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research report

AMIR CURCIO DOS REIS, PT, MS1 JOO CARLOS FERRARI CORREA, PT, PhD1 ANDR SERRA BLEY, PT, MS1
NAYRA DEISE DOS ANJOS RABELO, PT, MS1 THIAGO YUKIO FUKUDA, PT, PhD2 PAULO ROBERTO GARCIA LUCARELI, PT, PhD1

Kinematic and Kinetic Analysis of the

Single-Leg Triple Hop Test in Women
With and Without Patellofemoral Pain

drop during single-leg activities,

iomechanical abnormalities of the lower extremities
shifting the center of mass medihave been associated with a number of ankle, knee,
ally away from the stance limb
5,23,35,37,42,44
hip, and lumbopelvic injuries.
Women with SUPPLEMENTAL
VIDEO ONLINE
and leading to a knee external
patellofemoral pain (PFP) commonly exhibit a medial
varus moment.
collapse of the knee, also called dynamic valgus.34,41 This
A number of kinematic and kinetic
dynamic valgus is characterized by a combination of excessive hip studies have described poor hip alignadduction and internal rotation and knee valgus during weight-bearing ment, often associated with excessive
activities, such as ascending and descending stairs, running, or jumping.6,40,50
Mechanically, this misalignment decreases patellofemoral joint contact area,
TTSTUDY DESIGN: Cross-sectional study.

TTOBJECTIVES: To compare the biomechanical

strategies of the trunk and lower extremity during

the transition period between the first and second
hop of a single-leg triple hop test in women with
and without patellofemoral pain (PFP).

TTBACKGROUND: Recent literature has shown

that PFP is associated with biomechanical

impairments of the lower extremities. A number
of studies have analyzed the position of the trunk
and lower extremities for functional activities such
as walking, squatting, jumping, and the step-down
test. However, studies on more challenging activities, such as the single-leg triple hop test, may be
more representative of sports requiring jumping
movements.

TTMETHODS: Women between 18 and 35 years

of age (control group, n = 20; PFP group, n =

20) participated in the study. Three-dimensional
kinematic and kinetic data were collected during
the transition period between the first and second

leading to increased articular stress and

potentially PFP.41,45 However, Powers39
theorized that hip abductor weakness can
alternately cause a contralateral pelvic
hops while participants performed the single-leg
triple hop test.

TTRESULTS: Compared to the control group,

women with PFP exhibited greater (P<.05) anterior

and ipsilateral trunk lean, contralateral pelvic drop,
hip internal rotation and adduction, and ankle
eversion, while exhibiting less hip and knee flexion.
A significant difference (P<.05) in time to peak
joint angle was also found between groups for
all the variables analyzed, except anterior pelvic
tilt and hip flexion. In addition, women with PFP
exhibited greater (P<.05) hip and knee abductor
internal moments.

TTCONCLUSION: Compared to the control group,

women with PFP exhibited altered trunk, pelvis,
hip, knee, and ankle kinematics and kinetics.
J Orthop Sports Phys Ther 2015;45(10):799-807.
Epub 24 Aug 2015. doi:10.2519/jospt.2015.5011

TTKEY WORDS: anterior knee pain, biomechanics,

hip, patella

trunk lean in the frontal plane, as well as

altered knee and hip internal moments
during low-impact activities in women
with PFP.10,15,33,39 But few data exist on
high-impact activities, which may add
important information, such as the timing and sequencing in which peak angles
of movement occur. The single-leg triple
hop test (SLTHT), which includes landing and propulsion phases, is widely used
in clinical practice to assess the dynamic
stability of the knee. A number of authors
have suggested that the hop test may be
an important tool in identifying individuals who are at risk for knee injuries and
to quantify improvements during the rehabilitation of individuals with PFP and
those recovering from anterior cruciate
ligament reconstruction.17,19,20,29
The aim of the present study was to
compare selected kinematics and kinetics of the trunk and lower extremities
of women with and without PFP during
the transition period between the first
and second hops of the SLTHT. We also
aimed to describe the time to peak joint

Department of Rehabilitation Science, Human Motion Analysis Laboratory, Universidade Nove de Julho, So Paulo, Brazil, 2Instituto Trata - Knee and Hip Rehab, So Paulo,
Brazil. The protocol for this study was approved by the Universidade Nove de Julho Human Research Ethics Committee. This study was supported in part by grant 2012/089095 from the So Paulo Research Foundation. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the article. Address correspondence to Dr Paulo Roberto Garcia Lucareli, Universidade Nove de Julho, Rua Vergueiro 235,
So Paulo, SP, Brazil. E-mail: plucareli@hotmail.com; paulolucareli@uninove.br t Copyright 2015 Journal of Orthopaedic & Sports Physical Therapy
1

journal of orthopaedic & sports physical therapy | volume 45 | number 10 | october 2015 | 799

[
angle in both groups during this task.
We hypothesized that, compared to the
control group, women with PFP would
exhibit greater ipsilateral trunk lean, contralateral pelvic drop, and hip adduction
and internal rotation, as well as different timing and sequencing of peak joint
angles. We also hypothesized that those
with PFP would have higher hip and knee
abductor internal moments.

