American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print

DOI: 10.1097/PHM.0000000000001367

Patellofemoral pain syndrome and pain severity is associated with

asymmetry of gluteus medius muscle activation measured via ultrasound

Karlie Payne, MBBS, BPhysio, Justin Payne, MBBS, BPhysio,

Theresa A Larkin, PhD, BSc (Hons), MEd

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School of Medicine, University of Wollongong, Wollongong, Australia

Corresponding author: Theresa Larkin. School of Medicine, University of Wollongong,

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Northfields Avenue, NSW, 2522, Australia. phone: +61 (2) 4221 5132; fax: +61 (2) 4221

4341; tlarkin@uow.edu.au
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Declarations: There are no Competing Interests. No Funding, grants or equipment were

provided for the project from any source. There are no financial benefits to the authors. This
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has not been presented previously.

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Abstract

Objective: To determine whether gluteus medius muscle thickness or activation differed

between left and right sides, and were associated with patellofemoral pain presence or

severity. Design: Males and females were recruited and screened by a physiotherapist for

inclusion in the control or PFPS group. Bilateral measures were obtained for Q angle, and

gluteus medius muscle thickness at rest and on contraction via standing hip external rotation,

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using ultrasound. Muscle activation was calculated as the percentage change in muscle

thickness on contraction relative to at rest. PFPS participants completed the Anterior Knee

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Pain Scale and a visual analogue pain scale. Results: Gluteus medius muscle thickness at rest

and on contraction, muscle activation, and Q angle were not different between control (n=27;

63% female) and PFPS (n=27; 59% female) groups. However, PFPS participants had a

significantly larger left-right side imbalance in gluteus medius muscle activation than
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controls (15.9±19.3% versus 4.4±21.9%; p< 0.05). Among PFPS participants, the magnitude

of asymmetry of gluteus medius muscle activation was correlated with knee pain score

(r=0.425, p=0.027). Conclusion: Asymmetry of gluteus medius muscle activation was

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associated with PFPS and pain severity. This is clinically relevant for PFPS prevention and

treatment, particularly since this was quantifiable using ultrasound.

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Key words: gluteus, muscle, patellofemoral pain syndrome, side imbalance

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What is known?

Gluteus medius muscle weakness and femoral malalignment are commonly associated with

patellofemoral pain syndrome; however, with inconsistent results. Asymmetries in muscle

measures have been associated with other musculoskeletal pain and/or injuries.

What is new?

Left versus right side asymmetry of activation of gluteus medius was larger in participants

with patellofemoral pain syndrome than control participants. In addition, the magnitude of

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the asymmetry of gluteus medius muscle activation was correlated with knee pain score.

Measurement of, and training to reduce asymmetry in, gluteus medius muscle activation

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represents a target for prevention and rehabilitation of patellofemoral pain syndrome.
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Introduction

Patellofemoral pain accounts for 25-40% of knee pain cases. 1 The term patellofemoral pain

syndrome (PFPS) is used due to its multifactorial aetiology. PFPS is characterised by

anteromedial retropatellar or peripatellar pain, typically exacerbated by running, jumping,

walking up or down stairs, squatting, and extended sitting or kneeling, and can impact

heavily on a person’s quality of life.2,3 Factors that contribute to PFPS are predominantly

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biomechanical, including malalignment of the femur and/or patella, and lower limb muscular

imbalances. 1 This research focusses on the impacts of muscular imbalance, specifically that

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of the gluteus medius muscle, and femoral alignment, with respect to PFPS, including pain

severity and impact on quality of life.

Gluteus medius attaches from the outer surface of the ilium and inserts on the lateral aspect of
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the greater trochanter of the femur.4 Its actions include hip abduction, internal rotation when

the hip is flexed, and external rotation when the hip is extended. 5,6 During single leg stance,

its activation and contraction prevents the contralateral side of the pelvis from dropping 4 and
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is therefore essential for pelvis stability while walking. It is thought that weakness or
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inadequate activation of gluteus medius muscle while weight-bearing can lead to internal

rotation of the femur, and consequently, lateral tracking of the patella, and PFPS. 1 However,
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there is inconsistency as to the influence of gluteus medius in relation to PFPS. Gluteus

