Artigo5-Trunk-Pelvis-HipandKneeKinematics Novo

[ RESEARCH REPORT ]
THERESA H. NAKAGAWA, PT, MS1 • ÉRIKA T.U. MORIYA2 • CARLOS D. MACIEL, PhD3 • FÁBIO V. SERRÃO, PT, PhD4
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
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T
he prevalence of individuals with patellofemoral pain syndrome in males.6 Previous studies have shown
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(PFPS) accounts for approximately 25% of all knee injuries that females and males have differences
in kinematics, strength, and neuromus-
treated in sports medicine clinics.1 Although the incidence is
cular activation during functional and
2.2 times higher in females, PFPS also occurs quite commonly sports activities.14,15,21,34,36,52 Yet there is
little information in the literature on
the biomechanical differences between
T STUDY DESIGN: Controlled laboratory study T RESULTS: Compared to controls, subjects with
females and males who present with or
using a cross-sectional design. PFPS had greater ipsilateral trunk lean (mean 
SD, 9.3°  5.3° versus 6.7°  3.0°; P = .012),
without PFPS. Determining whether
T OBJECTIVES: To determine whether there are
contralateral pelvic drop (10.3°  4.7° versus 7.4° there are mechanical differences be-
Journal of Orthopaedic & Sports Physical Therapy®
any differences between the sexes in trunk, pelvis,

hip, and knee kinematics, hip strength, and gluteal  3.8°; P = .003), hip adduction (14.8°  7.8° ver- tween females and males with PFPS
muscle activation during the performance of a sus 10.8°  5.6°; P<.0001), and knee abduction during functional activities would help
single-leg squat in individuals with patellofemoral (9.2°  5.0° versus 5.8°  3.4°; P<.0001) when clinicians to better design sex-specific
pain syndrome (PFPS) and control participants. performing a single-leg squat. Subjects with PFPS interventions.
T BACKGROUND: Though there is a greater also had 18% less hip abduction and 17% less hip Movements of the trunk in the frontal
incidence of PFPS in females, PFPS is also quite external rotation strength. Compared to female plane can directly influence the frontal
common in males. Trunk kinematics may affect controls, females with PFPS had more hip internal plane moment at the knee.37 An increased
hip and knee function; however, there is a lack of rotation (P<.05) and less muscle activation of the
ipsilateral trunk lean is a common com-
studies of the influence of the trunk in individuals gluteus medius (P = .017) during the single-leg
pensation for hip abductor weakness, be-
with PFPS. squat.
cause this maneuver moves the resultant
T METHODS: Eighty subjects were distributed T CONCLUSION: Despite many similarities in ground reaction force vector closer to the
into 4 groups: females with PFPS, female controls, findings for males and females with PFPS, there
males with PFPS, and male controls. Trunk, pelvis, hip joint center, thereby decreasing the
may be specific sex differences that warrant
hip, and knee kinematics and gluteal muscle demand on the hip abductor muscles.12,42
consideration in future studies and when clinically
activation were evaluated during a single-leg evaluating and treating females with PFPS. But ipsilateral trunk lean may result in
squat. Hip abduction and external rotation ec- the ground reaction force vector passing
J Orthop Sports Phys Ther 2012;42(6):491-501,
centric strength was measured on an isokinetic lateral to the knee joint center, creating
Epub 8 March 2012. doi:10.2519/jospt.2012.3987
dynamometer. Group differences were assessed
a valgus moment at the knee.21 A higher
using a 2-way multivariate analysis of variance (sex T KEY WORDS: anterior knee pain, biomechanics,
by PFPS status). electromyography, patella valgus moment at the knee may increase
the dynamic quadriceps angle and conse-
1
PhD candidate, Federal University of São Carlos, São Carlos, SP, Brazil. 2Physical Therapist, Federal University of São Carlos, São Carlos, SP, Brazil. 3Adjunct Professor, University
of São Paulo, School of Engineering, Department of Electrical Engineering, São Carlos, SP, Brazil. 4Adjunct Professor, Federal University of São Carlos, Department of Physical
Therapy, São Carlos, SP, Brazil. The protocol for this study was approved by the Federal University of São Carlos Institutional Review Board. Address correspondence to Theresa
H. Nakagawa, Federal University of São Carlos, Department of Physical Therapy, Rodovia Washington Luís, km 235 – CEP: 13565-905 São Carlos, SP, Brazil. E-mail: theresa.
[email protected]
Conteúdo licenciado para Leylianne Silva journal

