Received: 6 January 2021 Revised: 30 May 2021 Accepted: 11 June 2021

DOI: 10.1002/pmrj.12655

ORIGINAL RESEARCH

Effect of static knee joint flexion on vastus medialis

obliquus fiber angle in patellofemoral pain syndrome: An
ultrasonographic study

an MD |
Ali Dog _Ilker Şengül MD | Ayhan Aşkın MD | Aliye Tosun MD

Department of Physical Medicine and Abstract

Rehabilitation, _Izmir Katip Çelebi University,
Atatürk Training and Research Hospital, _Izmir,
Turkey
Correspondence
_Ilker Şengül, Department of Physical Medicine
and Rehabilitation, _Izmir Katip Çelebi
University, School of Medicine, Basın Sitesi
Mahallesi Gazeteci Hasan Tahsin Caddesi,
35150, _Izmir, Turkey.
Email: ilkrsngl@gmail.com
Introduction: In patients with patellofemoral pain syndrome, the vastus medialis
obliquus muscle fiber angle measured by ultrasound at knee extension was found
to be different from that in healthy individuals. An important feature of
patellofemoral pain syndrome is the increase in pain severity during activities that
require knee flexion.
Objective: To investigate whether there was an ultrasonographic change in
the vastus medialis obliquus fiber angle by flexing the knee joint in patients with
patellofemoral pain syndrome compared to healthy pain-free individuals.
Design: A cross-sectional clinical study.
Setting: An outpatient clinic of a tertiary care hospital.
Participants: Forty-seven patients with patellofemoral pain syndrome (median
age of 40 years) and 43 healthy volunteers (median age of 39 years) were
included in the study.
Interventions: No intervention.
Main Outcome Measures: Vastus medialis obliquus fiber angle measured by
ultrasonography at three different positions of knee joint including extension,
30 of flexion, and 45 of flexion.
Results: There was no significant change in the vastus medialis obliquus fiber
angle with knee flexion in both groups (p > .05 for each group). However, the
median vastus medialis obliquus fiber angle values in the group with
patellofemoral pain syndrome were significantly lower at all knee joint angles
than those in the comparison group (p < .05 at all knee joint angles).
Conclusions: Although the vastus medialis obliquus fiber angle does not
change with static knee flexion, the lower angle of the vastus medialis obliquus
fiber in those with patellofemoral pain syndrome implicitly suggests that vastus
medialis obliquus dysfunction may exist.

KEYWORDS
fiber angle, patellofemoral pain syndrome, ultrasonography, vastus medialis obliquus muscle

INTRODUCTION For a smooth and gentle patellar movement

Patellofemoral pain syndrome (PFPS) is defined as the
presence of peripatellar or retropatellar pain in at least
one of the activities including squatting, stair ambulation,
jogging/running, and hopping/jumping.1 Major risk fac-
tors for the development of PFPS are female sex,
overuse of the patellofemoral joint, failure of the extensor
mechanism, and lower extremity malalignments, as well
as activities that put a load on the patellofemoral joint.2,3
throughout the range of motion of the knee, the forces
acting on the patella must be balanced. In this context,
stabilization of the patella is provided by static and
dynamic elements. Although bony structures and liga-
ments provide static stabilization, vasti muscles (vastus
lateralis and medialis) provide dynamic stabilization.4
The lower part of the vastus medialis, the vastus
medialis obliquus (VMO), is the primary muscle respon-
sible for dynamic medial stabilization of the patella.5