7,8 9
medius activation has been reported to be delayed, of shorter duration, not significantly
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2,10 11
different and decreased among individuals with PFPS compared with controls.
11-17 7
Reduced, or not significantly different, hip abduction and/or hip external rotation
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strength, and no difference in gluteus medius muscle thickness as measured by ultrasound

have been reported among those with versus without PFPS; however, increased hip abduction

and external rotation strength were found to be risk factors for the development of

patellofemoral pain. 18,19

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A major limitation with previous research is the lack of bilateral gluteus medius measures and

no data on whether the patellofemoral pain was unilateral and on the left or right side, or

bilateral. Only two studies assessed gluteus medius muscle strength on both the affected and

unaffected side of participants with PFPS, but these included only 13 and 10 participants. 14,16

In terms of comparisons between participants with versus without PFPS, only the affected (or

most affected for those with bilateral patellofemoral pain) limb has been assessed, and

compared with any of: the matched left, right or dominant side, 10,11,15,17,20 or the dominant, 2

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16 9,12,13 14
non-dominant; right, or a randomly selected, side of control participants. These

inconsistencies likely contribute to the lack of consensus in terms of associations between,

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and preclude analysis of the influence of side (left versus right or dominant versus non-

dominant) on, gluteus medius activity and PFPS. In addition, previous studies have been

limited in terms of participant numbers and sex; the majority have included only female
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participants and less than 41 total control and PFPS participants.

Only assessing unilateral gluteus medius muscle function, with respect to both PFPS and

control participants is a significant omission because of the potential influence of lower limb
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dominance. More commonly the left leg is used for stance and posture and the right leg is
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used for coordinated functions such as kicking and jumping. Side disparities in the lower
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limb muscles that result from this dominance may predispose to injury. Considering the
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role of gluteus medius in pelvic stability during single leg stance, the left and right gluteus
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medius muscles likely differ in thickness and/or function due to the effect of leg dominance,

and the degree of asymmetry may impact the presence and/or severity of PFPS. Indeed,

asymmetry of gluteus medius muscle and hip abduction strength have been associated with
23-25
low back pain and iliotibial band syndrome, and it is reasonable to hypothesise that this

may also influence PFPS. Interestingly, latent profile analysis of 127 participants with PFPS

identified three subgroups with strong, weak and intermediate hip abductor strength,26 but

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again there were no data for the distribution of left, right and bilateral patellofemoral pain. 25

These different profiles, as well as the conflicting results in the literature, may be due to

different proportions of participants with left versus right versus bilateral patellofemoral pain

and may represent a confounding effect of any inherent gluteus medius side imbalance. An

influence of asymmetry in gluteus medius muscle thickness or activation has not previously

been considered with respect to PFPS.

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Malalignment of the femur can contribute to patellofemoral pain independent of gluteus

medius muscle weakness.27 Indeed, a recent review of 16 studies concluded that increased

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hip internal rotation and gluteal muscle weakness were two of the four common findings in

patients with PFPS. 28 Increased internal femoral rotation results in a larger Q angle, the

angle at the midpoint of the patella, between the lines from this point to the anterior superior
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iliac spine (ASIS) proximally, and the tibial tuberosity distally. However, there are
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inconsistencies with respect to PFPS among females, with reports of a positive association
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between a Q angle of at least 20 degrees and PFPS, and no difference in Q angle among

those with versus without PFPS.29

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Gluteus medius is easily visualized using ultrasound, which is a non-invasive and easily

accessible imaging modality that is increasingly used in physiotherapy for diagnosis and
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6,15
rehabilitation. The percent change in muscle thickness, as measured using ultrasound,

from the passive (at rest) to the contracted state is referred to as muscle activation, 31 and has
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high correlation with muscle activation measures obtained via electromyography. By

enabling real-time measurement of muscle activation, this may be beneficial with respect to

providing patients with real-time visual feedback on muscle activation levels, to assist with

diagnosis and rehabilitation. Further, using ultrasound to assess gluteal muscle activity

addresses the need to evaluate the “value of gluteal muscle activity screening in identifying

individuals most likely to develop PFPS”. 8

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This study aimed to determine whether: 1) gluteus medius muscle thickness (measured via

ultrasound) at rest or on contraction, or activation (percent change in muscle thickness),

differed between the left and right sides and between those with versus without PFPS; 2)

gluteus medius thickness or activation or asymmetry of these, or femoral alignment

(measured by the Q angle) were associated with presence, severity and/or duration of

patellofemoral pain. Note, comparisons were made between left and right sides rather than

the dominant versus non-dominant sides for simplicity, since the upper limb dominance is a

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confounder (e.g. if someone is left-footed but right-handed, their left side would be the

stabilizing limb when reaching out with the upper limb, but their right side would be the

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stabilizing limb for activities such as kicking).

