is one of the most
complained about injuries of the knee and especially in females. People with
PFPS have pain during functional activities, decrease in level of activity, and
the risk of having osteoarthritis later on in their lives. The Q angle was used
in this journal. The Q angle looks at the orientation of the four quadriceps
muscles that act on the patella. The Q angle is a line from the tibial tubercle
to the patella and the other line going to the ASIS. A normal value is 15
degrees. As the degree goes up, the lateral force on the patella will increase
as well. Keeping in mind that females usually have a higher Q angle .
Because of the higher angle, Q angle is a factor for gender differences for
PFPS. With that being said, not all females with PFPS have a higher Q angle.
When the Q angle increases in the frontal plane, it will increase
retropatellar stress from 20-90 degrees knee flexion. They have also found
that repetitive weightbearing activities can damage the cartilage as well.

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 The location of the patella and the femur relationship could possibly predict
the location of lesions on the cartilage of patients with PFPS. In females
specifically, decreased hip external rotation and abduction strength can
increase the tendency for females to have the transverse and frontal plane
rotations that causes the increased stress. Females that ended up with PFPS
also had less hip abduction and external rotation strength. PFPS patients
exhibited more knee external rotation, decreased knee internal rotation,
increased hip adduction, and decreased hip internal rotation. So, patients
with PFPS have different lower extremity mechanics.
2. Sex differences in running mechanics and patellofemoral joint kinetics following an
exhaustive run By: John D. Wilson, Justin R. Loss, Richard W. Willy, and Stacey A.
Meardon
a. This journal gives fault to running mechanics for as to why females are
more prone than males to develop PFPS. In runners, the elevated
patellofemoral joint kinetics. Those are dependent on speed, foot strike
pattern, step length, and peak contact forces between 4 and 10 weights of
the body. After running there is an increase peak hip and knee flexion,
increased rearfoot excursion, increased knee flexion at initial contact, and
increased step length. They did note that it was still unclear as to if males
and females have the same experiences with running mechanics. They found
no effects of sex for the patellofemoral joint kinetic variables of interest so
the changes of mechanics and patellofemoral joint kinetics were the same
with males and females. They also noted that females can have decreased
peak knee extension during the run. The limitations were interesting
because they found that for any quadriceps force, the hamstrings and
gastrocnemius would increase the patellofemoral joint force during the run.
The males had greater hamstring forces than females during the run. In the
ending remarks, they stated that there was greater hip adduction during
running has been found in people who have and later will develop PFPS.
3. Patellofemoral pain syndrome in female athletes: A review of diagnoses, etiology
and treatment options By: Molly Vora, Emily Curry, Amanda Chipman, Xinning Li,
and Elizabeth Matzkin.
a. Females with PFPS have a decrease in abduction, external rotation, and
extension strength of the affected side. PFPS is a result of imbalances in the
forces that control tracking of the patella during knee flexion and extension.
PFPS is hard to define because it has an array of symptoms and levels of
pain and physical difficulties. Constantly overloading and overusing the
patellofemoral joint can contribute to PFPS rather than just a
malalignment. The overuse injury is of the extensor apparatus, patellar
instability, and chondral and osteochondral damage. Femoral neck
anteversion, genu valgum, knee hyperextension, Q angle, tibia varum and
excessive rearfoot pronation are possible alignment issues that can be
associated with PFPS. With a higher Q angle, there is a higher lateralization
angle on the patella so that increased the load on the lateral facet of the
patella and the femoral condyle. If there is a 10% increase in Q angle, there
is a 45% increase in stress on the patellofemoral joint. In females, if the Q