de Sousaof orthopaedic & sports physical therapy
- [email protected] | volume 42 | number 6 | june 2012 | 491
[ RESEARCH REPORT ]
quently increase the lateral vector force trunk, pelvis, and hip kinematics. Sev- METHODS
acting on the patella, which may result eral studies have reported diminished
in greater stress on the lateral compart- isometric hip muscle strength accom- Subjects
ment of the patellofemoral joint. 37,38 panied by altered hip kinematics in his cross-sectional study in-
Dierks et al12 and Souza and Powers42
previously reported that some of the in-
dividuals with PFPS evaluated in their
individuals with PFPS.12,42,45,46 During
weight-bearing activities, the hip must
contract eccentrically to control the
T cluded 80 subjects divided into 4
groups, with 20 subjects per group:
females with PFPS (female PFPS), age-
studies had greater hip abduction during movement of the femur in the frontal matched pain-free females serving as a
weight-bearing activities. These authors and transverse planes. Decreased ec- control group (female controls), males
speculated that this might be due to a centric hip torque in individuals with with PFPS (male PFPS), and age-
compensatory movement of the trunk PFPS has been reported,7,10 but sex dif- matched pain-free males serving as a
toward the stance limb. However, trunk ferences have not been investigated. De- control group (male controls). The a prio-
kinematics were not measured in these creased hip muscle activation may also ri sample size was calculated based on the
studies. Therefore, increased ipsilateral contribute to abnormal hip kinematics. hip internal rotation range of motion of
trunk lean during functional activities, as Although a few studies have evaluated the first 5 subjects of each of the 4 groups,
a compensation for weak hip abductors, the amplitude of gluteal muscle activa- while they performed a single-leg squat.
which is commonly found in individu- tion in females,42,49 none have done so in Calculations were made using α = .05,
als with PFPS,7,10,29 may be a potential males with PFPS. Thus, more studies are β = .20, a within-group standard devia-
contributor to poor patellofemoral joint required to evaluate hip eccentric torque tion of 5.0°, and an expected difference
mechanics. and hip muscle activation in males and between groups of 4.1°. Based on these
During weight-bearing activities, females with PFPS during functional parameters, 18 subjects per group were
because both excessive hip adduction activities. required to adequately power the study
(which increases knee valgus) and hip Based on the current literature, the for this variable of interest.
internal rotation have been shown to purpose of this study was to compare All participants were between 18 and
directly affect patellofemoral joint kine- trunk, pelvis, hip, and knee kinematics, 35 years of age. The male and female
matics and kinetics,38,41 several studies as well as gluteal muscle activation, be- participants with PFPS recruited for this
have evaluated hip kinematics in individ- tween males and females with and with- study met the following criteria: (1) in-
uals with PFPS. However, the findings of out PFPS, while performing a single-leg sidious onset of symptoms unrelated to
these studies have been inconsistent. In squat. The single-leg squat is a common a traumatic event; (2) retropatellar or
the frontal plane, some studies have re- rehabilitation14 exercise that has been peripatellar knee pain with at least 2 of
ported increased hip adduction12,30,39,45-47 demonstrated to be useful in evaluating the following functional activities: stair
and others have not.4,11,42 It is possible lower extremity alignment of patients ascent or descent, running, kneeling,
that hip adduction may be the result of with PFPS in an outpatient clinical squatting, prolonged sitting, jumping,
adduction of the femur relative to the setting.48 isometric quadriceps contraction, and
pelvis, the pelvis dropping on the con- It was hypothesized that, compared palpation of the medial and/or lateral
tralateral side, or a combination of both. to controls, individuals with PFPS would facet of the patella; and (3) pain of more
Yet, only 1 study specifically evaluated present with increased ipsilateral trunk than 3 months in duration. The control
contralateral pelvic drop in individuals lean, contralateral pelvic drop, hip ad- subjects were selected if they had no his-
with PFPS, and only in females after a duction, hip internal rotation, and knee tory of knee injury or pain. The exclusion
protocol of exertion.45 More conflicting abduction during a single-leg squat task. criteria for all groups were as follows: (1)
results have been reported in regard to In addition, compared to controls, partic- previous history of knee surgery; (2) his-
movement of the hip in the transverse ipants with PFPS would exhibit less hip tory of back, hip, or ankle joint injury or
plane. Some authors have reported in- abduction and external rotation eccen- pain; (3) patellar instability; (4) pain on
creased hip internal rotation,8,30,42,43 tric torque when tested on an isokinetic palpation of the patellar tendon, iliotibial
whereas others have reported less2,45,46 or dynamometer, and decreased muscular band, or pes anserinus tendons; (5) signs
no difference4,39 in hip internal rotation activation of the gluteus medius and or symptoms of meniscal or knee liga-
in those with PFPS compared to healthy gluteus maximus, during the single-leg ment involvement; and (6) any neurolog-
controls. No study, to our knowledge, has squat. It was also hypothesized that these ical involvement that would affect gait.