It was hypothesized that: 1) gluteus medius muscle thicknesses and activation would be

significantly different between the left and right sides for control and PFPS participants and
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significantly different between control and PFPS participants; 2) among participants with

PFPS, gluteus medius muscle measures on the pain versus non-pain side would be influenced

by the side (left versus right) of the pain.

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Materials and Methods

Study Design and Participants

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Following ethics approval by the University of Wollongong Human Research Ethics

Committee (ethics number = GSM15/015), participants were recruited via advertisement to

the University of Wollongong student and staff community. This was a cross-sectional study

with 2 groups of participants, and conforms to all STROBE guidelines and reports the

required information accordingly (see Supplemental Checklist, Supplemental Digital Content

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 33
1, http://links.lww.com/PHM/A936). Sample size of a minimum of 26 participants per

group has been reported for differences in gluteus medius muscle thickness at an alpha of
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0.05 and 80% power. All interested participants underwent screening and examination by

an experienced physiotherapist to determine their suitability for inclusion in the PFPS or

control group. For inclusion in the PFPS group, participants were required to have had

anterior knee pain within the past 12 months for at least 2 weeks duration. The diagnosis of

PFPS was made based on a clinical examination that encompassed assessment of the history

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and aggravating factors and through a process of elimination of other causes of knee pain.
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A participant was confirmed to have PFPS if: they had anterior knee pain, peripatellar, or

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retropatellar pain, not specific to the joint line or medial or lateral collateral ligament; their

knee pain was exacerbated after at least two of the following activities: prolonged sitting,

squatting, kneeling, jumping, and ascending or descending stairs; they had no history of knee
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trauma; no bruising or swelling; no signs of neuropathic pain; and no evidence of injury to a

specific structure, i.e. all ligaments, tendons and articular cartilages intact and non-tender.

Exclusion criteria included: currently undergoing physiotherapy or exercise treatment for

their knee pain; total knee replacement; patellar dislocation; previously diagnosed knee
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pathologies or surgeries. Control participants were required to have had no knee pain for the
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previous 12 months. Further exclusion criteria for both groups were: chronic low back pain;

previous lumbar spine surgery; total hip replacement; previously diagnosed trochanteric
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bursitis; gluteal or hamstring tendon surgeries; use of analgesic medication in the previous 48

hours. Eligible participants attended the Phytness Physiotherapy at the University of

Wollongong campus for a single instance of data collection. Each participant gave signed

informed consent prior to participation and was assigned a unique code such that all data

collected remained confidential and anonymous. Participants completed two questionnaires

and then underwent biometric measurements and ultrasound of the gluteus medius muscle.

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Data collection

The Anterior Knee Pain Scale (AKPS) 35 was used to gather information on the symptoms of
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participants’ patellofemoral pain; this is reliable and valid as an assessment tool in PFPS.

All participants were asked about their frequency of participation in walking, cycling, and

activities that are associated with a lower limb side dominance (soccer, tennis and jumping

activities), with response options of never; a few times per year; once per month; a few times

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per month; once per week; a few times per week; every day. For analyses, responses were

grouped into two categories: up to a few times per month and at least once a week. A second

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questionnaire was developed for those with PFPS and asked participants to indicate their

current level of knee pain using a visual analogue scale (VAS) of 0 – 10, where 0 = no pain,

and 10 = the worst pain imaginable, and the impact of this knee pain on their quality of life

using a VAS of 0 – 10, where 0 = no impact, and 10 = extreme impact). Both the AKPS and a
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10 point VAS are recommended to assess pain and functional outcome measures in PFPS.

Height, weight, and left and right Q angle were then measured and recorded for all

participants. The Q angle was measured using a goniometer with the patient supine with the
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knees in line with the ipsilateral ASIS (anterior superior iliac spine). Each participant then

underwent ultrasound imaging of their gluteus medius muscle bilaterally by a different

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researcher who conducted all ultrasound measures for consistency and was blinded in terms

of whether a participant was in the control or PFPS group, using a Sonoscape S6 Portable
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Digital Colour Doppler Ultrasound System with a linear array transducer (5-12 MHz).