PM&R: The Journal of Injury, Function and Rehabilitation. 2021;1–9. http://www. © 2021 American Academy of Physical Medicine and Rehabilitation. 1
pmrjournal.org
2 EFFECT OF KNEE FLEXION ON VMO FIBER ANGLE
The decrease in VMO muscle strength, delay in firing
pattern, or failure to balance the vastus lateralis may
cause a decrease in medial patellar stability, asymme-
try of biomechanical forces acting on the patella, and
ultimately a lateral shift of the patella.6,7 Consequently,
impaired dynamic medial stabilization may be related to
the development of patellofemoral pain. Therefore,
quadriceps strengthening exercise in general or selec-
tive VMO strengthening exercise is often recommended
in the management of the PFPS.8 However, there has
been no definitive evidence to explain the causal rela-
tionship between VMO weakness or insufficiency and
PFPS.9-16 Apart from the static and dynamic stabilizers
of the patella, the effect of adjacent limb segments on
patellar movement is of importance.17 For a proper
patellar movement, the hip and ankle-foot complex
should also be neuroanatomically and biomechanically
sufficient. Theoretically, pronation deformity in the sub-
talar joint or disturbance in the pronation-supination
cycle of the talus during walking may impair patellar
tracking.18 However, the causal relationship between
subtalar joint disorder and patellar maltracking has not
been fully revealed.19 Proximally, hip disorders may
also be associated with PFPS. Retrospective studies
have reported a relationship between hip abduction,
extension, and external rotation insufficiency and
PFPS.20,21 On the other hand, a causal relationship
has not been found between hip weakness and PFPS
in prospective studies.22
Ultrasonography can provide valuable information
about soft tissues around the patellofemoral joint, includ-
ing VMO. VMO features that can be evaluated with ultra-
sound include fiber orientation angle, pennation angle,
level of attachment to the patella, cross-sectional area,
and muscle volume.23 Of these features, the VMO fiber
angle (or fiber orientation angle) is defined as the angle
between the direction of the VMO fibers and the direc-
tion of the femoral axis.24 In patients with patellofemoral
pain, ultrasonographic differences assessed at the
extension of the knee joint have been reported in both
the insertion level and the VMO fiber angle compared to
individuals with a painless healthy knee.24 An important
feature of PFPS is the increase in pain severity during
activities that require knee flexion.1 We hypothesize that
if the medial patellar stabilizers including VMO are defi-
cient, there will be a change in the VMO fiber angle with
knee flexion as a result of the lateral shift of the patella.
This study aimed to investigate whether the VMO fiber
angle changes ultrasonographically with knee flexion
compared to the extension position in PFPS.
METHODS
This study is a non-randomized and non-blinded,
cross-sectional clinical study with a comparison group.
The study was carried out between January 2020 and
August 2020 in the physical medicine and rehabilitation
outpatient clinic of a university hospital after obtaining
ethics committee approval. All participants provided
written informed consent to participate in the study.
Participants
Study candidates were patients between 18 and
50 years of age who had been diagnosed with PFPS
and healthy individuals without knee pain (controls).
Patients who agreed to participate in the study were
re-evaluated with history taking and physical examina-
tion to confirm the diagnosis of PFPS. Individuals who
were sensitive to palpation in the medial and/or lateral
patellar facet with positive patellar grinding or appre-
hension test in addition to peripatellar and/or retro-
patellar pain in at least two activities including
squatting, stair ascent and descent, running and
jumping, were diagnosed as PFPS.25,26 If imaging
modalities including plain radiography and/or mag-
netic resonance imaging had been performed for the
knee region, these images were re-examined in terms
of differential diagnosis. Participants in the compari-
son group were selected based on the age and sex
distribution of patients who were already enrolled. Vol-
unteers who participated in light or moderate physical
activity at their job or recreation based on the Tegner
Activity Scale27 were included in the study. Exclusion
criteria were a history of trauma, pain related to other
knee structures outside the patellofemoral joint, his-
tory of patellar dislocation or subluxation, passive
motion restriction in the knee joint, osteoarthritis of the
patellofemoral joint or tibiofemoral joint based on knee
images if performed, and presence of any inflamma-
tory rheumatic disease. The presence of any neuro-
logical disease affecting the extremities, suspicion of
referred pain, physical activity levels of 0 to 2 and 6 to
10,27 malalignment, and/or limitation of motion in the
hip, ankle, and foot were other exclusion criteria.
Lower extremity malalignments including leg length
discrepancy, femoral and tibial rotational deformities,
genu varum and valgus, genu recurvatum, quadriceps
angle, and rearfoot angle were assessed clinically
based on the measurement techniques defined in the
literature.28,29 A difference of 1 cm or more between
the two lower extremities was considered abnormal in
the true leg length measurement.30 To accept the
measurement as normal or abnormal for other
malalignment measurements, the upper values
according to gender were accepted as the threshold
values.29 The range of motion of the lower extremity
joints was measured bilaterally using a standard
goniometer in accordance with measurement
techniques.31
DOĞAN ET AL. 3

