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BJSM Online First, published on September 23, 2017 as 10.1136/bjsports-2017-098241
PhD Academy Award

The interaction of hip and foot biomechanics in the

presentation and management of patellofemoralpain
Simon Lack1,2

1
Department of Sports and
Exercise Medicine, William
Harvey Research Institute,
School of Medicine and
Dentistry, Queen Mary
University, London, UK
2
Pure Sports Medicine, London,
UK
Correspondence to
Dr Simon Lack, Department of
Sports and Exercise Medicine,
Mile End Hospital, London E1
4DG, UK; s.lack@q mul.ac.uk
Accepted 4 September 2017
What did I do?
My thesis, consisting of six independent studies,
investigated whether the interaction of hip and foot
biomechanics better explains patellofemoral pain
(PFP) presentation and management and could be
used to inform feasibility studies delivering biome-
chancially tailored interventions for individuals
with this recalcitrant condition.
Why did I do it?
PFP remains one of the most common conditions
within sports medicine, orthopaedic and general
practice settings.1 Long-term treatment outcomes
are poor and emerging evidence indicates PFP may
be on a continuum with patellofemoral osteoar-
thritis.2 Delivering tailored interventions, directed
at the hip and foot, that reflected mine and others
clinical practice has been proposed as an approach
that improves patient outcome.3 To achieve
patient-specific intervention, a greater under-
standing of effective treatments and the mecha-
nisms of these effects was required.

How did I do it?

I conducted two systematic reviews with
meta-analysis to (Study 1) identify predictors of
conservative management outcomes and (Study 2)
explore the effects and mechanisms of proximal
rehabilitation interventions.4 5 A reliability study
(Study 3) tested a battery of clinical measures
Figure 2 Testing within the human performance
laboratory using motion capture and electromyography
during a step-up task.
(including strength dynamometry, joint range
of motion, foot posture and lower limb func-
tion) designed to identify biomechanical defi-
cits common in individuals with PFP (figure1).
Participants from the private and public health
sectors in London were used for the subsequent

Figure 1 Demonstrating the application of clinical

To cite: LackS.
Br J Sports Med Published
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measures, including using the iPhone inclinometer for Figures 3 Multi-channel electromyography
ankle dorsiflexion, hip rotation range and 1st metatarsal collection of hip muscle activation during the
phalangeal joint extension, and handheld dynamometry completion of rehabilitation exercise in individuals with
for assessment of hip extension strength. patellofemoralpain.

LackS. Br J Sports Med 2017;0:12. doi:10.1136/bjsports-2017-098241 1

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PhD Academy Award
three studies. I completed an observational study (Study 4)
of individuals with PFP investigating possible biomechanical
mechanisms of effect for in-shoe foot orthoses (figure2).6
Using multichannel electromyography, in a casecontrol study
design (Study 5), I examined the muscle activity of the hip
region during common rehabilitation exercises. A randomised
feasibility trial (Study 6) implemented a tailored interven-
tion to determine rates of recruitment, retention and adverse
effects.
What did I find?
Outcome predictors for conservative management are currently
at a derivation stage of development. Within clinically reasoned
paradigms, predictors of treatment outcome supported the
implementation of a specified treatment approach. It was
concluded, however, that within a complex heterogeneous
PFP group, single predictors might be insufficiently sensitive
to identify individuals likely to experience a positive outcome
following a specific conservative intervention. This conclusion
provided the rationale for developing a reliable battery of clin-
ical tests to further inform this tailored approach to conser-
vative management. Fourteen clinical measures showed good
intra-rater reliability and inter-rater reliability for the assess-
ment of lower limb biomechanics. Proximal rehabilitation,
using both open and closed kinetic chain exercisesdirected at
the hip and quadriceps, was found to be effective at reducing
pain and improving function. The review identified a limited
understanding for the mechanism of effect for exercise inter-
ventions, which provided rationale for an investigation into
the activation pattern exhibited during proximal rehabilitation
exercise in those with PFP. Gluteal muscle electromyographic
activity was comparable between symptomatic and asymp-
tomatic individuals and showed exercises that preferentially
activated the gluteal muscles. Tailoring interventions using
biomechanical characteristics, within a randomised trial, was
found to be feasible for recruitment and retention.
What is the most important clinical impact/
practical application?
Interventions directed proximal and distal to the patellofem-
oral joint are effective in the management of PFP.
2 LackS. Br J Sports Med 2017;0:12. doi:10.1136/bjsports-2017-098241
Indicators of treatment success are at a derivation stage.
Adopted within reasoned paradigms, clinicians should
consider
patellar taping for those with greater usual pain
foot orthoses for older and exercise for younger
individuals
foot orthoses for patients with greater forefoot valgus
and rearfoot eversion magnitude peak.
Proximal rehabilitation, in combination with quadriceps
exercise, should be encouraged in the management of PFP.
Proximal exercises, including slow side bridge clam, slow
four-point fire hydrant and fast standing fire hydrant
(figure3), produce desired neuromusclar activation patterns.
Twitter @simonthephysio
Acknowledgements The support of my PhD supervisors Dr Dylan Morrissey and
Dr Christian Barton is acknowledged and was very much appreciated throughout the
completion of my PhD
Funding This work was supported by the Private Physiotherapy Education Fund
(PPEF) grant number A1 and A2.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2017. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
References
1 Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002
running injuries. Br J Sports Med 2002;36:95101.
2 Witvrouw E, Lysens R, Bellemans J, et al. Open versus closed kinetic chain exercises
for patellofemoral pain. A prospective, randomized study. Am J Sports Med
2000;28:68794.
3 Stefanik JJ, Noehren B, Bazett-Jones DM, Willson JD, et al. Patellofemoral pain:
consensus statement from the 3rd international patellofemoral pain research retreat
held in Vancouver. Br J Sports Med 20132014;48:4114;48:4114.
4 Lack S, Barton C, Sohan O, et al. Proximal muscle rehabilitation is effective for
patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med
2015;49:136576.
5 Lack S, Barton C, Vicenzino B, et al. Outcome predictors for conservative
patellofemoral pain management: a systematic review and meta-analysis. Sports Med
2014;44:170316.
6 Lack S, Barton C, Woledge R, et al. The immediate effects of foot orthoses on hip and
knee kinematics and muscle activity during a functional step-up task in individuals with
patellofemoral pain. Clin Biomech 2014;29:105662.
 Downloaded from http://bjsm.bmj.com/ on September 23, 2017 - Published by group.bmj.com

The interaction of hip and foot biomechanics

in the presentation and management of
patellofemoral pain
Simon Lack

Br J Sports Med published online September 23, 2017

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