been published that compares pelvis and alterations in kinematics, strength, and All subjects were recruited through
hip kinematics between sexes in individ- neuromuscular function would be more posted flyers in physical therapy clinics,
uals with PFPS. evident in females than in males with athletic health clubs, and common ar-
Hip muscle weakness may influence PFPS. eas in the university. All potential par-
492 |licenciado
Conteúdo june 2012 | volume 42 | number 6 | journal of orthopaedic & sports physical therapy
para Leylianne Silva de Sousa - [email protected]
ticipants were evaluated by a licensed limb (right or left) of each sex- and age-
physical therapist, who screened for in- matched control participant was tested.
clusion and exclusion criteria. Potential Kinematic and EMG Evaluation Prior to
subjects who satisfied the criteria were testing, the subjects performed a 5-min-
consecutively enrolled and reported to ute warm-up by walking on a treadmill
the Federal University of São Carlos for at a speed of 1.66 m/s. Before electrode
testing. The subjects signed a written placement, the skin was shaved, abrad-
informed-consent form, and the study ed, and cleaned with isopropyl alcohol.
was approved by the Federal University The surface EMG electrodes were placed
of São Carlos Ethics Committee for Hu- parallel to the mid–muscle belly of the
man Investigations. gluteus medius and the gluteus maxi-
mus.20 The gluteus medius electrode was
Instrumentation placed one half of the distance between
Three-dimensional trunk, pelvis, hip, and the iliac crest and the greater trochanter
knee joint kinematics were measured us- (FIGURE 1A).20 The gluteus maximus elec-
ing a Flock of Birds tracking device trode was placed midway between the
(miniBIRD; Ascension Technology Cor- sacral vertebrae and the greater trochan-
poration, Burlington, VT) in conjunction ter (FIGURE 1A), corresponding with the
with MotionMonitor software (Innova- greatest prominence of the middle of the
tive Sports Training, Inc, Chicago, IL). buttocks.20 The reference electrode was
This 6-degrees-of-freedom measure- positioned on the radial styloid process
ment system simultaneously tracks the on the same side as the evaluated lower
position and orientation of receivers at- FIGURE 1. (A) Gluteus medius (lower black
limb.
tached to body segments. The transmit- square) and maximus (upper black square) The EMG data during the single-leg
ter consisted of 3 orthogonal coils that electromyographic sensor positions, (B) hip squat were normalized to the maximal
generated a magnetic field. The 5 elec- abduction maximal voluntary isometric contraction voluntary isometric contraction (MVIC).
tromagnetic sensors, attached to the ster- test position, and (C) hip extension maximal Participants performed 1 practice trial
voluntary isometric contraction test position.
num, sacrum,8 the distal lateral thighs,8 prior to the three 5-second data collec-
and the anteromedial aspect of the proxi- tion trials for each muscle, each of which
mal tibia8 of the participant, collected the dex Multi-Joint System 2; Biodex Medi- were separated by a 30-second rest.5,35
changes in the electromagnetic flux in the cal Systems, Inc, Shirley, NY). The handheld dynamometer simultane-
field generated by the transmitter. The ki- Maximal voluntary isometric hip ab- ously provided resistance and measured
nematic data were collected at a sampling duction and extension force were mea- the force generated during each MVIC.5
rate of 90 Hz. sured using a handheld dynamometer If the subjects were unable to perform 3
The electromyographic (EMG) signals (Lafayette Instrument Company, Lafay- measurements with a variability of less
of the gluteus medius and gluteus maxi- ette, IN). than 10%, another trial was performed.5
mus were recorded at 2000 Hz, using The gluteus medius MVIC was re-
double-differential surface electrode DE- Procedures corded with the participant in sidelying,
3.1 sensors (Delsys Inc, Boston, MA), with The subjects reported to the Musculo- with the evaluated limb in the neutral
three 1 × 10-mm bars, 99.9%-Ag conduc- skeletal Laboratory for 2 testing sessions. position, supported by pillows between
tors, and an interelectrode distance of 10 The kinematic and EMG evaluations the lower extremities.5 An adjustable
mm, amplified by a Bagnoli 8-channel were performed during the first session, nylon strap, placed just proximal to the
system (Delsys Inc, Boston, MA). Unit and the eccentric hip torque tests were iliac crest and secured firmly around the
specifications included a common-mode evaluated during the second session on underside of the table, was used to sta-
rejection ratio of 96 dB, amplifier gain of a separate day. There was a 1-week in- bilize the subject’s trunk. The handheld
1000, and input impedance exceeding 10 terval between the 2 sessions to prevent dynamometer was positioned over the
MΩ. The EMG signals were digitized us- any possible influence of fatigue on the femoral condyle, under a nylon strap se-
ing a 12-bit A/D board synchronized with evaluations. cured around the distal thigh and the ex-
the motion analysis data. In the 12 subjects who reported bilat- amination table, which was used to resist
Peak eccentric hip abduction and ex- eral symptoms (7 females and 5 males), hip abduction (FIGURE 1B).
ternal rotation torques were measured the lower extremity reported to be most The gluteus maximus MVIC was
using an isokinetic dynamometer (Bio- affected was tested. The corresponding recorded with the subject in a prone