Demographic and clinical characteristics
Characteristics of the participants including age, gen-
der, body mass index (BMI), side of self-reported leg
dominance, level of physical activity, and symptom
duration in patients with PFPS were recorded.
Sonographic measurements of VMO
fiber angle
The ultrasonographic measurement of the VMO fiber
angle was performed using the method described in
the study of Lin et al32 with the Philips HD
15 Purewave USG device (USA) (5-12 MHz electronic
real-time linear-array transducer probe). A standard
0 to 180 plastic manual goniometer was used to
determine the knee flexion angles (for 30 and 45 ).
The stationary arm was placed on the femoral axis
between the center of the greater trochanter and the
lateral epicondyle of the femur, and the movable arm
was placed on the axis of the tibia between the lateral
femoral epicondyle and the center of the lateral
malleolus.33 An assistant helped to keep the knee
flexion position of 30 and 45 to prevent the distortion
of the flexion position during ultrasonographic mea-
surements. The assistant tried to prevent the distor-
tion of the knee angle by fixing the ankle in the neutral
position while the heel was in contact with the
examination table. The participants were also
instructed not to move their hips.
VMO fiber angle relative to the femoral axis was
measured with the subject in the supine position for
three knee joint positions; extension (0 ) and 30 and
45 of flexion. The femoral axis was determined as the
linear line between the anterior superior iliac spine
(ASIS) and the center of the patella. The center of the
patella was re-identified in each of the knee joint posi-
tions. The center of the patella was determined as the
intersection of the mediolateral line extending across
the widest part of the patella and the vertical line con-
necting the base and top of the patella.34 The ASIS
was then identified by palpation and then marked with
a pen. Subsequently, the axis line was determined by
pulling straight an undeformed tape measure from
ASIS to the center of the patella with the help of
another assistant. Then, while the assistant was keep-
ing the tape measure tight, a 20-cm line was drawn
from the center of the patella towards proximal with the
help of a standard flexible plastic ruler placed on the
tape. After the determination of the femoral axis, the
ultrasound probe was placed in the transverse position
just proximal to the upper end of the patella and gradu-
ally moved medially to the point where the VMO was
visible on the ultrasound device monitor. The ultra-
sound probe was then moved slightly distal within the
insertion level of the VMO to the patella. Within
the upper and lower levels of insertion, the ultrasound