Ultrasound quantification of muscle thicknesses

For ultrasound measures, the gluteus medius muscle was located as the midpoint of a triangle

formed between the iliac tubercle, the ASIS and the greater trochanter. The ultrasound probe

was placed at this location in a longitudinal orientation for scanning, and the ilium and

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gluteus medius muscle were identified. To maintain consistency between participants, the

lateral gluteus minimus musculotendinous junction and the ASIS were identified and the

ultrasound probe was moved until these were the most lateral landmarks in the image, with

the gluteus medius muscle then visualized in the centre of the screen. The thickness of the

gluteus medius was measured in millimeters at the centre of the muscle belly from the

superficial fascial margin to the deep fascial margin. Ultrasound was conducted with the

participant standing and holding onto the back of a chair for stability: i) for quantification of

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gluteus medius muscle thickness at rest (passive) the participant stood at ease with their body

weight equally distributed across both legs; ii) for quantification of gluteus medius muscle

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thickness on contraction (contracted) the participant then shifted most of their weight to the

contralateral leg, raised the ipsilateral heel but kept the toe in contact with the ground, and

externally rotated their hip. The probe was held in the same position and in contact with the
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participant’s skin during collection of both measurements. Ultrasound identification and

quantification was performed in triplicate for each condition, on the right and left side.

Gluteus medius muscle activation was calculated as the percentage change in muscle

thickness between at rest and contracted states, relative to the thickness at rest.
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Statistical analyses
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Data were analysed using IBM SPSS Statistics 21. The Shapiro-Wilk test of normality was
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used to determine whether the ultrasound measures of passive and active muscle thickness

were normally distributed. Chi-square tests were used to compare frequency of participation

in selected activities between control and PFPS groups. A three-way repeated measures

ANOVA with factors of side (left and right), repeat (triplicate measures) and muscle

condition (passive and contracted) with between group comparisons for sex and clinical

status (control versus PFPS) was conducted to determine any influences on gluteus medius

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muscle thickness. A two-way repeated measures ANOVA was then conducted for gluteus

medius muscle activation, with factors of side and repeat, and between group comparisons for

sex and clinical status (control versus PFPS). To determine any influence of the side of pain

in the PFPS group, a one-way repeated measures ANOVA was conducted for each of gluteus

medius muscle thickness at rest, contracted, and muscle activation to compare these for the

pain and non-pain side, with a between group comparison for left-sided versus right-sided

pain. Post-hoc comparisons were conducted incorporating Bonferroni correction. All

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correlations are reported using Pearson’s correlation co-efficient. Cronbach’s alpha and the

intraclass correlation coefficient (with 95% confidence interval) were calculated as measures

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of reliability for passive and active gluteus medius muscle thickness measurements. For both

passive and active gluteus muscle thickness, these were assessed for triplicate measures of the

total of all left and right side values for each participant (n = 108). A coefficient of variation
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was calculated based on all triplicate measures for the left and right side of each participant (n

= 324) for passive and contracted gluteus medius muscle thickness. The minimum detectable

change at a 95% confidence interval (MDC95) was calculated as the standard error of the

mean (for triplicate measures of left and right side passive and active muscle thickness for all
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participants; n = 324) x 1.96 x √2.

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Results
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Participants and anthropometric data analyses

After initial screening, 2 participants were excluded from the PFPS group due to their knee

pain not being indicative of PFPS, and 2 participants were excluded from the control group

because they had back pain or knee pain within the previous 12 months. Data from a total of

27 control and 27 PFPS participants were included in final analyses. Of the 54 participants,

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there were 21 males and 33 females. Demographic and anthropometric data and muscle

measures are included in Table 1. There were no significant differences between the control

and PFPS groups for the full cohort, or males or females in terms of the anthropometric data

including Q angle, except that females who had PFPS were significantly older than female

controls (Table 1). The left-side and right-side Q angles were significantly correlated (r =

0.671, p < 0.0001) but neither left nor right Q angle was correlated with any of the muscle

measures (passive or contracted thickness, or muscle activation) for either side. There were