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 angle is higher than 20 degrees, that is abnormal. In active flexion and
extension, lateral patellar translation and tilt was present in almost half of
the knees with anterior pain. Abnormal tracking is a potential cause of
PFPS. Dynamic lateral patella tracking is a risk factor for PFPS, static
patellar malalignment can also be factor. Also differential action of the
quadriceps is a factor of PFPS. Decreased strength due to atrophy or
inhibition of the lower extremity muscles has shown to be a contributor.
There could be decreased knee extensor strength, weak eccentric muscle
strength, imbalanced vastus medialis oblique and vastus lateralis, as well as
the hip muscles being weak can lead to PFPS. Females with greater hip
abduction strength is an increased risk of developing PFPS. In females that
already have PFPS, there was lower knee extensor strength in the knee with
symptoms. Females with PFPS, have decreased torque, total volume, and
cross sectional area of the quadriceps muscle. They also found that females
have more hip internal rotation to maximum angular displacement
compared to males. The weaker thigh muscles of females can be associated
with the stiffening of the knee and lower leg with females. PFPS is linked to
decrease in vastus medialis oblique muscle mass. Females also show greater
external knee valgus movement and hip internal rotation than males.
Female patients with PFPS were more involved in sports that were
competitive and that their pain was from increased activity levels. So
increase or change in activity is something that can lead to PFPS developing
rather than just high activity levels. 62% of females were at a greater risk
for PFPS. The contributing factors were anatomical, hormonal factors, knee
laxity, and neuromuscular factors expose patients to be at risk for the
development of PFPS. In females, they lack hip muscle strength and external
rotation and abduction. Also females that have had an injury to the lower
extremity had a large deficit of external rotation strength. There is also a
link between menstrual phases and hormonal factors with developing PFPS.
Vastus medialis and vastus medialis oblique firing rates vary during the
menstrual cycle. There are some identified risk factors for females and they
are overuse, trauma, muscle dysfunction, tight lateral musculature, patellar
hypermobility, and low quadriceps flexibility. In the concluding remarks,
females with PFPS have a decrease in abduction, external rotation, and
extension strength of the affected side.

4. Relationship Between Lower-Extremity Strength and Subjective Function in

Individuals With Patellofemoral Pain By: Neal R. Glaviano and Susan Saliba
a. This journal discusses that strength and the lack of strength can be a factor
of patellofemoral pain. Muscle weakness is associated with abnormal
movement patterns. This will increase the patellofemoral stress. Quadriceps
strength is a large contributor to functional movement. The cause of
quadriceps weakness was not looked at for this study but could be related
to increase in joint irritability in testing, muscle atrophy, and inhibition can
lead to the weakness of the function of the quadriceps function. Males with
PFPS also are present with quadriceps weakness but both males and

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 females with PFPS are also seen with quadriceps weakness. If there is a 10%
increase in Q angle, there is a 45% increase in stress on the patellofemoral
joint. In females, if the Q angle is higher than 20 degrees, that is abnormal.

CLINICAL BOTTOM LINE

My research gave me the information to somewhat answer my question about
why females are more susceptible to develop patellofemoral pain syndrome rather
than males. I specifically was looking into gender differences and biomechanics of
females. In my first resource, the Q angle for females were higher than males and that
increased the lateral force on the patella for females making Q angle a risk factor for
PFPS. In females specifically, decreased hip external rotation and abduction strength
can increase the tendency to have transverse and frontal plane rotations that causes
the increased stress. The females that ended up with PFPS, exhibited decreased hip
abduction and external rotation strength and they thought that strength is an
underlying factor for developing PFPS.
In my second resource, running mechanics was the main subject under study.
They found that after running there is an increase peak hip and knee flexion, increased
rearfoot excursion, increased knee flexion at initial contact, and increased step length
but they did not separate males and females to explain if both groups experience this.
They also noted that females can have decreased peak knee extension during the run
and males had greater hamstring forces than females during the run.
In my third resource, they specifically looked at females. Females with PFPS
have a decrease in abduction, external rotation, and extension strength of the affected
side. With a higher Q angle, there is a higher lateralization angle on the patella so that
increased the load on the lateral facet of the patella and the femoral condyle. Females
with greater hip abduction strength is an increased risk of developing PFPS. In females
that already have PFPS, there was lower knee extensor strength in the knee with
symptoms. Females with PFPS, have decreased torque, total volume, and cross
sectional area of the quadriceps muscle. They also found that females have more hip
internal rotation to maximum angular displacement compared to males. The weaker
thigh muscles of females can be associated with the stiffening of the knee and lower leg
with females. Females also show greater external knee valgus movement and hip
internal rotation than males. So increase or change in activity is something that can
lead to PFPS developing rather than just high activity levels. 62% of females were at a
greater risk for PFPS. The contributing factors were anatomical, hormonal factors,
knee laxity, and neuromuscular factors expose patients to be at risk for the
development of PFPS. In females, they lack hip muscle strength and external rotation
and abduction. There is also a link between menstrual phases and hormonal factors
with developing PFPS. Vastus lateralis and vastus medialis oblique firing rates vary
during the menstrual cycle. There are some identified risk factors for females and they
are overuse, trauma, muscle dysfunction, tight lateral musculature, patellar
hypermobility, and low quadriceps flexibility. In the concluding remarks, females with