F I G U R E 1 The ultrasonographic measurement of the vastus medialis obliquus (VMO) fiber angle. VMO fiber angle was determined by
measuring the angle between the line representing the femoral axis and the probe long axis when the VMO muscle fibers appear almost parallel
to each other on the ultrasound screen. The femoral axis was determined as the linear line between the anterior superior iliac spine and the
center of the patella. The center of the patella was determined as the intersection of the mediolateral line extending across the widest part of the
patella and the vertical line connecting the base and top of the patella. This figure shows the measurement method in the extension position of
the left knee. The direction of the VMO fibers relative to the femoral axis was measured with the subject in the supine position for three knee joint
positions; extension (0 ) and 30 and 45 of flexion. Note the parallel positioning of the VMO muscle fibers when the knee joint was at
extension. L, lateral; M, medial
4 EFFECT OF KNEE FLEXION ON VMO FIBER ANGLE
probe was rotated to find the position where the mus-
cle fibers were almost parallel to each other on the
monitor (Figures 1–3). A sufficient amount of gel was
used under the ultrasound probe to avoid erroneous
measurements. Too much pressure was not applied to
the skin so that the probe did not disrupt the muscle
fibers. The direction of the probe was considered to be
the direction of the VMO fibers. The probe was held in
this position and after leaving marks on both ends of
the probe with a pen, a line was drawn passing
through these marks. The angle between the femoral
axis and probe axis measured with a standard 0 to
180 flexible goniometer was accepted as the VMO
fiber angle. All measurements, including ultrasono-
graphic measurements, were performed by the same
researcher.
F I G U R E 2 The parallel
positioning of the vastus medialis
obliquus (VMO) muscle fibers
when the right knee joint was at
30 of flexion. Unlike the
ultrasonographic VMO fiber angle
measurement at extension, a
bending of the fibers is observed
as they approached the patella
with knee flexion. However, the
parallelism between the VMO
fibers does not deteriorate.
L, lateral; M, medial
F I G U R E 3 The parallel
positioning of the vastus medialis
obliquus muscle fibers when the
right knee joint was at 45 of
flexion. The bending of the fibers
is also observed as they
approached the patella at 45 of
flexion with preserved
parallelism. L, lateral; M, medial
Sample size
The VMO fiber angle values reported in the study of Jan
et al were used to calculate the sample size.18 Accord-
ingly, it was calculated that at least 38 participants in each
group should be included in the study to detect a signifi-
cant difference between the two groups based on a 0.66
effect size with 20% type II and 5% type I errors. The
sample size was calculated using the G * Power software
program (version 3.1.9.4, Germany).
Reliability study
The reliability analysis was conducted by calculating
the intra-class correlation coefficient (ICC) using the
DOĞAN ET AL.
test-retest method. VMO fiber angles of nine healthy
volunteers were measured with 1-day intervals at three
knee joint angles (0 , and 30 , and 45 ). In addition to
the random order of volunteers, knee joint angles were
also randomly selected. A total of 81 VMO fiber angle
measurements were performed for nine volunteers.
The ICC was calculated separately for the VMO fiber
angle at each knee joint angle.
Statistical analysis
The MedCalc statistical package program (MedCalc
Software Ltd, Ostend, Belgium version 19.4.0) was
used for analyses including reliability. A chi-square
test was used for the comparison of categorical vari-
ables. Although the t-test was used in the comparison
of normally distributed numerical variables (excluding
VMO fiber angle) between the groups, the Mann-
Whitney U test was used for the comparison of non-
normally distributed numerical variables (excluding
VMO fiber angle). The mixed analysis of variance
(ANOVA), which was planned to determine whether
the changes in the VMO fiber angle with knee flexion
differ according to the groups, could not be per-
formed because the assumptions were not met.
Instead, the Friedman test was used for within-group
comparisons, and the t-test or Mann-Whitney U test
was used for between-group comparisons. The sta-
tistical significance level was determined as .05 and
below.
RESULTS
Characteristics of participants
Ninety-seven participants (51 with the diagnosis of
PFPS and 46 healthy individuals) were assessed for
the final eligibility. Although plain radiography of the
knee had been requested in 42 of 51 patients, no
patient had undergone magnetic resonance imaging.
Four subjects with the diagnosis of PFPS were
excluded, one with an irregularity on the posterior sur-
face of the patella on the lateral plain radiograph of the
knee, one with leg length discrepancy of 1.5 cm, one
with bilateral genu valgus, and one with calcaneal val-
gus. Three healthy pain-free individuals who did not
want to participate in the study were excluded from
the study. Consequently, a total of 90 participants
(67 female and 23 male), with a median (interquartile
range [IQR]) age of 39.5 (30.8 to 44.0) years were
included in the study. Forty-seven of these 90 partici-
pants were in the PFPS group, and 43 were in the
control group. The ratio of women in the PFPS group
and control group was 76.5% and 72.1%, respectively.
The proportion of participants with a light level of
5
physical activity was higher in both groups. Groups
were comparable in terms of age, sex, BMI, level of
physical activity, and side of self-reported leg domi-
nance. In the PFPS group, the most affected knee, or
in the case of bilateral involvement the more painful
knee, was the right knee. The median (IQR) duration
of symptoms in the PFPS group was 12 (4 to 24)
months. The characteristics of the participants are dis-
played in Table 1.
Reliability
The ICC for VMO fiber angles at full extension, and 30
and 45 of knee flexion, was found to be excellent as
0.925, 0.980, and 0.974, respectively.
VMO fiber angle
Unlike the ultrasonographic VMO fiber angle measure-
ment at extension (Figure 1), a bending of the fibers
was observed as they approached the patella with knee
flexion (Figures 2 and 3). However, the parallelism
between the VMO fibers did not deteriorate.
The median (IQR) VMO fiber angles were 52 (49 to 53)
degrees, 52 (50 to 55) degrees, and 52 (52 to 54)
degrees at extension, 30 of knee flexion, and 45 of
knee flexion, respectively, in the PFPS group. In the
comparison group, the median (IQR) MVO fiber angle
values were 58 (57 to 60) degrees, 59 (57 to 61)
degrees, and 58 (57 to 61) degrees at given sequential
knee positions, respectively. The VMO fiber angle did
not change significantly with knee flexion in both the
PFPS group and the control group (p = .10, p = .79,
respectively). However, the median VMO fiber angle of
the PFPS group at all knee angles was significantly
lower than the control group (p < .001 at full extension,
p < .001 at 30 flexion, and p < .001 at 45 flexion)
(Table 2 and Figure 4). Changes in the VMO fiber angle
with knee flexion were also comparable (Table 3 and
Figure 4).
DISCUSSION
This study aimed to investigate whether the VMO fiber
angle changes with knee flexion in patients with PFPS
compared to healthy controls. The results of the study
showed that the VMO fiber angle did not change with
knee flexion in both groups, but the VMO fiber angle
was lower in the PFPS group compared to healthy
knees at all knee joint flexion angles as well as at
extension.
The VMO acts as the primary medial dynamic stabi-
lizer of the patella.35 Its insufficiency may cause an
imbalance between the lateral forces produced by the
6 EFFECT OF KNEE FLEXION ON VMO FIBER ANGLE