METHODS
Participants

his cross-sectional study included 20 women with PFP (PFP

group) and 20 age-matched painfree women (control group). All volunteers were informed about the study
procedures and signed informed consent in accordance with the Brazilian
National Health Council Resolution
Number 196/96. The protocol for this
study was approved by the Universidade
Nove de Julho Human Research Ethics
Committee.
The sample size was calculated a priori, based on peak knee flexion angle reported in a previous study, which showed
that maximal amplitudes of movement in
the sagittal plane were related to changes
in knee valgus kinetic and kinematic values.35 Calculations were performed using
= .05, = .10 (90% power), and a mean
between-group difference of 11 for knee
flexion, assuming a standard deviation of
10. Based on these parameters, 17 participants per group were required to adequately power the study for this variable
of interest.
All women in the study were between
18 and 35 years of age (TABLE 1), the age
range within which women commonly
have PFP.3,21,30 Women with PFP were
included if they had anterior knee pain
for at least 3 months and reported increased pain for 2 or more activities that
commonly provoke PFP, as outlined by
Thome et al.48 These activities included
ascending and descending stairs, squatting, kneeling, jumping, long periods of
sitting, resisted isometric knee extension

research report
TABLE 1

Demographic Data
Control (n = 20)*

PFP (n = 20)*

Age, y

23.1 3.3

23.5 2.1

Body mass, kg

55.9 7.1

55.3 4.8

Height, m

1.65 0.12

1.71 0.13

BMI, kg/m2

21.3 2.7

20.2 1.8

VAS (0-10)

...

4.9 1.6

Abbreviations: BMI, body mass index; PFP, patellofemoral pain; VAS, visual analog scale.
*Values are mean SD.

Zero is no pain and 10 is the worst imaginable pain. The score is for the average pain intensity
experienced during the last 2 weeks.

at 60 of knee flexion, and pain on palpation of the medial and/or lateral facet of
the patella.
The women in the PFP group were
recruited from an outpatient rehabilitation program by a physical therapist with
more than 10 years of clinical experience
in knee rehabilitation. Women of similar
demographic characteristics, who came
to the clinic for treatment of upper extremity tendinopathies and did not have
lower extremity involvement, were recruited from the same clinic at the time
of discharge to serve as the control group.
All participants were considered to be
physically active, based on their weekly
engagement in physical activity.6
Potential participants were excluded
if they exhibited any of the following:
neurological disorder; injury to the hip,
ankle, or lumbosacral region; rheumatoid arthritis; heart condition; previous
surgery involving the lower extremities;
or pregnancy. Women who had other
knee pathologies, such as patellar instability, patellofemoral dysplasia, meniscal
or ligament tears, osteoarthritis, or tendinopathies, were also excluded, as were
those who exhibited a leg-length difference of more than 1 cm, when measured
in supine, from the anterior superior iliac
spine to the medial malleolus.

Procedures
Individuals who met the inclusion and
exclusion criteria and were willing to participate were scheduled for testing in the

movement-analysis laboratory. Women

who were symptomatic were first asked
about the length of time they had experienced symptoms and the intensity of their
pain, using a visual analog scale.12,13 Anthropometric assessment was subsequently performed and included measurements
of body mass, height, distance between
anterior superior iliac spines, leg length,
knee and ankle width, and tibial torsion.15
The volunteers walked on a treadmill for 10 minutes at a speed of 2 m/s.
After this warm-up, they familiarized
themselves with the SLTHT until they
felt comfortable with the activity. During
these practice hops, the distance reached
with the first hop was measured, and
this distance was used to determine the
starting location of the participants so
that they would land in the center of the
concealed force platform when performing the subsequent SLTHT.
Consistent with the conventional gait
model,14,25 which has been used to assess
hop tasks in the literature,26-28,51-53 23 reflective spherical markers were placed
on the participants in the following locations: on the 2 anterior and posterior
superior iliac spines, over the center of
the patella, on the lateral femoral epicondyles, over the lower one third of the
surface of the shanks, on the lateral malleoli, over the second metatarsals, on the
calcanei, on the acromioclavicular joints,
on the spinous process of the seventh cervical vertebra, on the spinous process of
the 10th thoracic vertebra, on the jugular

800|october 2015|volume 45|number 10|journal of orthopaedic & sports physical therapy

0%

60%

100%

Landing

Propulsion

FIGURE 1. Landing and propulsion during the transition between the first and second hops of the single-leg triple hop test. The graph shows from initial contact (0%) to toe-off
(100%), with the transition from landing to propulsion occurring at 60%, defined based on the peak knee flexion angle.

TABLE 2

Anterior trunk lean

were asked to cross their arms in front of

the thorax while performing the task.

Peak Joint Angle for the

Trunk, Pelvis, Hip, Knee, and Ankle
in Women With and Without PFP
Control
(n = 20)*
31.2 6.0

Instrumentation

PFP (n = 20)*

Between-Group
Differences

Effect Size

P Value

35.9 5.1

4.7 (1.1, 8.3)

0.8

.038

5.7 (4.2, 7.2)

Ipsilateral trunk lean

3.5 2.4

9.2 2.4

2.3

.001

Ipsilateral trunk rotation

17.1 5.3

11.5 3.2

5.6 (8.4, 2.8)

1.2

.003

35.0 5.1

33.2 3.3

1.8 (4.8, 1.2)

0.4

.299

4.1 1.6

7.3 2.0

3.2 (2.0, 4.4)

1.7

.001

Anterior pelvic tilt

Contralateral pelvic drop
Ipsilateral pelvic rotation

14.0 3.0

10.9 1.6

3.1 (4.6, 1.6)

1.2

.001

Hip flexion

58.6 3.7

54.4 5.4

4.2 (7.2, 1.2)

0.9

.029

Hip adduction

6.9 0.6

10.3 0.6

3.4 (3.0, 3.8)

0.9

.002

Hip internal rotation

8.9 0.9

12.5 3.3

3.6 (2.1, 5.2)

1.4

.002

56.7 4.9

47.8 2.8

8.9 (11.5, 6.4)

1.4

.001

Knee flexion
Knee adduction
Ankle dorsiflexion
Ankle eversion

7.8 3.0

8.4 2.2

0.6 (1.1, 2.3)

0.2

.614

32.5 1.5

26.7 0.8

5.8 (6.6, 5.0)

4.8

.003

6.7 2.2

10.6 4.3

0.9

.019

3.9 (1.7, 6.1)

Abbreviation: PFP, patellofemoral pain.