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no differences between the control and PFPS groups in terms of participation in any of the

selected activities. All but two participants in each group walked at least once per week ( =

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1.083, p = 0.298), and 35% of PFPS participants and 27% of control participants cycled at

least once per week ( = 0.361, p = 0.548). In terms of the activities associated with lower

limb dominance, 35% of PFPS participants and 42% of control participants participated in
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jumping activities at least once per week ( = 0.325, p = 0.569), while only two control

participants played soccer at least once per week ( = 2.080, p = 0.149), and no participant

played tennis more frequently than a few times per month. Only 1 control participant was
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left-hand and left-foot dominant, and 3 participants (1 from control group and 2 from PFPS

group) were left-foot, but right-hand dominant.

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Distribution and reliability of gluteus medius muscle measures

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All ultrasound data were normally distributed (left and right passive muscle thickness: p =

0.553 and p = 0.194, respectively; left and right contracted muscle thickness: p = 0.544 and p

= 0.072, respectively). Measures of passive and active gluteus medius muscle thickness (n =

108 in triplicate) showed good reliability: Cronbach’s alpha = 0.917 and 0.914, respectively;

intraclass correlation coefficient and 95% confidence intervals = 0.914 [0.880 – 0.939] and

0.913 [0.880 – 0.938], respectively. The coefficients of variation for all passive and active

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measures were 22% and 20%, respectively. For at rest and contracted gluteus medius muscle

thickness respectively, SEM = 0.32 mm and 0.39 mm, and MDC95 = 0.9 mm and 1.1 mm;

these are all within close agreement to previously reported measures for gluteus medius

muscle thickness as measured by ultrasound. 15,38

Gluteus medius muscle passive and contracted thicknesses

There was a significant main effect of muscle condition (passive versus contracted) on

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muscle thickness (F1,51 = 180.018, p < 0.0001), but no effects of side or repeat (F1,51 = 0.155,

p = 0.696 and F2,50 = 0.423, p = 0.657, respectively; three-way ANOVA). There was a

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between groups effect on muscle thickness for sex (p = 0.035) but not for clinical status

(control versus PFPS; p = 0.272). When the overall means (three repeats of each of the left

and right sides) for passive and contracted gluteus medius muscle thicknesses were compared,
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males had significantly thicker muscle on contraction than females (37.4 ± 5.5 versus 34.0 ±

6.2 mm, p = 0.040) and there was a trend for males to have thicker passive muscle at rest than

females (28.1 ± 5.1 versus 25.5 ± 4.9 mm, p = 0.064). Left and right side passive and

contracted muscle thickness measures for the control and PFPS groups, including per sex are
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presented in Table 1.
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Gluteus medius muscle activation

Gluteus medius muscle activation was significantly affected by side and repeat (F1,51 = 5.965,
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p = 0.018 and F2,50 = 3.886, p = 0.027, respectively; two-way ANOVA). Activation was

higher on the right side than the left side (p = 0.001) and the third repeat was higher than the

first and second (p = 0.010 and p = 0.014, respectively; post-hoc comparisons with

Bonferroni correction). There were no between groups effects for sex or clinical status (p =

0.987 and 0.521, respectively).

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Side imbalances in muscle measures for control and PFPS groups

Among the control group, there were no significant differences between the left-side and

right-side measures for passive muscle thickness (p = 0.783), contracted muscle thickness (p

= 0.129), or muscle activation (p = 0.306). However, for the PFPS group, each of these

measures was significantly different between the left and right sides: passive muscle

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thickness was significantly smaller on the left side (p = 0.031), while contracted muscle

thickness (p = 0.045) and muscle activation (p < 0.0001) were both significantly larger on the

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left side. Consequently, the PFPS cohort had a significantly larger side imbalance for gluteus

medius muscle activation than the control cohort (Table 1).