TABLE 1 Demographic and clinical characteristics of the participants according to the study groups

PFPS group Comparison

(n = 47) group (n = 43) p

Age, year, median (IQR) 40 (32 to 43) 39 (29 to 44) .974

Sex, n (%) .805
Female 36 (76.5) 31 (72.1)
Male 11 (23.4) 12 (27.9)
BMI, kg/m 2
26.2  4.2 24.7  4.0 .094
Level of physical activity, n (%) >.99
Light 32 (68.1) 29 (67.4)
Moderate 15 (31.9) 14 (32.6)
Dominant extremity, n (%) >.99
Right 45 (95.7) 42 (97.7)
Side of affected kneea - -
Right 39 (83)
Left 8 (17)
Symptom duration, month, median (IQR) 12 (4 to 24) - -
Abbreviations: BMI, body mass index; IQR, interquartile range; PFPS, patellofemoral pain syndrome; Q angle, quadriceps angle.
a
In the case of bilateral patellofemoral pain, the most painful knee was included in the analysis.

TABLE 2 Fiber angle values of the vastus medialis obliquus according to the knee flexion angles (degree)

0 (extension) 30 45 pa

PFPS group (n = 47) 52 (49 to 53) 52 (50 to 55) 52 (52 to 54) .099
Comparison group (n = 43) 58 (57 to 60) 59 (57 to 61) 58 (57 to 61) .793
pb <.001 <.001 <.001
Note: Fiber angle values of the vastus medialis obliquus values are demonstrated as median (interquartile range).
Abbreviation: PFPS, patellofemoral pain syndrome.
a
Significance level according to the Friedman test.
b
Significance level according to the Mann-Whitney U test.

vastus lateralis, and as a result, patellofemoral joint
problems and anterior knee pain may develop.35 It has
been reported that, in individuals with PFPS, VMO
fibers insert onto the patella at a smaller angle, which
may negatively affect the medial stabilization of the
patella.24,32 As opposed to the studies of Lin et al32 and
Jan et al,24 the VMO fiber angle was measured at the
knee joint flexion angles of 30 and 45 , with the
relaxed quadriceps in addition to the measurement at
extension. The aim of measuring the VMO fiber angle
in different flexion angles of the knee joint was to
understand whether there would be a change in the
VMO fiber angle due to the patellar tracking as the
knee flexed. In theory, if there is an impairment in
patellar tracking during knee flexion, a deviation in the
angle between the direction of VMO fibers and the
femoral axis can be expected. In accordance with the
literature,24,32 the VMO fiber angle was significantly
lower in patients with PFPS compared to healthy
knees at the extension of the knee joint. VMO fiber
angle was also significantly lower in patients with
PFPS compared to healthy knees at 30 and 45 of
knee joint flexion. However, contrary to our
hypothesis, there was no significant change in the
angle of the VMO fibers with knee flexion in PFPS
patients. In addition, the VMO fiber angle did not
change significantly with knee flexion in healthy knees
either. Because VMO activity is more pronounced dur-
ing weight transfer and muscle activation,36 the
expected change in the VMO fiber angle might not
have occurred due to the lack of VMO contraction.
However, the significance of a smaller angle in
patients with PFPS remains unclear. It may be possi-
ble to consider that firing of the VMO with a baseline
smaller patellar attachment angle negatively affects
medial stabilization and may result in patellofemoral
pain development. In addition, whether the VMO fiber
angle does change with active knee flexion or with
VMO contraction is controversial. Gallina et al37 have
reported that the VMO fiber angle did not change with
dynamic knee flexion in healthy individuals. On the
other hand, as far as we know, alteration in the VMO
fiber angle with dynamic knee flexion and/or extension
in patients with PFPS has not been studied. Although
the PFPS is a dynamic disorder, static measurements
may have a predictive value. It is known that VMO and
DOĞAN ET AL. 7

F I G U R E 4 The plot of the

changes in the vastus medialis
obliquus fiber angles with knee
flexion. The fiber angle values of
the vastus medialis obliquus are
demonstrated as the median.
Error bars indicate the 25% and
75% percentiles. VMO, vastus
medialis obliquus; PFPS,
patellofemoral pain syndrome