*Values are mean SD degrees.

Values in parentheses are 95% confidence interval.

Determined using Cohen d (0.0-0.2, trivial; 0.3-0.5, small; 0.6-0.8, medium; and 0.9 or higher,
large).

notch where the clavicles meet the sternum, on the xiphoid process of the sternum, and one offset anywhere over the
right scapula. For the conventional gait
model, the same markers are required
during static and dynamic trials.
After all markers were attached, 1 static standing reference trial and 3 SLTHT
trials were performed with the symptom-

atic limb for those with PFP or with the

dominant limb for those in the control
group. Two minutes of rest was provided
between each trial. As it was not possible
to standardize footwear, participants
were barefoot during testing. In addition,
to standardize the position of the participants and to avoid compensatory movements of the upper limbs, the participants

An 8-camera BTS SMART-D (BTS SpA,

Milan, Italy) system was used to capture
the 3-D marker trajectories. The cameras
were interfaced to a microcomputer and
placed around a force plate embedded in
the floor (model 9286; Kistler Holding
AG, Winterthur, Switzerland). The force
plate was interfaced to the same microcomputer that was used for kinematic
data collection via an analog-to-digital
converter, enabling the synchronization
of kinematic and kinetic data.
Based on the results of the pilot study,
sampling frequencies of 100 Hz (kinematic) and 400 Hz (kinetic) were used.
These sampling rates have previously
been used in a number of studies to assess
the kinematics4,11,24,46 and kinetics1,4,27,28,46
of jump tasks.

Data Analysis
Kinematic data were converted to the
C3D format using MATLAB software
(The MathWorks, Inc, Natick, MA),
applying the BTK 0.1.10 code (Biomechanical ToolKit),2 then labeled and processed in Vicon Nexus software (OMG
plc, Oxford, UK)36 using the Plug in Gait
model. As in previous studies assessing
dynamic tasks, the kinematic data were
filtered using a fourth-order, zero-lag,
Butterworth, 12-Hz low-pass filter. 18

journal of orthopaedic & sports physical therapy | volume 45 | number 10 | october 2015 | 801

research report

Trunk
rotation

PFP

Hip
adduction

Pelvic
rotation

Knee
adduction
Hip internal
rotation

Ankle
dorsiflexion

Pelvic
tilt

Knee
flexion

Hip
adduction

Anterior
trunk lean

Ankle
eversion
Pelvic
drop

Pelvic
drop

Knee
adduction

Ipsilateral
trunk lean

Hip
flexion

Hip internal
rotation

Hip
flexion

Ankle
dorsiflexion
Anterior
trunk lean

Control
Ipsilateral
trunk lean

Trunk
rotation

Knee
flexion

Pelvic
tilt

Ankle
eversion

Pelvic
rotation
20%

40%

60%

80%

100%

Percentage of the landing and propulsion cycle

Landing

Propulsion

FIGURE 2. Time to peak joint angle as a percent of the weight-bearing phase. *There was a significant group difference (P<.05) for all variables except for anterior pelvic tilt and
hip flexion. Abbreviation: PFP, patellofemoral pain.

Joint kinematics were calculated using a

joint coordinate system approach14,25 and
were reported relative to a static standing
trial, to quantify the movement of one
segment in relation to another or of one
segment relative to the laboratory. Kinematics, ground reaction forces, and anthropometric data were used to calculate
articular internal moments and power
(scalar product of moment and angular
velocity) of the hip, knee, and ankle, using inverse dynamic equations in Vicon
Nexus software. Kinetic data were normalized to body mass.
Kinematic and kinetic data were obtained for the weight-bearing period
between the first and second hops of the
SLTHT. Therefore, the period of interest was from initial foot contact with the
force plate (0%) to toe-off (100%) (FIGURE
1). Internal joint moment for the lower
extremity was recorded at peak knee
flexion angle and represented the end
of the landing phase. The average power
recorded during the landing phase was
used to compare groups.
The peak joint angles, time to peak
joint angles, and internal peak moments
and power of each joint studied were imported into Excel (Microsoft Corporation,
Redmond, WA) for statistical analysis.

The time-to-peak-joint-angle analysis

was performed to understand the timing
and sequencing with which the maximum
amplitude of each joint was achieved during the transition period between the first
and second hops of the SLTHT.

RESULTS

he multivariate ANOVAs indicated significant differences for

kinematic variables (P<.001), joint
internal moments (P<.001), and joint
powers (P<.001).

Statistical Analysis
The Kolmogorov-Smirnov test (with the
Lilliefors correction factor) was used
to test the normality of the kinematic
and kinetic data. Descriptive statistics,
means, and standard deviations were
calculated for all variables. The average of 3 trials was used for all statistical analyses of the kinematic and kinetic
data. The kinematic and kinetic variables were compared between groups
using 2 separate multivariate analyses
of variance (ANOVAs). If there were
significant multivariate effects, univariate effects were tested for all relevant
variables. The significance level was
set at P<.05. Cohen d effect sizes were
calculated and defined as trivial if the
value was between 0.0 and 0.2, small if
between 0.3 and 0.5, medium if between
0.6 and 0.8, and large if 0.9 or higher.38
All statistical comparisons were performed with SPSS Version 15.0 (SPSS
Inc, Chicago, IL).