[ RESEARCH REPORT ]
position on an examination table. The differences between groups across any
subjects maintained 0° of hip flexion of the kinematic variables under static
and 90° of knee flexion. An adjustable conditions.
nylon strap placed on both iliac crests The subjects were then given the op-
and secured firmly around the table was portunity to practice the single-leg squat.
used to stabilize the subject’s pelvis. The They were instructed to squat to an angle
handheld dynamometer was positioned greater than 60° of knee flexion during
5 cm proximal to the popliteal crease, a 2-second period, then to return to the
and a second nylon strap was secured initial single-leg-stance position over an-
around the distal posterior thigh and the other 2-second period.46 Thus, it took 4
examination table, to resist hip extension seconds, as monitored by a digital met-
(FIGURE 1C). Strong verbal encouragement ronome, to perform a single-leg squat.
was given throughout testing. The muscle After each trial, feedback was provided
testing order was randomized to account to indicate whether the trial was valid.
for ordering bias. A trial was considered valid if the sub-

Following the MVIC testing, the par- ject had performed the single-leg squat
ticipants were measured with electro- to at least 60° of knee flexion, within a
magnetic tracking sensors. Each sensor 4-second period, without losing his/her
was placed over an area of least muscle balance. If the trial was not considered
mass to minimize potential sensor move- valid, an additional trial was performed.
ment and secured using double-sided, The data from 3 valid trials were col-
adhesive medical tape (Transpore; 3M, St lected for analysis, with a 1-minute rest
Paul, MN). Before dynamic testing, the interval between trials.
FIGURE 2. Test positions used to measure (A) hip
medial and lateral malleoli and femoral In a prior study, to determine the abduction eccentric torque and (B) hip external
epicondyles were digitized to determine test-retest reliability of the kinemat- rotation eccentric torque.
the ankle joint center and knee joint cen- ics measurements, 8 participants were
ter, respectively. The hip joint center was tested on 2 occasions separated by 3 to knee flexed to 90°. The upper thigh of
estimated using the functional approach 5 days. The intraclass correlation coef- the test leg and the trunk were stabilized
described by Leardini et al,26 with the ficient (ICC3,1) and standard error of with straps. The axis of the dynamometer
data being collected as subjects moved measurement were 0.93 and 0.07° for was aligned with the long axis of the fe-
the hip into a minimum of 14 different ipsilateral trunk lean, 0.95 and 1.29° for mur10 (FIGURE 2B) and the lever arm was
static positions, representing positive and contralateral pelvic drop, 0.92 and 1.83° attached 5 cm above the lateral malleolus.
negative rotations around all 3 axes. The for hip adduction, 0.78 and 2.73° for hip The range of motion of the test was from
trunk angle was designated by the sternal internal rotation, and 0.92 and 1.81° for 5° of hip internal rotation to 20° of hip
sensor, sacral sensor, and the respective knee abduction. external rotation.7
hip joint center. The C7-T1, T12-L1, and Eccentric Torque Evaluation Before test- For both hip abduction and external
L5-S1 interspaces were also digitized. ing, each subject completed a 5-minute rotation, the subjects first performed 5
When the sensors were digitized, a static submaximal warm-up on a cycle ergom- submaximal and 3 maximal reciprocal
file was collected to determine the resting eter. To evaluate hip abduction eccentric eccentric familiarization contractions,
angles of the trunk, pelvis, hip, and knee. torque, the subject was in a sidelying po- with a 1-minute rest between the series.
The subjects were instructed to stand on sition on the dynamometer testing table. After a 3-minute rest, the subjects per-
their evaluated lower limb, with 90° of The evaluated hip was placed superiorly formed 5 repetitions with their maximal
knee flexion on the contralateral lower and in neutral alignment in all 3 planes eccentric voluntary effort.7 The eccentric/
limb and their arms crossed over their (FIGURE 2A). The rotational axis of the dy- eccentric hip abduction/hip adduction
chests. No support was provided to sub- namometer was aligned with the hip joint and hip external rotation/hip internal
jects during the static trial. Three static center in the frontal plane,10 and the lever rotation method was used to evaluate
standing trials were recorded and used to arm was attached 5 cm above the knee eccentric torque. Only eccentric hip ab-
determine the lower-limb anatomical po- joint line of the evaluated limb. The range duction and external rotation torque val-
sition. This static measurement was used of motion of the test was from 0° (neutral ues were used for data analysis. Testing
as the neutral alignment for each par- position) to 30° of hip abduction. was performed at an angular speed of
ticipant, with subsequent measurements For the hip external rotation test, the 30°/s.10All subjects received strong ver-
referring to this position. There were no participant was seated with the hip and bal encouragement during eccentric hip
494 |licenciado
TABLE 1 Subject Demographics*
Female Controls Females, Both Groups Males, Both Groups

Female PFPS (n = 20) Male PFPS (n = 20) (n = 20) Male Controls (n = 20) (n = 40) (n = 40)
Age, y 22.3  3.1 24.2  4.4 21.8  2.6 23.5  3.8 22.1  2.8 23.8  4.0
Mass, kg 61.1  7.5 77.0  9.6 59.4  7.3 74.6  9.1 60.3  7.4† 75.8  9.8
Height, m 1.66  0.59 1.80  0.51 1.63  0.73 1.76  0.61 1.64  0.69† 1.78  0.61
Abbreviation: PFPS, patellofemoral pain syndrome.
*Data are mean  SD.
†
Females significantly different from males (P<.05).
abduction and external rotation torque calculated by subtracting the peak val- RESULTS
testing. The testing order was random- ues acquired during the single-leg squat
ized to account for ordering bias. Peak from the value recorded in the static ale and female participants
hip abduction and external rotation ec-
centric torque (Nm) were determined
using Biodex software (Biodex Medical
standing position. The kinematic data
were processed using custom MATLAB
software (The MathWorks, Inc, Natick,
M were evenly matched for age (P =
.27). Significant sex main effects
(no interaction) were observed for body
Systems, Inc, Shirley, NY). The average MA). mass and height, with males being sig-
of 5 maximal eccentric contractions was Raw EMG signals were band-pass nificantly heavier (P = .001) and taller
used for the analysis. All torque data filtered at 35 to 500 Hz, and a 60-Hz (P<.001) than females (TABLE 1).
were normalized for body weight multi- notch filter was applied. The data were A 2-way multivariate analysis of vari-
plied by height (Nm/kg·m).7 full-wave rectified, and a 75-millisecond, ance revealed a significant multivariate
Prior to the study, to establish test- moving-average window, smoothing al- sex-by-PFPS-status interaction (Wilks λ
retest reliability of eccentric hip torque gorithm was used to generate a linear = .325, F = 7.544, df = 9, P = .015).
measurements, 9 participants were test- envelope.42 The maximum amplitude
ed on 2 occasions, separated by 1 week. across the MVICs represented 100% Kinematics
The ICC3,1 and standard error of mea- activity.5 The averaged EMG data dur- There was no significant difference
surement were 0.97 and 0.07 Nm/kg·m ing single-leg squats were expressed as (P>.05) in maximum excursion of knee
for hip abduction and 0.87 and 0.07 Nm/ a percentage of EMG during the MVIC. flexion during single-leg squats among
kg·m for hip lateral rotation. For the kinematic and EMG variables, the 4 groups (mean  SD female PFPS,
the average of 3 trials was used for the 64.7°  3.8°; male PFPS, 66.1°  3.5°;
Data Analysis statistical analysis. female controls, 65.2°  2.9°; male con-
All kinematic data were filtered using trols, 67.4°  3.2°).
a fourth-order, zero-lag, low-pass But- Statistical Analysis Ipsilateral Trunk Lean Significant sex
terworth filter at 6 Hz.46,52 The Euler The kinematics, EMG, and torque vari- and PFPS status main effects (no in-
angles were calculated using the joint ables were compared between males and teraction) were observed. Females with
coordinate systems definitions recom- females with and without PFPS, using a and without PFPS demonstrated sig-
mended by the International Society of 2-way multivariate analysis of variance nificantly greater ipsilateral trunk lean
Biomechanics17,51 using the MotionMoni- (sex by PFPS status). If there were sig- than males (mean difference, 2.9°; 95%
tor software. The kinematic variables of nificant multivariate effects, univariate confidence interval [CI]: 1.6, 5.2; P =
interest included maximum excursion of effects were examined. For all univari- .009). Subjects with PFPS showed sig-
ipsilateral trunk lean, contralateral pelvic ate F tests, significant main effects were nificantly greater ipsilateral trunk lean
drop, hip adduction, hip internal rota- reported if there were no significant in- than the controls (mean difference,
tion, and knee abduction. The difference teractions. Scheffé post hoc tests were 2.6°; 95% CI: 1.1, 4.2; P = .012) (TABLE
between contralateral pelvic drop and used to determine significant pairwise 2, FIGURE 3).
hip adduction excursion measurements differences when there was a significant Contralateral Pelvic Drop There was a
was that the former was measured in the interaction. The statistical analyses were significant PFPS status main effect (no
laboratory reference frame and the lat- performed using SPSS Version 17 statisti- interaction) for contralateral pelvic drop.
ter in the subject frame. These variables cal software (SPSS Inc, Chicago, IL). The Subjects with PFPS had significantly
represented the movement excursions alpha level was set at .05. greater contralateral pelvic drop than the