T A B L E 3 Comparison of the change values in the fiber angle of change in the VMO fiber angle did not emerge.
the vastus medialis obliquus with knee flexion (degree) Indeed, fiber angle and direction of action may not be
PFPS group Comparison the same as in pennate muscles.42 Gallina et al37
(n = 47) group (n = 43) pa have reported that the attachment angle of VMO fiber
to the central aponeurosis (pennation angle) changes
0 –30 1 ( 2 to 2) 1 ( 2 to 2) .440
with dynamic knee flexion. Thus a dynamically mea-
0 –45 1 ( 2 to 1) 0.5 ( 1 to 1) .265
sured pennation angle in PFPS may provide more
 
30 –45 0 ( 2 to 2) 0 ( 2 to 1) .839 valuable information in this regard. However, the pen-
Note: Fiber angle values of the vastus medialis obliquus values are nation angle was not both statically and dynamically
demonstrated as median (interquartile range). evaluated in this study.
Abbreviation: PFPS, patellofemoral pain syndrome.
a
Significance level according to the Mann-Whitney U test.

medial patellofemoral ligament (MPFL) fibers are inter-
twined.38,39 The MPFL also contributes to the dynamic
stabilization of the patella thanks to this relationship.40
Conversely, due to this relationship, the VMO may
contribute to the static stabilization function of MPFL,
especially during knee flexion. Because the VMO
communicates with the medial patellofemoral complex
through its tendon fibers and fascia,41 it is likely to
contribute to a more controlled lateral and inferior
movement of the patella during passive or active knee
flexion. However, this hypothesis needs to be studied.
Another point in our study was that the parallelism of
VMO fibers close to the patella was preserved with
knee flexion, but linearity was not. Ignoring the change
in the linearity of fibers close to the patella with knee
flexion could be one of the reasons that the expected
LIMITATIONS
Our study has several limitations. First, the ultrasono-
graphic examination is dependent on the person who
performs it. The fact that the researcher performing the
ultrasonographic evaluation was not blinded might
have created a bias. Although the VMO fiber angle was
measured at different knee flexion angles, the mea-
surements were static. The results of measurements
performed during the contraction of the muscle could
have been different. Measuring the VMO angle manu-
ally might also have caused errors. The non-exclusion
of other potential etiological and confounding factors
such as the anatomical shape of the femoral trochlea,
femoral rotation, medial-lateral patellar retinaculum,
and quadriceps tension was also a limiting factor. We
could not completely exclude the effect of the hip and
8 EFFECT OF KNEE FLEXION ON VMO FIBER ANGLE
ankle-foot disorders or dysfunctions on patellar move-
ment. To minimize the effect of biomechanical forces
related to hip and ankle-foot complex on patellar track-
ing, participants with neurological and orthopedic disor-
ders affecting the hip and ankle-foot complex were
excluded from the study. In addition, the fact that the
muscles around the hip, ankle, and foot were not in
active contraction during the measurements made the
biomechanical forces arising from these joints to be
minimal. Nevertheless, passive flexion of the hip due to
passive knee flexion may have affected the patellar
movement. In addition, the presence of asymptomatic
patellar maltracking may have confounded the data of
the comparison group. Finally, although we consider
that ultrasonographic examination of the non-dominant
side (mostly the left knee) in healthy subjects may be
an advantage as it is less likely to be exposed to
microtrauma, this issue may be considered by others
as a limitation or a methodological problem.
CONCLUSION
The results of this study suggest that a structural
characteristic of the VMO, fiber angle, may be related
to patellofemoral pain. However, the difference
between PFPS and healthy knees in terms of the
VMO fiber angle does not indicate a causal relation-
ship. Studies in which the VMO fiber angle and pen-
nation angle are measured dynamically during active
knee flexion may provide more useful information to
understand the role of the VMO in PFPS
etiopathogenesis. Future research focusing on the
combination of ultrasonographic and electrophysio-
logic studies may contribute more to the understand-
ing of the structure-function relationship.
DISCLOSURES
All authors declare that they have no disclosures or
conflicts of interest.
ETHICAL APPROVAL
This study has been approved by the _Izmir Katip Çelebi
University Non-Interventional Clinical Studies Institu-
tional Review Board (approval number: 08 August
2019/308).
ORCID
_
Ilker Şengül https://orcid.org/0000-0002-7675-7814
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How to cite this article: Dog
an A, Şengül _I,
Aşkın A, Tosun A. Effect of static knee joint
flexion on vastus medialis obliquus fiber angle in
patellofemoral pain syndrome: An
ultrasonographic study. PM&R: The Journal of
Injury, Function and Rehabilitation. 2021;1-9.
https://doi.org/10.1002/pmrj.12655