Performance
The mean SD distance for the first
jump of the SLTHT for the women in the
control group was 1.05 0.17 m, compared to 0.96 0.11 m for the women in
the PFP group (P = .091).

Kinematics
TABLE 2 provides the descriptive peak

joint angle data, as well as the results

of statistical analysis for between-group
comparisons.
TrunkWhen compared to the control
group, the women in the PFP group exhibited greater anterior (P = .038) and
ipsilateral (P = .001) trunk lean, but less
ipsilateral trunk rotation (P = .003).
PelvisWhen compared to the control
group, the women in the PFP group exhibited greater contralateral pelvic drop (P =
.001) and less ipsilateral rotation (P = .001).
There was no significant difference between
groups for anterior pelvic tilt (P = .299).

802|october 2015|volume 45|number 10|journal of orthopaedic & sports physical therapy

TABLE 3

Ankle Women with PFP exhibited a low-

Time to Peak Joint Angle as a

Percent of the Weight-Bearing Phase
Control
(n = 20)*

PFP (n = 20)*

Anterior trunk lean

61 3

69 3

Ipsilateral trunk lean

28 2

38 1

Ipsilateral trunk rotation

17 5

12 1

Anterior pelvic tilt

37 2

Contralateral pelvic drop

28 1

Between-Group
Differences

Effect Size

P Value

8 (6, 10)

2.3

.001

10 (9, 11)

5.9

.001

5 (8, 2)

1.2

.003

38 2

1 (0, 2)

0.5

.100

38 1

10 (9, 11)

7.3

.001

Ipsilateral pelvic rotation

24 2

14 1

10 (11, 9)

5.3

.001

Hip flexion

35 3

36 3

1 (1, 3)

0.3

.540

Hip adduction

23 3

33 3

10 (8, 12)

3.3

.001

Hip internal rotation

22 1

12 2

10 (11, 10)

7.4

.001

Knee flexion

62 3

60 3

2 (4, 0)

0.6

.032

Knee adduction

15 2

12 3

3 (5, 1)

1.1

.003

Ankle dorsiflexion

62 4

58 3

4 (6, 2)

1.1

.032

Ankle eversion

62 4

58 3

4 (6, 2)

1.1

.019

Abbreviation: PFP, patellofemoral pain.

*Values are mean SD percent.

Values in parentheses are 95% confidence interval.

Determined using Cohen d (0.0-0.2, trivial; 0.3-0.5, small; 0.6-0.8, medium; and 0.9 or higher,
large).

Hip Women in the PFP group exhibited

greater hip adduction (P = .002) and internal rotation (P = .002). However, they
exhibited less hip flexion (P = .029).
KneeWhen compared to the control
group, the women in the PFP group exhibited less knee flexion (P = .001). No
significant difference was found for knee
adduction (P = .614).
AnkleWomen with PFP exhibited
greater ankle eversion (P = .019) and less
dorsiflexion (P = .003) than those in the
control group.
Time to Peak Data on the time to peak
joint angle as a percentage of contact
time are provided in FIGURE 2 and TABLE 3.
The women in the PFP group exhibited a
significantly (P<.05) faster time to peak
joint angle for the following variables:
ipsilateral trunk rotation, ipsilateral pelvic rotation, hip internal rotation, knee
flexion, knee adduction, ankle dorsiflexion, and ankle eversion. They conversely
exhibited a significantly (P<.05) slower
time to peak joint angle for the following
variables: anterior trunk lean, ipsilateral

trunk lean, contralateral pelvic drop, and

hip adduction. There were no significant
between-group differences (P>.05) for
time to peak joint angle for hip flexion
and anterior pelvic tilt.
Kinetics TABLE 4 provides the descriptive statistics for all kinetic variables as
well as the results of the between-group
comparisons.
Hip Women with PFP exhibited a greater internal hip abductor moment than
those in the control group (P = .017), but
less hip power absorption in the frontal
plane (P = .006). No statistically significant differences were found between
groups for internal hip extensor moment
(P = .679) and hip power absorption in
the sagittal plane (P = .931).
KneeWomen with PFP exhibited a
greater internal knee abductor moment
than those in the control group (P = .001)
and greater knee power absorption in the
frontal plane (P = .001). Conversely, they
exhibited a lower internal knee extensor
moment (P = .001) and less knee power
absorption in the sagittal plane (P = .006).

er internal ankle plantar flexor moment

than those in the control group (P = .035)
and less ankle power absorption in the
sagittal plane (P = .018). No significant
differences were found between groups
for the internal ankle invertor moment
(P = .051) and ankle power absorption in
the frontal plane (P = .420).