[ RESEARCH REPORT ]
Maximum Excursion of Trunk, Pelvis, Hip, and Knee in Males
TABLE 2
and Females With and Without Patellofemoral Pain Syndrome*
Female PFPS Male PFPS Female Controls Male Controls Controls

(n = 20) (n = 20) (n = 20) (n = 20) Females (n = 40) Males (n = 40) PFPS (n = 40) (n = 40)
Ipsilateral trunk lean 11.1  4.6 7.5  3.9 7.5  3.5 6.4  2.3 9.5  4.5‡ 6.6  3.2 9.3  5.3§ 6.7  3.0
Contralateral pelvic drop 11.3  4.3 9.2  4.6 6.6  2.9 7.1  4.5 9.0  4.3 8.6  4.2 10.3  4.7§ 7.4  3.8
Hip adduction 20.4  6.0 13.9  7.3 14.3  4.6 7.2  3.8 17.4  6.1‡ 10.5  5.7 14.8  7.8§ 10.8  5.6
Hip internal rotation 15.6  5.8† 9.8  4.8 9.7  5.4 9.5  4.3 12.8  5.5 9.7  4.4 12.7  6.1 9.6  5.1
Knee abduction 11.2  4.6 7.1  3.5 7.2  3.3 4.2  2.3 9.2  4.1‡ 5.4  3.2 9.2  5.0§ 5.8  3.4
Abbreviation: PFPS, patellofemoral pain syndrome.
*Data are mean  SD deg.
†
Female PFPS significantly greater than male PFPS and controls (P<.05).
‡
§
Subjects with PFPS significantly different from controls (P<.05).
controls (mean difference, 2.9°; 95% CI:

20
1.2, 5.2; P = .003) (TABLE 2).
Hip Adduction There were signifi-
cant sex and PFPS status main effects