PFPS group associations between side of pain, knee pain characteristics and gluteus medius
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muscle activation

Among the PFPS group, 15 participants had left knee pain, 10 participants had right knee

pain and 2 participants had pain in both knees. For the 2 participants with bilateral knee
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pain, this was worse on the right side and so they were classified this way for analyses with

respect to the pain side. Excluding or including them in analyses did not affect any of the
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statistical outcomes. In terms of duration of the knee pain, 44% of participants had

experienced knee pain for at least 3 years, 22% for between 1 and 2 years, 15% between 3
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and 6 months, and 19% between 2 weeks and 2 months. There was no significant difference

between the pain and non-pain sides for passive or contracted muscle thickness or muscle

activation; however, there was a significant interaction with the side (left versus right) of the

pain for each of these measures (Table 2). Passive muscle thickness was significantly thinner

on the pain side for those with left-side pain (p = 0.03) but not different between sides for

those with right-side pain (p = 0.46). Contracted muscle thickness was not different between

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sides for those with left-side pain (p = 0.47); however, this was almost significantly thinner

on the pain side for those with right-side pain (p = 0.052). For those who had right-side pain,

gluteus medius muscle activation was significantly less on their pain-side (p = 0.002) while

for those who had left-side pain, gluteus medius muscle activation was significantly greater

on their pain side (p = 0.03). There was no significant influence of pain duration on muscle

activation for the pain-side or the non-pain side. Overall, the only significant influence on

gluteus medius muscle activation among PFPS participants was side, with left side activation

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being significantly higher than right side activation (p < 0.0001; Student’s paired t-test),

regardless of the side of the knee pain.

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Correlations between knee pain scores, quality of life and asymmetry of gluteus medius

muscle activation
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The mean score (visual analogue scale) for current level of knee pain among the PFPS group

was 2.8 ± 1.9 (0 = no pain; 10 = the worst pain imaginable) and for the impact of knee pain

on quality of life was 2.5 ± 2.1 (0 = no impact; 10 = extreme impact). These scores were

significantly correlated (r = 0.582, p = 0.001). The mean total score for questions 1-8 of the
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anterior knee pain scale, pertaining to symptoms relevant to: limp, support, walking, stairs,

squatting, running, jumping, and prolonged sitting with knee flexed, with a possible scores
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ranging from 0 (most impact of knee pain) to 60 (no impact of knee pain), was 49.6 ± 8.9.

This was significantly correlated with the scores for pain (r = -0.598, p = 0.002) and impact
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on quality of life (r = -0.684, p < 0.0001) such that impact of knee pain (lower anterior knee

pain scale score) was associated with pain severity and impact on quality of life (as measured

by the visual analogue scale). Pain score was significantly correlated with the magnitude of

the side imbalance for muscle activation (r = 0.425, p = 0.027) but not with any of left-side or

right-side muscle activation, or side imbalance for gluteal muscle thickness at rest or when

contracted.

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Discussion

Overall, none of gluteus medius muscle thickness at rest or on contraction, or gluteus medius

muscle activation were different between participants with versus without PFPS. Among

those with PFPS, gluteus medius activation was also not different between the pain side and

the non-pain side. However, participants with PFPS had a significantly larger imbalance

between their left and right sides for gluteus medius muscle activation compared with

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controls. Among those with PFPS, their gluteus medius passive muscle thickness was

significantly smaller, but their contracted muscle thickness and muscle activation were

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significantly larger, on the left side than the right side. Further, magnitude of imbalance

between the left versus right side for gluteus medius activation was correlated with knee pain

score. The result of gluteus medius muscle activation being significantly greater on the left

side than the right side for participants with PFPS influenced comparisons of the pain versus
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non-pain side; this may contribute to the inconsistent results in the literature and should be

taken into account for future research. The results also support that quantification of gluteus

medius activation with ultrasound is adequate. This is beneficial in clinical practice because
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of its instant visual feedback, which can be utilised to train an individual’s muscle activation,

and assess contraction during functional movements.

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The most significant finding in the current study was that a left versus right side imbalance of

gluteus medius activation was associated with PFPS presence and pain severity, regardless of
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the side of the knee pain. Those with PFPS had an average left versus right side muscle

activation difference of 15.9 ± 19.3%, significantly greater than those without PFPS. Further,

PFPS pain scores were significantly correlated with asymmetry of gluteus medius activation.

These findings have not been previously reported. However, asymmetries in muscle

measures have been associated with other musculoskeletal pain and/or injuries, including for
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gluteus medius muscle strength with low back pain, hip abduction strength with iliotibial

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 24 39
band syndrome, and erector spinae and hamstring muscle activity with low back pain.

The findings here are clinically relevant and warrant further investigation, particularly

because muscle activation is easily measured using ultrasound, and could be used as an

indicator of PFPS susceptibility or progression.