DISCUSSION

his study compared selected

trunk and lower extremity kinematic and kinetic variables between
women with and without PFP for the
weight-bearing period between the first
and second hops of the SLTHT. In comparison to women in the control group,
those with anterior knee pain exhibited
greater anterior and ipsilateral trunk
lean, contralateral pelvic drop, hip adduction and internal rotation, and ankle
eversion, but less ipsilateral trunk and
pelvic rotation, hip and knee flexion,
and ankle dorsiflexion. Furthermore,
women with PFP exhibited greater hip
and knee internal abductor moment, less
hip power absorption and greater knee
power absorption in the frontal plane,
but less knee extensor and ankle plantar
flexor internal moments with less knee
and ankle power absorption in the sagittal plane.
Compared to the control group, time
to peak joint angle for women with PFP
occurred earlier for ipsilateral trunk and
pelvic rotation, hip internal rotation,
knee adduction, knee flexion, and ankle
dorsiflexion and eversion, whereas it occurred later for anterior and ipsilateral
trunk lean, contralateral pelvic drop, and
hip adduction.
Some of these findings, especially the
greater ipsilateral trunk lean,33 contralateral pelvic drop,33 hip adduction,15,31,33
and hip internal rotation,31,33 are consistent with what has previously been reported in the literature when comparing
individuals with PFP to a control group
free of pathology. The novel finding of
this study is related to the knee frontal

journal of orthopaedic & sports physical therapy | volume 45 | number 10 | october 2015 | 803

[
plane data, which, though not previously reported in the literature, have
previously been described by Powers39
as an alternate model of frontal plane
deviations.
These findings are consistent with the
high demands placed on the hip abductors during the SLTHT, which leads to
the contralateral pelvic drop and ipsilateral trunk lean, potentially reflecting hip
abductor weakness.7,9,33,41,45 Specifically,
the contralateral pelvic drop moves the
center of mass of the body medially away
from the knee joint, increasing knee internal valgus moment.39 Moreover, the
contralateral pelvic drop explains the
uncommon combination of hip adduction and knee adduction presented in
our study. While both groups that participated in this study exhibited a similar
movement pattern, the pattern was more
pronounced in those with PFP.
In the transverse plane, women with
anterior knee pain exhibited a greater
amount of hip internal rotation and
reached peak hip internal rotation earlier. Theoretically, this excessive and early
internal rotation could be attributed to
weakness or a deficit of activation of the
hip external rotators.22,31,33,43
In the frontal plane, women with PFP
exhibited a greater amount of hip adduction, which was reached later during the
movement. Furthermore, those with PFP
exhibited greater ipsilateral trunk lean
and contralateral pelvic drop, associated
with greater hip internal abductor moment and less hip power absorption than
individuals in the control group (FIGURE 3).
Similar to hip adduction, both contralateral pelvic drop and ipsilateral
trunk lean occurred later in the PFP
group than in the control group. Consistent with the findings of others, these
findings may be explained by a deficit
in torque produced by the hip abductor
muscles.33,40 In our opinion, weak hip abductors may initially be able to control
the pelvis, but they cannot sustain this
position during the entire movement.
Because contralateral pelvic drop occurs
in association with an internal hip ab-

research report
TABLE 4

Power and Internal Moment for the

Hip, Knee, and Ankle in Women
With and Without PFP
Control
(n = 20)*

PFP (n = 20)*

Between-Group
Differences

Effect
Size

P Value

Joint moment, Nm/kg

Hip abductor

1.8 0.5

2.2 0.2

0.4 (0.2, 0.6)

1.0

.017

Hip extensor

2.9 0.5

2.8 0.5

0.1 (0.4, 0.2)

0.2

.679

Knee abductor

0.9 0.3

2.1 0.4

1.2 (1.0, 1.4)

3.3

.001

Knee extensor

2.8 0.4

1.9 0.3

0.9 (1.1, 0.7)

2.5

.001

Ankle plantar flexor

2.4 0.4

2.0 0.3

0.4 (0.6, 0.2)

1.1

.035

Ankle invertor

0.4 0.2

0.6 0.3

0.2 (0.0, 0.4)

0.7

.051

Hip in the sagittal plane

6.0 1.0

6.0 1.1

0.0 (0.6, 0.6)

0.0

.931

Hip in the frontal plane

1.1 0.3

0.8 0.2

0.3 (0.4, 0.1)

0.7

.006

Knee in the sagittal plane

1.1 0.2

0.9 0.2

0.2 (0.3, 0.1)

0.7

.006

Joint power absorption, W/kg

Knee in the frontal plane

1.0 0.2

1.9 0.6

0.9 (0.6, 1.2)

1.9

.001

Ankle in the sagittal plane

1.1 0.2

0.9 0.2

0.2 (0.3, 0.1)

0.6

.018

Ankle in the frontal plane

0.4 0.1

0.3 0.1

0.1 (0.2, 0.0)

1.0

.420

Abbreviation: PFP, patellofemoral pain.

*Values are mean SD.

Values in parentheses are 95% confidence interval.

Determined using Cohen d (0.0-0.2, trivial; 0.3-0.5, small; 0.6-0.8, medium; and 0.9 or higher,
large).

ductor moment and power absorption

in the hip joint, ipsilateral trunk lean is
expected as a compensatory adjustment
to promote lateral displacement of the
ground reaction forces.37,40,49
In the sagittal plane, women from the
symptomatic group exhibited less hip and
knee flexion, less ankle dorsiflexion, less
internal knee extensor and ankle plantar
flexor moment, as well as less knee and
ankle power absorption. A greater knee
flexion angle and greater internal knee
extensor moment and power absorption
lead to increased compressive force on
the patellofemoral joint.16,17,32 We believe
that women in the PFP group limited
their sagittal plane movement during
the SLTHT in an attempt to reduce the
demand on the quadriceps and, consequently, to decrease patellofemoral joint
stress. The symptomatic women also exhibited exaggerated movements in terms
of anterior trunk lean, which peaked later
than it did in the control group. This may

have occurred as a compensatory mechanism of the trunk, moving the center of

mass of the trunk more directly above the
knee joint, to reduce load-absorption demands on the lower extremity.47
A number of studies have assessed the
biomechanical behavior of patients with
PFP while performing less demanding
tasks.7,8,25,31,43 The present study used
3-D analysis of proximal (trunk, pelvis,
and hip), local (knee), and distal joints
(ankle) to study a more challenging task
(SLTHT), requiring greater neuromuscular control. We believe that this knowledge can play an important role in clinical
decision making aimed at interventions
to prevent abnormal movements in lower
limbs during functional activities.
The present study has a number of
potential limitations. First, the study
only assessed the transition between the
first and second jumps, based on data
from a pilot study that showed greater
kinetic and kinematic peak values oc-