Ipsilateral Trunk Lean, deg
†
15 *
(no interaction) for hip adduction. Fe-
males presented significantly greater
hip adduction compared to males
10
(mean difference, 6.9°; 95% CI: 4.3,
9.3; P<.0001), and subjects with PFPS
demonstrated significantly greater hip
5
adduction than the controls (mean dif-
ference, 4.0°; 95% CI: 2.8, 7.8; P<.0001)
(TABLE 2). 0
Hip Internal Rotation There was a sta- Females, n = 40 Males, n = 40 PFPS, n = 40 Controls, n = 40
tistically significant sex-by-PFPS-status
interaction (P = .04) for hip internal FIGURE 3. Mean  SD maximum excursion of ipsilateral trunk lean in males and females with and without PFPS.
rotation during a single-leg squat. Post Significant sex and PFPS status main effects were observed. Abbreviation: PFPS, patellofemoral pain syndrome.
hoc analysis revealed that females with *Females significantly greater than males (P<.05). †Subjects with PFPS significantly greater than controls (P<.05).
PFPS had significantly greater hip in-
ternal rotation than males with PFPS Eccentric Torque Electromyography
(mean difference, 5.8°; 95% CI: 1.5, Significant sex and PFPS status main ef- There was a significant sex-by-PFPS-
10.9; P = .02), control females (mean fects (no interaction) were observed for status interaction for the gluteus medius
difference, 5.9°; 95% CI: 1.7, 11.0; P = the eccentric torque measurements (TA- EMG signal amplitude during the single-
.02), and control males (mean differ- BLE 3). Males generated significantly high- leg squat (P = .017). The post hoc analysis
ence, 6.1°; 95% CI: 1.6, 10.9; P = .03) er peak eccentric hip abduction torque revealed diminished activation of the glu-
(TABLE 2, FIGURE 4). (0.17 Nm/kg·m; 95% CI: 0.10, 0.25; teus medius in females with PFPS when
Knee Abduction There were significant P<.0001) and peak eccentric hip exter- compared to the females in the control
sex and PFPS status main effects (no in- nal rotation torque (0.17 Nm/kg·m; 95% group (5.7% MVIC; 95% CI: 1.2, 11.7; P =
teraction) for knee abduction. Females CI: 0.13, 0.21; P<.0001) when compared .035). However, there was no difference
showed significantly greater knee abduc- to females. Subjects with PFPS generated between males with and without PFPS
tion than males (mean difference, 3.9°; less peak eccentric hip abduction torque (P = .95). Both female groups had great-
95% CI: 2.1, 5.3; P<.0001). Subjects (–0.15 Nm/kg·m; 95% CI: –0.23, –0.10; er MVIC values than both male groups
with PFPS demonstrated significantly P<.001) and peak eccentric hip external (P<.01 for all 4 comparisons) (TABLE 3,
greater knee abduction than the controls rotation torque (–0.10 Nm/kg·m; 95% FIGURE 5).
(mean difference, 3.4°; 95% CI: 1.8, 5.2; CI: –0.13, –0.06; P<.0001) when com- A significant sex main effect (no in-
P<.0001) (TABLE 2). pared to control subjects. teraction) was found for the gluteus
496 |licenciado
Peak Eccentric Torque and Electromyographic Signal Amplitudes
TABLE 3
in Males and Females With and Without Patellofemoral Pain Syndrome*
Female PFPS Male PFPS Female Controls Male Controls Females Controls
(n = 20) (n = 20) (n = 20) (n = 20) (n = 40) Males (n = 40) PFPS (n = 40) (n = 40)
Eccentric torque, Nm/kg·m
Hip abduction 0.56  0.13 0.75  0.22 0.73  0.15 0.88  0.21 0.65  0.16‡ 0.82  0.22 0.67  0.20§ 0.81  0.19
Hip external rotation 0.35  0.07 0.52  0.09 0.44  0.06 0.61  0.09 0.40  0.08‡ 0.57  0.11 0.44  0.12§ 0.53  0.12
Electromyography signal, % MVIC
Gluteus medius 23.7  4.3† 17.9  8.1 29.4  5.5 17.0  5.4 26.5  5.6 17.5  6.6 20.8  6.8 23.2  7.6
Gluteus maximus 24.1  3.9 20.6  7.5 24.6  2.7 18.9  8.9 24.3  3.3‡ 19.7  8.1 22.3  6.1 21.7  7.1
Abbreviations: MVIC, maximal voluntary isometric contraction; PFPS, patellofemoral pain syndrome.
*Data are mean  SD.
†
Females with PFPS significantly lower activation than female control subjects (P<.05). Both female groups significantly greater than both male groups
(P<.01 for all 4 comparisons).

‡
§
Subjects with PFPS significantly different from controls (P<.05).
gluteus medius and maximus muscles at

25
a greater percent of their maximum effort
than men.
*
The present results revealed that
20
males and females with PFPS presented
Hip Internal Rotation, deg
very similar patterns of kinematic and

15 strength alterations compared to their
respective control groups; however, al-
10
terations in hip internal rotation and glu-
teus medius activation were only found
in females with PFPS. It may, therefore,

5
be important to acknowledge and ad-
dress these specific differences between
0 the sexes when evaluating and treating
Female PFPS, n = 20 Male PFPS, n = 20 Female Controls, n = 20 Male Controls, n = 20 patients with PFPS.
The findings of a combination of hip
FIGURE 4. Mean  SD maximum excursion of hip internal rotation in males and females with and without PFPS. abductor weakness and increased ipsi-
A significant sex-by-PFPS-status interaction was observed. Abbreviation: PFPS, patellofemoral pain syndrome.
lateral trunk lean are consistent with the
*Female PFPS significantly greater than male PFPS and controls (P<.05).
concept that increased ipsilateral trunk
maximus EMG signal amplitude dur- compared to pain-free controls, while lean may act as a compensatory mecha-
ing the single-leg squat. Females (PFPS performing a single-leg squat. Individu- nism for hip abductor weakness. Theo-
and controls) demonstrated significantly als with PFPS also showed diminished retically, this compensation would serve
greater activation of the gluteus maxi- hip abduction and hip external rota- to better control the contralateral pelvic
mus when compared to the male groups tion strength as measured eccentrically. drop and the amount of hip adduction
(4.7% MVIC; 95% CI: 1.8, 7.5; P = .002) Overall, the noted differences were more of the stance limb during functional ac-
(TABLE 3). evident in females than in males. Inter- tivities.12,42 However, males and females
estingly, females with PFPS had greater with PFPS still presented increased con-
DISCUSSION hip internal rotation than males with tralateral pelvic drop and hip adduction
PFPS and both control groups. Females compared to the pain-free controls. It is
he current study demonstrated with PFPS also had decreased neuromus- possible that increased ipsilateral trunk
T that males and females with PFPS

presented increased ipsilateral
trunk lean, contralateral pelvic drop, hip
cular activation of the gluteus medius
during the single-leg squat when com-
pared to female controls. Overall, during
lean may compensate for hip abductor
weakness by shifting the center of mass
over the hip joint center. However, this
adduction, and knee abduction when the single-leg squat, women activated the compensation would be only partially ef-