The finding that gluteus medius activation did not differ between participants with versus

without PFPS is in agreement with previous research that measured this using

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2,9,10
electromyography during treadmill running. Similarly, the lack of difference in gluteus

medius muscle thickness between groups agrees with a recent study that also measured this

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using ultrasound. There is little research in this area and highly variable results across
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studies. Further, as evidenced in the current study, side is a confounding variable and

measuring on just one side may not provide the complete picture. Among the PFPS

participants in the current study, their left-side gluteus medius muscle was significantly
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thinner at rest, but thicker on contraction and consequently showed significantly larger

muscle activation. This can most likely be attributed to an effect of side dominance, since the

only 2 participants who were left-foot dominant did not participate in soccer, tennis or
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jumping activities which would favour the right lower limb to be the stabiliser, and were

right-hand dominant. It is reasonable that the non-dominant, left side has greater gluteus
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medius activation since it is more often the stabilising leg for right-handed individuals.

Whether this general side imbalance predisposes to PFPS requires further investigation,
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particularly with respect to development of pain since this did not correspond specifically to

either the pain-side or non-pain side.

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Females had a significantly greater Q angle compared to males, which was expected.
40
Indeed this may contribute to the higher prevalence of PFPS in females than males.

However, there are inconsistencies in the literature as to whether the Q angle is a reliable

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 29
predictor or consequence of PFPS. In the current study there was no association between

Q angle and gluteus medius activation or presence or severity of patellofemoral pain.

Males did have significantly thicker gluteus medius muscle on contraction and a trend

towards significantly thicker gluteus medius muscle at rest, but there was no difference

between males and females for gluteus medius activation. Many studies have examined

gluteus medius activation with respect to PFPS only among female participants, which

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precludes any gender comparisons. A recent study did report a gender difference in maximal

voluntary isometric contraction, being significantly greater among females than males, and

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significantly reduced among females with PFPS compared with control females. Including

males and females should be taken into consideration in similar research protocols.

There were several limitations to this research. First, since PFPS is both an anatomical and a
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functional problem, it may be more appropriate to measure the Q angle while weight-bearing
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as well as supine. Secondly, the action of gluteus medius that is most relevant to PFPS is

that of preventing the contralateral hip from dropping by contracting the greater trochanter of

the femur towards the ilium. However, this isometric contraction is unable to visualised or
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measured using B mode ultrasound. Participants were asked to externally rotate their femur,

which resulted in an obvious and measurable change in thickness via ultrasound due to this
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being a concentric contraction. It may be more relevant to PFPS to include gluteus medius

activation measures using M mode ultrasound with the participant being required to maintain
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pelvic stability in single stance. In addition, strength evaluation or motion analysis was not

included; considering additional measures such as these in future studies would add important

functional information. Further, assessment of participation in activities that contribute to

asymmetry of gluteus medius muscle activity was limited, and this study lacked a true

matching protocol for the control participants to those in the PFPS group. Lastly, although

analyses were conducted to determine whether duration or severity of PFPS was associated

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with gluteus medius muscle measures, this varied largely across the cohort. A larger and

more homogenous cohort in terms of their PFPS may help to elucidate whether there are

different biomechanical contributors to various presentations of PFPS.

Conclusions

This is the first study to report an association between a side imbalance in gluteus medius

muscle activation and patellofemoral pain syndrome, including with pain severity, among

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males and females. This is clinically relevant with respect to treatment and future prevention

of PFPS. Further, these results demonstrate the importance of including bilateral muscle

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measures and the side of pain in statistical analyses, in research that aims to determine

differences in muscle functionality between the affected and non/less-affected limb in

participants with PFPS, and between PFPS and control participants.

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Acknowledgements

The authors would like to thanks Asmahan Elgellaie for assisting with ultrasound

measurement and data collection, Angela Rodwell for biomechanical advice, Phytness

Phyiotheraphy, and all participants. There was no financial assistance for this project,

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 Table 1. Demographic and anthropometric data and muscle measures for the control and

patellofemoral pain syndrome (PFPS) groups. Values are mean ± standard deviation.

*denotes a significant difference (post-hoc Students unpaired t-tests, p < 0.05) between the

same cohort for control versus PFPS groups.