804|october 2015|volume 45|number 10|journal of orthopaedic & sports physical therapy

CONCLUSION

ompared to the control group,

women with PFP exhibited altered
kinematics and kinetics of the trunk,
hip, knee, and ankle in all 3 planes of motion during the weight-bearing transition
period between the first and second hops
of the SLTHT. t

KEY POINTS
FINDINGS: Compared to the control group,

women with PFP exhibited altered kinematics and kinetics of the trunk, hip,
knee, and ankle in all 3 planes of motion
during the weight-bearing transition period between the first and second hops
of the SLTHT.
IMPLICATIONS: These biomechanical alterations are different from those identified
during other weight-bearing functional
movements in this population. Therefore, incorporating higher-demand tasks
in the clinical evaluation may provide
additional information useful for intervention.
CAUTION: These data are limited to young
women during a specific high-impact
activity (SLTHT) and do not establish
cause and effect.
FIGURE 3. Frontal plane alignment of the lower extremity and trunk at 60% of the weight-bearing phase between
hops 1 and 2 for representative women in the control (A) and patellofemoral pain (B) groups (ONLINE VIDEO).
The red line indicates the ground reaction forces at that same moment.

curring between the first and second

jumps. Because the participants in the
study were not aware that data were
collected solely in this transition phase,
the potential lab effect (ie, Hawthorne
effect) that may occur during data collection might have been minimized, but
likely not completely eliminated. Second, soft tissue movement and other
technical limitations might have affected the measurement of the small
amount of motion that takes place in
the frontal and transverse planes, especially at the ankle. However, given
the low standard deviation found in
both groups, these limitations probably
did not affect the results of the present

study. Third, because it was difficult to

standardize footwear used during data
collection, we decided to test all participants barefoot, which is not typical
for a jumping task. Finally, participants
crossed their arms during testing, which
might have influenced the performance
of the task. However, this position was
used to avoid compensatory movements
of the upper limbs.
The primary clinical implication of
these findings is that it may be beneficial
to consider highly challenging activities
when assessing patients with PFP. Future studies should consider incorporating electromyographic assessment of the
trunk, hip, and knee musculature.

REFERENCES
1. A
 ugustsson J, Thome R, Lindn C, Folkesson M, Tranberg R, Karlsson J. Single-leg hop
testing following fatiguing exercise: reliability
and biomechanical analysis. Scand J Med
Sci Sports. 2006;16:111-120. http://dx.doi.
org/10.1111/j.1600-0838.2005.00446.x
2. Barre A, Armand S. Biomechanical ToolKit:
open-source framework to visualize and process biomechanical data. Comput Methods
Programs Biomed. 2014;114:80-87. http://dx.doi.
org/10.1016/j.cmpb.2014.01.012
3. Barton CJ, Levinger P, Webster KE, Menz HB.
Walking kinematics in individuals with patellofemoral pain syndrome: a casecontrol study.
Gait Posture. 2011;33:286-291. http://dx.doi.
org/10.1016/j.gaitpost.2010.11.022
4. Benjaminse A, Habu A, Sell TC, et al. Fatigue
alters lower extremity kinematics during a
single-leg stop-jump task. Knee Surg Sports
Traumatol Arthrosc. 2008;16:400-407. http://
dx.doi.org/10.1007/s00167-007-0432-7
5. Bizzini M, Childs JD, Piva SR, Delitto A. System-

journal of orthopaedic & sports physical therapy | volume 45 | number 10 | october 2015 | 805

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

atic review of the quality of randomized controlled trials REFERENCES

for patellofemoral pain syndrome. J
Orthop Sports Phys Ther. 2003;33:4-20. http://
dx.doi.org/10.2519/jospt.2003.33.1.4
Blackburn JT, Padua DA. Sagittal-plane trunk
position, landing forces, and quadriceps
electromyographic activity. J Athl Train.
2009;44:174-179.
Bolgla LA, Malone TR, Umberger BR, Uhl TL. Hip
strength and hip and knee kinematics during
stair descent in females with and without patellofemoral pain syndrome. J Orthop Sports Phys
Ther. 2008;38:12-18. http://dx.doi.org/10.2519/
jospt.2008.2462
Brechter JH, Powers CM. Patellofemoral joint
stress during stair ascent and descent in
persons with and without patellofemoral pain.
Gait Posture. 2002;16:115-123. http://dx.doi.
org/10.1016/S0966-6362(02)00090-5
Cichanowski HR, Schmitt JS, Johnson RJ,
Niemuth PE. Hip strength in collegiate female
athletes with patellofemoral pain. Med Sci
Sports Exerc. 2007;39:1227-1232. http://dx.doi.
org/10.1249/mss.0b013e3180601109
Claudon B, Poussel M, Billon-Grumillier C,
Beyaert C, Paysant J. Knee kinetic pattern during gait and anterior knee pain before and after
rehabilitation in patients with patellofemoral
pain syndrome. Gait Posture. 2012;36:139-143.
http://dx.doi.org/10.1016/j.gaitpost.2012.02.003
Coventry E, OConnor KM, Hart BA, Earl JE,
Ebersole KT. The effect of lower extremity
fatigue on shock attenuation during singleleg landing. Clin Biomech (Bristol, Avon).
2006;21:1090-1097. http://dx.doi.org/10.1016/j.
clinbiomech.2006.07.004
Crossley KM, Bennell KL, Cowan SM, Green
S. Analysis of outcome measures for persons with patellofemoral pain: which are
reliable and valid? Arch Phys Med Rehabil.
2004;85:815-822. http://dx.doi.org/10.1016/
S0003-9993(03)00613-0
da Cunha RA, Costa LO, Hespanhol Junior LC,
Pires RS, Kujala UM, Lopes AD. Translation,
cross-cultural adaptation, and clinimetric
testing of instruments used to assess patients
with patellofemoral pain syndrome in the Brazilian population. J Orthop Sports Phys Ther.
2013;43:332-339. http://dx.doi.org/10.2519/
jospt.2013.4228
Davis RB, 3rd, unpuu S, Tyburski D, Gage JR. A
gait analysis data collection and reduction technique. Hum Mov Sci. 1991;10:575-587. http://
dx.doi.org/10.1016/0167-9457(91)90046-Z
Dierks TA, Manal KT, Hamill J, Davis IS. Proximal
and distal influences on hip and knee kinematics in runners with patellofemoral pain during
a prolonged run. J Orthop Sports Phys Ther.
2008;38:448-456. http://dx.doi.org/10.2519/
jospt.2008.2490
Escamilla RF, Fleisig GS, Zheng N, Barrentine
SW, Wilk KE, Andrews JR. Biomechanics of
the knee during closed kinetic chain and open
kinetic chain exercises. Med Sci Sports Exerc.