[ RESEARCH REPORT ]
consistent with the data from Willson
et al,45 who reported greater contralat-
40
† eral pelvic drop in females with PFPS
when compared to female controls dur-
*† ing jumping after an exertion protocol.
Gluteus Medius, %MVIC
30
Though the present study used a less-de-
manding activity, it also found increased
20
contralateral pelvic drop in subjects with
PFPS compared to pain-free controls.
This was the only kinematic variable for
10 which findings were similar in both males
and females. The present study also adds
to the growing body of literature that has
0 reported increased hip adduction dur-
Female PFPS, n = 20 Male PFPS, n = 20 Female Controls, n = 20 Male Controls, n = 20 ing functional and sports activities in
subjects with PFPS,12,30,39,45-47 and is in
FIGURE 5. Mean  SD gluteus medius electromyographic signal amplitudes in males and females with and agreement with previous studies show-
without PFPS. A significant sex-by-PFPS-status interaction was observed. Abbreviation: %MVIC, percent maximal ing greater hip adduction in females
voluntary isometric contraction; PFPS, patellofemoral pain syndrome. *Female controls significantly greater
compared to males.15,52
than female PFPS (P<.05). †Both female groups significantly greater than both male groups (P<.01 for all 4
comparisons). No difference between males with and without PFPS (P>.05). Recently, a prospective study dem-
onstrated that increased hip internal
fective in reducing the above pelvic and tion occur in combination. The authors rotation during jump landing was a risk
hip movements. Previous studies23,24 stated that, because the trunk comprises factor that predisposed individuals to
have reported that individuals with se- more than half the body’s mass, ipsilat- PFPS.8 However, there are conflicting re-
vere knee osteoarthritis show signifi- eral trunk motion increases the ground sults concerning hip internal rotation in
cantly increased ipsilateral trunk lean reaction force passing lateral to the knee subjects with PFPS compared to controls
and less peak hip adduction during gait and, consequently, the knee abduction during weight-bearing activities. Studies
when compared to controls and subjects load. In the frontal plane, knee valgus have reported greater,8,30,42,43 less,2,45,46
with mild and moderate osteoarthritis. may be a result of hip adduction, knee and no difference4,39 in hip internal rota-
The authors stated that patients with the abduction, or a combination of both. In tion in subjects with PFPS compared to
most severe knee osteoarthritis would the present study, the subjects with PFPS controls. Our results showed increased
have received the greatest mechanical showed greater ipsilateral trunk lean, hip internal rotation in individuals with
benefit, based on the greater magnitude hip adduction, and knee abduction than PFPS, but only in females. It may be use-
of trunk lean. Alternatively, another pos- the controls during the single-leg squat. ful to consider this sex-specific hip kine-
sible explanation for the present findings Consistent with the results of Hewett et matic alteration when treating females
is that the amount of trunk lean in the al,21 females in the present study showed with PFPS. Mechanically, excessive hip
subjects with PFPS might not have been greater ipsilateral trunk lean compared internal rotation during weight-bearing
sufficient to decrease the contralateral to males. The increased knee valgus pre- activities directly affects patellofemoral
pelvic drop and hip adduction during the sented by subjects with PFPS may have kinematics. Souza et al41 reported great-
single-leg squat. detrimental consequences, because it er lateral patellar tilt and displacement
It has been reported that increased ip- may increase the lateral forces acting on associated with increased hip internal
silateral trunk lean may increase the val- the patella.22,37,38 This may result in in- rotation in females with PFPS when
gus moment of the knee joint.23,31 Myer creased contact pressure between the lat- compared to female controls during the
et al32 demonstrated that higher knee ab- eral femoral condyle and the lateral facet single-limb squat. Previous studies have
duction moments during landing were of the patella, which may lead to PFPS. also demonstrated a relationship between
associated with a greater incidence of Therefore, although it has been proposed excessive femoral rotation and increased
PFPS among female recreational athletes that increased ipsilateral trunk lean could patellofemoral joint stress via decreased
during a basketball season. Also, Hewett compensate for hip abductor weakness, it patellofemoral joint contact area. 3,27,40
et al,21 based on video analysis of noncon- has the potential to promote detrimental The present findings of reduced hip
tact anterior cruciate ligament injuries effects on the tibiofemoral and patello- abduction and external rotation strength
in female athletes, reported that greater femoral joints. in males and females with PFPS com-
ipsilateral trunk angle and knee abduc- The results of the current study are pared to controls are consistent with the
498 |licenciado
results of previous studies.7,10,29,45,47 This on the hip abductor muscles. Females between the evaluated groups during
suggests that hip strengthening,13,16,25,50 with PFPS presented 33% more ipsilat- the single-leg squat were small, Huberti
potentially focusing on eccentric action, eral trunk lean than the female controls, and Hayes22 found that a 10° increase in
should be incorporated in the rehabili- whereas males with PFPS only demon- the quadriceps angle resulted in a 45%
tation programs for males and females strated 15% greater trunk lean than the increase in the peak contact pressure on
with PFPS. The authors chose to evalu- male controls. Although the difference the lateral aspect of the patellofemoral
ate eccentric muscle action because the in trunk lean between the males and fe- joint,37 suggesting that relatively small
hip abductors and external rotators must males with PFPS was not significant, it differences may influence patellofemoral