Control group PFPS group

Cohort Females Males Cohort Females Males
n = 27 n = 17 n = 10 n = 27 n = 16 n = 11

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Measure

Age (years) 27.6 ± 5.6 25.4 ± 2.3 31.4 ± 7.4 30.8 ± 7.9 32.2 ± 9.5* 28.7 ± 4.7

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Height (cm) 171.0 ± 9.9 166.1 ± 7.7 179.4 ± 7.5 173.8 ± 8.2 168.1 ± 3.7 182.0 ± 5.3
Weight (kg) 73.2 ± 19.9 64.4 ± 13.4 88.0 ± 21.0 73.1 ± 12.9 67.2 ± 10.2 81.7 ± 11.8
BMI (kg/m2) 24.8 ± 5.5 23.4 ± 5.3 27.2 ± 5.1 24.1 ± 3.3 23.8 ± 3.4 24.6 ± 3.1
Q angle right
10.6 ± 4.2 11.8 ± 4.3 8.5 ± 3.3 12.2 ± 5.3 13.9 ± 5.5 9.8 ± 4.3
(degrees)
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Q angle left
11.2 ± 5.3 13.0 ± 5.7 8.2 ± 2.6 12.7 ± 6.4 14.3 ± 7.5 10.4 ± 3.8
(degrees)

Muscle
thicknesses
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Right-side passive
27.2 ± 5.8 25.9 ± 5.6 29.5 ± 5.6 26.4 ± 4.6 25.7 ± 4.4 27.3 ± 5.0
(mm)
Right-side
35.3 ± 6.1 33.7 ± 5.8 38.1 ± 5.9 33.6 ± 6.4 33.1 ± 7.2 34.4 ± 5.3
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contracted (mm)
Left-side passive
27.4 ± 5.8 26.0 ± 5.4 29.8 ± 6.0 25.0 ± 4.8 24.3 ± 5.1 26.1 ± 4.3
(mm)
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Left-side
36.6 ± 6.4 35.1 ± 6.7 39.0 ± 5.4 35.8 ± 7.2 33.9 ± 7.0 38.4 ± 6.9
contracted (mm)

Muscle activation

Right-side (%) 32.2 ± 15.7 32.8 ± 18.7 31.2 ± 9.2 29.3 ± 16.6 30.0 ± 18.1 28.1 ± 14.9
Left-side (%) 36.6 ± 20.8 38.0 ± 22.2 34.2 ± 19.0 45.1 ± 21.4 42.3 ± 22.7 49.2 ± 19.8

Difference left-
right

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Passive thickness 0.18 ± 3.3 0.05 ± 3.6 0.38 ± 2.9 -1.3 ± 3.1 -1.4 ± 2.6 -1.2 ± 3.7
(mm)
Active thickness 1.2 ± 4.1 1.4 ± 4.2 0.93 ± 4.1 2.1 ± 5.2 0.78 ± 5.2 4.0 ± 4.6
(mm)
Activation (%) 4.4 ± 21.9 5.2 ± 23.4 3.0 ± 20.3 15.9 ± 19.3* 12.3 ± 16.1 21.1 ± 23.0

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 Table 2. Muscle measures for the patellofemoral pain syndrome (PFPS) group and based on left-side versus right-side pain. Values are
mean ± standard deviation. † Output from one-way ANOVA with repeated measures and between-groups analysis of pain side (left versus
right): main effects of pain versus non-pain, and interactions between pain and side (left versus right).

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PFPS group (n = 27) Left-side pain (n = 15) Right-side pain (n = 12) Pain† Pain * Side†
Pain side Non-pain Pain side Non-pain Pain side Non-pain F1,25 p F1,25 p
Passive muscle
25.3 ± 4.6 26.1 ± 4.9 24.8 ± 4.5 26.7 ± 4.5 25.9 ± 5.0 25.3 ± 5.4 0.980 0.332 4.635 0.041
thickness (mm)
Active muscle
34.1 ± 6.5 35.3 ± 7.2 34.7 ± 6.4 33.8 ± 6.3 33.4 ± 6.9 37.0 ± 8.2 1.957 0.174 5.232 0.031

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thickness (mm)
Muscle
36.8 ± 19.9 37.6 ± 21.7 41.6 ± 19.5 28.1 ± 14.6 30.7 ± 19.4 49.6 ± 23.7 0.453 0.856 18.445 < 0.0001
activation (%)

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