research report
1998;30:556-569.
17. F itzgerald GK, Lephart SM, Hwang JH, Wainner RS. Hop tests as predictors of dynamic
knee stability. J Orthop Sports Phys Ther.
2001;31:588-597. http://dx.doi.org/10.2519/
jospt.2001.31.10.588
18. Ford KR, Myer GD, Hewett TE. Reliability of
landing 3D motion analysis: implications for
longitudinal analyses. Med Sci Sports Exerc.
2007;39:2021-2028. http://dx.doi.org/10.1249/
mss.0b013e318149332d
19. Fukuda TY, Melo WP, Zaffalon BM, et al. Hip posterolateral musculature strengthening in sedentary women with patellofemoral pain syndrome:
a randomized controlled clinical trial with
1-year follow-up. J Orthop Sports Phys Ther.
2012;42:823-830. http://dx.doi.org/10.2519/
jospt.2012.4184
20. Fukuda TY, Rossetto FM, Magalhes E, Bryk FF,
Lucareli PR, de Almeida Carvalho NA. Shortterm effects of hip abductors and lateral rotators
strengthening in females with patellofemoral
pain syndrome: a randomized controlled clinical
trial. J Orthop Sports Phys Ther. 2010;40:736742. http://dx.doi.org/10.2519/jospt.2010.3246
21. Hains G, Hains F. Patellofemoral pain syndrome
managed by ischemic compression to the
trigger points located in the peri-patellar and
retro-patellar areas: a randomized clinical trial.
Clin Chiropr. 2010;13:201-209. http://dx.doi.
org/10.1016/j.clch.2010.05.001
22. Halabchi F, Mazaheri R, Seif-Barghi T. Patellofemoral pain syndrome and modifiable intrinsic
risk factors; how to assess and address? Asian J
Sports Med. 2013;4:85-100.
23. Heiderscheit BC. Lower extremity injuries: is it
just about hip strength? J Orthop Sports Phys
Ther. 2010;40:39-41. http://dx.doi.org/10.2519/
jospt.2010.0102
24. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R,
Rayens WS. Hip abductor function and lower
extremity landing kinematics: sex differences. J
Athl Train. 2007;42:76-83.
25. Kadaba MP, Ramakrishnan HK, Wootten ME.
Measurement of lower extremity kinematics during level walking. J Orthop Res. 1990;8:383-392.
http://dx.doi.org/10.1002/jor.1100080310
26. Kernozek TW, Torry MR, Iwasaki M. Gender
differences in lower extremity landing mechanics caused by neuromuscular fatigue. Am J
Sports Med. 2008;36:554-565. http://dx.doi.
org/10.1177/0363546507308934
27. Mackala K, Stodka J, Siemienski A, oh
M. Biomechanical analysis of squat jump
and countermovement jump from varying starting positions. J Strength Cond Res.
2013;27:2650-2661. http://dx.doi.org/10.1519/
JSC.0b013e31828909ec
28. Mackala K, Stodka J, Siemienski A, oh M.
Biomechanical analysis of standing long jump
from varying starting positions. J Strength
Cond Res. 2013;27:2674-2684. http://dx.doi.
org/10.1519/JSC.0b013e31825fce65
29. Magalhes E, Fukuda TY, Sacramento SN, Forgas