act eccentrically to control or resist exces- may account for the differences in gluteus joint loading.
sive femoral adduction and internal ro- medius activation. Finally, in this study, the focus was on
tation during functional weight-bearing There was no difference in gluteus studying proximal factors that may in-
activities.15,38 In addition, hip eccentric maximus activation between the subjects fluence the patellofemoral joint. Future
torque has been associated with func- with and without PFPS during the activ- studies should combine the evaluation
tional capacity and pain level in females ity evaluated. These results are in agree- of proximal (trunk, pelvis, and hip), lo-
with PFPS.33 ment with those of Willson et al,49 who cal, and distal (ankle and foot) mechanics
Although males and females with also observed no difference in gluteus during functional activities in individuals
PFPS showed diminished hip external maximus activation during running in with PFPS.9,19
rotation eccentric torque, only females females with PFPS compared to controls.
with PFPS demonstrated increased hip Conversely, Souza and Powers42 demon- CONCLUSION
internal rotation during the single-leg strated increased gluteus maximus acti-
squat. Souza and Powers43 reported that vation during weight-bearing activities ompared to controls, males and
the greater hip internal rotation motion
occurring during running in women with
PFPS was associated with diminished
in females with PFPS. It was postulated
by the authors that this was a reflection
of increased recruitment of their weaker
C females with PFPS showed in-
creased ipsilateral trunk lean, con-
tralateral pelvic drop, hip adduction,
hip muscle performance, especially hip hip extensors in an attempt to better con- and knee abduction during a single-leg
extension endurance. Conversely, Will- trol hip internal rotation. The findings of squat. These altered kinematics were ac-
son and Davis47 found no relationship the present study did not support this companied by decreased strength of the
between isometric hip external rotation hypothesized method of compensation. hip abductors and external rotators, as
strength and hip internal rotation excur- In agreement with previous studies,14,18,34 measured eccentrically on an isokinetic
sion during jumping in women with and it was observed that females presented dynamometer. Additionally, in contrast
without PFPS. No previous study has greater gluteus medius and maximus ac- to males, females with PFPS showed
evaluated this relationship in males with tivation than males during a single-leg increased hip internal rotation and de-
PFPS. The small magnitude of movement squat. creased gluteus medius activation during
and the technical challenges to measure Previous studies have identified in- the single-leg squat. Therefore, despite
hip transverse plane motion may ac- creased hip internal rotation8 and knee many similarities in findings for males
count for some of the differences among abduction moment32 as risk factors for and females with PFPS, there are specific
studies. PFPS. Although Leetun et al28 showed sex differences that may warrant consid-
Decreased gluteus medius activation that lower isometric hip external rota- eration in future studies and when evalu-
during a single-leg squat was observed in tion strength predisposed collegiate ath- ating and treating females with PFPS. t
females with PFPS compared to female letes to lower-limb injuries, Thijs et al44
control participants. However, there was recently suggested that isometric hip KEY POINTS
no difference in gluteus medius activation muscle strength might not be a predis- FINDINGS: Compared to controls, males
between males with and without PFPS. posing factor for PFPS in female runners. and females with PFPS showed in-
Previous studies reported no difference Further prospective studies are necessary creased ipsilateral trunk lean, contra-
in gluteus medius activation between to draw definite conclusions about the lateral pelvic drop, hip adduction, and
females with and without PFPS during role of trunk and pelvis kinematics and knee abduction during a single-leg
running and step-down and drop-jump hip strength and muscular activation in squat. Only females with PFPS pre-
tasks.42,49 A possible explanation for the PFPS. Future studies may consider in- sented increased hip internal rotation
lesser activation of the gluteus medius in vestigating gluteus medius and maximus and reduced gluteus medius activation
females with PFPS in the present study onset times, as these variables have been during the single-leg squat. Both males
is that increased ipsilateral trunk lean shown to be associated with hip kinemat- and females with PFPS had reduced
could have reduced the demand placed ics.49 Although the kinematic differences eccentric strength of the hip abductors

[ RESEARCH REPORT ]
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[ RESEARCH REPORT ]

Trunk, Pelvis, Hip, and Knee Kinematics,

any differences between the sexes in trunk, pelvis,

Conteúdo licenciado para Leylianne Silva journal

Conteúdo licenciado para Leylianne Silva journal

for ordering bias. A trial was considered valid if the sub-

Female Controls Females, Both Groups Males, Both Groups

Conteúdo licenciado para Leylianne Silva journal

Female PFPS Male PFPS Female Controls Male Controls Controls

controls (mean difference, 2.9°; 95% CI:

cant sex and PFPS status main effects

(P<.01 for all 4 comparisons).

gluteus medius and maximus muscles at

very similar patterns of kinematic and

in females with PFPS. It may, therefore,

T that males and females with PFPS

Conteúdo licenciado para Leylianne Silva journal

Conteúdo licenciado para Leylianne Silva journal

http://dx.doi: 10.1016/j.ptsp.2011.04.004 2010;40:277-285. http://dx.doi.org/10.2519/ patellofemoral pain syndrome. Clin Biomech

2011;46:246-256. 19. http://dx.doi.org/10.2519/jospt.2009.2885 Phys Ther. 2011;41:625-632. http://dx.doi.

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