6
 PFPS have a decrease in abduction, external rotation, and extension strength of the
affected side.
In my fourth source, the journal discussed strength and how weakness can be a
huge contributor to developing PFPS.

Implications for Clinical Practice

I found that females are more likely to develop PFPS because of naturally
increased Q angle and that puts more lateral force on the patella. Increased Q
angle can cause lack of hip abduction and external rotation musculature and
that can also be a contributor. Running mechanics in females have been shown
to change in an individual with PFPS. They also found that females have more
hip internal rotation to maximum angular displacement compared to males.
Females also show greater external knee valgus movement and hip internal
rotation than males. The contributing factors were anatomical, hormonal
factors, knee laxity, and neuromuscular factors expose patients to be at risk for
the development of PFPS. There is also a link between menstrual phases and
hormonal factors with developing PFPS. Vastus medialis and vastus medialis
oblique firing rates vary during the menstrual cycle. So if we now know that
females have a different body type and that their muscles are not always the
same because of Q angle and mechanics, then we realize that females and
males are different. Females having less muscle development makes them
weaker and not able to properly take the forces put on them. Also we know that
the menstrual cycles affect females and how their muscles fires. Those muscles
help with protecting the patellofemoral area. This information can help clinical
practice by understanding the real differences between males and females. Now
knowing that females have decreased in abduction, external rotation, and
extension strength can help with specifically diagnosing and knowing what to
strengthen. Learning about firing rates varying during menstrual cycles is
really significant because that is a true difference between males and females.
Quadriceps muscle weakness or imbalances can cause stress to the
patellofemoral area and can be a contributor to PFPS.

Recommendations for Future Research

We still need more information on prevention, why males are not as likely, and to
narrow down symptomology for diagnosing patients.

REFERENCES:
Glaviano NR, Saliba S. Relationship Between Lower-Extremity Strength and Subjective
Function in Individuals With Patellofemoral Pain. Journal of Sport Rehabilitation.
2018;27(4):327-331. doi:10.1123/jsr.2016-0177.

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Vora M, Curry E, Chipman A, Matzkin E, Li X. Patellofemoral pain syndrome in female
athletes: A review of diagnoses, etiology and treatment options. Orthopedic Reviews.
2018;9(4):98-102. doi:10.4081/or.2017.7281.

Willson JD, Davis IS. Lower extremity mechanics of females with and without patellofemoral
pain across activities with progressively greater task demands. Clinical Biomechanics.
2008;23(2):203-211. doi:10.1016/j.clinbiomech.2007.08.025.

Willson JD, Loss JR, Willy RW, Meardon SA. Sex differences in running mechanics and
patellofemoral joint kinetics following an exhaustive run. Journal of Biomechanics.
2015;48(15):4155-4159. doi:10.1016/j.jbiomech.2015.10.021.