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

A, Cohen M, Abdalla RJ. A comparison of hip

strength between sedentary females with and
without patellofemoral pain syndrome. J Orthop
Sports Phys Ther. 2010;40:641-647. http://
dx.doi.org/10.2519/jospt.2010.3120
Magalhes E, Silva AP, Sacramento SN, Martin
RL, Fukuda TY. Isometric strength ratios of the
hip musculature in females with patellofemoral
pain: a comparison to pain-free controls. J
Strength Cond Res. 2013;27:2165-2170. http://
dx.doi.org/10.1519/JSC.0b013e318279793d
McKenzie K, Galea V, Wessel J, Pierrynowski
M. Lower extremity kinematics of females with
patellofemoral pain syndrome while stair stepping. J Orthop Sports Phys Ther. 2010;40:625632. http://dx.doi.org/10.2519/jospt.2010.3185
Mostamand J, Bader DL, Hudson Z. Reliability
testing of the patellofemoral joint reaction force
(PFJRF) measurement during double-legged
squatting in healthy subjects: a pilot study. J
Bodyw Mov Ther. 2012;16:217-223. http://dx.doi.
org/10.1016/j.jbmt.2011.03.003
Nakagawa TH, Moriya ET, Maciel CD, Serro
FV. Trunk, pelvis, hip, and knee kinematics, hip
strength, and gluteal muscle activation during a
single-leg squat in males and females with and
without patellofemoral pain syndrome. J Orthop
Sports Phys Ther. 2012;42:491-501. http://
dx.doi.org/10.2519/jospt.2012.3987
Nguyen AD, Shultz SJ, Schmitz RJ, Luecht RM,
Perrin DH. A preliminary multifactorial approach
describing the relationships among lower extremity alignment, hip muscle activation, and
lower extremity joint excursion. J Athl Train.
2011;46:246-256.
Petschnig R, Baron R, Albrecht M. The relationship between isokinetic quadriceps strength
test and hop tests for distance and one-legged
vertical jump test following anterior cruciate
ligament reconstruction. J Orthop Sports Phys
Ther. 1998;28:23-31. http://dx.doi.org/10.2519/
jospt.1998.28.1.23
Plug in Gait manual. Available at: http://wweb.
uta.edu/faculty/ricard/Classes/KINE-5350/
PIGManualver1.pdf. Accessed August 24, 2015.
Pollard CD, Sigward SM, Powers CM. Limited
hip and knee flexion during landing is associated with increased frontal plane knee motion
and moments. Clin Biomech (Bristol, Avon).
2010;25:142-146. http://dx.doi.org/10.1016/j.
clinbiomech.2009.10.005
Portney LG, Watkins MP. Foundations of Clinical
Research: Applications to Practice. 2nd ed. Upper Saddle River, NJ: Prentice Hall Health; 2000.
Powers CM. The influence of abnormal hip
mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther.
2010;40:42-51. http://dx.doi.org/10.2519/
jospt.2010.3337
Powers CM. The influence of altered lowerextremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys
Ther. 2003;33:639-646. http://dx.doi.org/10.2519/
WWW.JOSPT.ORG
jospt.2003.33.11.639

806|october 2015|volume 45|number 10|journal of orthopaedic & sports physical therapy

MORE INFORMATION

 41. P
 rins MR, van der Wurff P. Females with
patellofemoral pain syndrome have weak hip
muscles: a systematic review. Aust J Physiother.
2009;55:9-15.
42. Salsich GB, Graci V, Maxam DE. The effects
of movement pattern modification on lower
extremity kinematics and pain in women with
patellofemoral pain. J Orthop Sports Phys Ther.
2012;42:1017-1024. http://dx.doi.org/10.2519/
jospt.2012.4231
43. Salsich GB, Long-Rossi F. Do females with
patellofemoral pain have abnormal hip and
knee kinematics during gait? Physiother
Theory Pract. 2010;26:150-159. http://dx.doi.
org/10.3109/09593980903423111
44. Selfe J, Richards J, Thewlis D, Kilmurray S. The
biomechanics of step descent under different
treatment modalities used in patellofemoral
pain. Gait Posture. 2008;27:258-263. http://
dx.doi.org/10.1016/j.gaitpost.2007.03.017
45. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation
between subjects with and without patellofemo-

46.

47.

48.

49.

50.

ral pain. J Orthop Sports Phys Ther. 2009;39:1219. http://dx.doi.org/10.2519/jospt.2009.2885

Struzik A, Zawadzki J. Leg stiffness during phases of countermovement and take-off in vertical
jump. Acta Bioeng Biomech. 2013;15:113-118.
Teng HL, Powers CM. Sagittal plane trunk posture
influences patellofemoral joint stress during running. J Orthop Sports Phys Ther. 2014;44:785792. http://dx.doi.org/10.2519/jospt.2014.5249
Thome R, Augustsson J, Karlsson J. Patellofemoral pain syndrome: a review of current
issues. Sports Med. 1999;28:245-262.
Willson JD, Binder-Macleod S, Davis IS.
Lower extremity jumping mechanics of female
athletes with and without patellofemoral
pain before and after exertion. Am J Sports
Med. 2008;36:1587-1596. http://dx.doi.
org/10.1177/0363546508315592
Willson JD, Davis IS. Lower extremity mechanics of females with and without patellofemoral
pain across activities with progressively greater
task demands. Clin Biomech (Bristol, Avon).
2008;23:203-211. http://dx.doi.org/10.1016/j.

clinbiomech.2007.08.025
51. Y eow CH, Lee PV, Goh JC. Effect of landing
height on frontal plane kinematics, kinetics and
energy dissipation at lower extremity joints. J
Biomech. 2009;42:1967-1973. http://dx.doi.
org/10.1016/j.jbiomech.2009.05.017
52. Yeow CH, Lee PV, Goh JC. An investigation of
lower extremity energy dissipation strategies
during single-leg and double-leg landing based
on sagittal and frontal plane biomechanics.
Hum Mov Sci. 2011;30:624-635. http://dx.doi.
org/10.1016/j.humov.2010.11.010
53. Yeow CH, Lee PV, Goh JC. Sagittal knee joint
kinematics and energetics in response to different landing heights and techniques. Knee.
2010;17:127-131. http://dx.doi.org/10.1016/j.
knee.2009.07.015

MORE INFORMATION
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