IJSPT
ORIGINAL RESEARCH
RELATIONSHIP BETWEEN HIP STRENGTH AND TRUNK, HIP, AND KNEE KINEMATICS DURING A JUMPLANDING TASK IN INDIVIDUALS WITH PATELLOFEMORAL PAIN Michelle Boling, PhD, ATC1 Darin Padua, PhD, ATC2
ABSTRACT Background/Purpose: Decreased strength of the hip musculature and altered mechanics of the lower extremity have been identified in individuals with patellofemoral pain (PFP). The aim of this study was to determine if a relationship exists between hip muscle strength and transverse and frontal plane motion at the hip and knee, and ipsilateral trunk flexion during a jump-landing task in individuals with PFP. Methods: Fifteen individuals (10 females, 5 males) with PFP participated in this investigation. A threedimensional motion analysis system was utilized to assess trunk, hip, and knee kinematics during a jumplanding task. An isokinetic dynamometer was utilized to assess concentric and eccentric strength of the hip musculature. Simple correlation analyses were performed to determine the relationships between hip muscle strength and peak frontal and transverse plane hip and knee kinematics and ipsilateral trunk flexion. Results: Decreased eccentric strength of the hip external rotators and abductors was significantly correlated to increased frontal plane motion at the hip and trunk, respectively (P0.05), which may be driven by the low subject numbers; however, due to the lack of gender differences, the correlational analyses were performed without regard to gender. Also, due to the moderate r-values reported for our significant findings, the results do not appear to be influenced by the low subject number. However, the lack of significant findings for the additional kinematic and hip muscle strength variables may be attributed to the low subject number. For example, the results for ipsilateral trunk flexion may be viewed as clinically meaningful, although not statistically significant, as all r-values show a negative relationship and range from 0.43-0.49. A final limitation of this investigation was the range of motion limits and positioning utilized for assessing strength of the hip musculature. As previously stated, the rationale for assessing concentric and eccentric contractions was to replicate how the muscles contract during functional tasks, however, it should be noted that our testing procedures did not exactly replicate the range of motion and joint positions that occurred during the jump-landing task. The range of motions used during strength testing was decided upon based on the level of comfort of the participant during pilot testing. Although there may be limits in the ability to generalize these results to functional tasks due to the small range of motion used to assess strength, the authors feel that the internal validity of the results is high due to all subjects performing the tests through the same arcs of motion. Future investigations should determine if set ranges of motion during strength testing influences the relationship between strength and lower extremity kinematics. CONCLUSION The findings of this investigation support an association between eccentric strength of the hip musculature and frontal plane motion at the trunk and hip. Based on these results and the results from prior studies reporting alterations in lower extremity strength and kinematics in individuals with PFP, it is important for clinicians to evaluate strength of the hip musculature along with lower extremity mechanics during dynamic tasks in indviduals with
PFP.9-15,22,23 It is also important to note the r-values for significant correlations were moderate in this study. Thus, future research should investigate additional biomechanical variables, such as neuromuscular control, in order to better understand the multiple factors that influence faulty mechanics in individuals with PFP. Gaining a clear understanding of all biomechanical factors influencing lower extremity mechanics during dynamic tasks will aid clinicians in developing more effective intervention programs for individuals with PFP. REFERENCES 1. Devereaux M, Lachman S. Patellofemoral arthralgia in athletes attending a sports injury clinic. Br J Sports Med. 1984;18:18-21. 2. DeHaven KE, Lintner DM. Athletic injuries: Comparison by age, sport, and gender. Am J Sports Med. 1986;14:218-224. 3. Milgrom C, Kerem E, Finestone A, Eldad A, Shlamkovitch N. Patellofemoral pain caused by overactivity. A prospective study of risk factors in infantry recruits. J Bone Joint Surg. 1991;73A 10411043. 4. Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G. Intrinsic risk factors for the development of anterior knee pain in an athletic population: A two-year prospective study. Am J Sports Med. 2000;28(4):480-489. 5. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639-646. 6. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):4251. 7. Huberti HH, Hayes WC. Patellofemoral contact pressures. The influence of Q angle and tendofemoral contact. J Bone Joint Surg. 1984;66A (5):715-724. 8. Lee T, Morris G, Csintalan R. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. 2003;33(11):686-693. 9. 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(1):12-18. 10. Boling MC, Padua DA, Alexander CR. Concentric and eccentric torque of the hip musculature in
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 668
11.
12.
13.
14.
individuals with and without patellofemoral pain. J Athl Train. 2009;44(1):7-13. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33 (11):671-676. Piva SR, Goodnite EA, Childs JD. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2005;35(12):793-801. Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2007;37(5):232-238. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-19.
15. Cichanowski HR, Schmitt JS, Johnson RJ, Niemuth PE. Hip strength in collegiate female athletes with patellofemoral pain. Med Sci Sports Exerc. Aug 2007;39(8):1227-1232. 16. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: sex differences. J Athl Train. JanMar 2007;42(1):76-83. 17. Willson JD, Ireland ML, Davis I. Core strength and lower extremity alignment during single leg squats. Med Sci Sports Exerc. May 2006;38(5):945-952. 18. Claiborne TL, Armstrong CW, Gandhi V, Pincivero DM. Relationship between hip and knee strength and knee valgus during a single leg squat. J Appl Biomech. 2006;22(1):41-50. 19. Hollman JH, Ginos BE, Kozuchowski J, Vaughn AS, Krause DA, Youdas JW. Relationships between knee valgus, hip-muscle strength, and hip-muscle recruitment during a single-limb step-down. J Sport Rehabil. Feb 2009;18(1):104-117. 20. Lawrence RK, 3rd, Kernozek TW, Miller EJ, Torry MR, Reuteman P. Influences of hip external rotation
21.
22.
23.
24.
25.
26.
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strength on knee mechanics during single-leg drop landings in females. Clin Biomech (Bristol, Avon). Jul 2008;23(6):806-813. Baldon RD, Lobato DFM, Carvalho LP, Santiago PRP, Benze BG, Serrao FV. Relationship Between Eccentric Hip Torque and Lower-Limb Kinematics: Gender Differences. J Appl Biomech. Aug 2011;27(3):223-232. 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(8):448-456. Willson JD, Davis IS. Lower extremity strength and mechanics during jumping in women with patellofemoral pain. J Sport Rehabil. Feb 2009;18(1):76-90. Dempsey AR, Lloyd DG, Elliott BC, Steele JR, Munro BJ. Changing sidestep cutting technique reduces knee valgus loading. Am J Sports Med. Nov 2009;37(11):2194-2200. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. J Arthroscopic Rel Surg. 1993;9 (2):159-163. 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 Rehab. 2004;85 815-822. Hawkey TJ, Halverson SD, Padua DA, Guskiewicz KM. Reliability of three different strength testing protocols for hip abduction, extension, and external rotation strength. J Athl Train. 2004;39 (2):S116. Bazett-Jones DM, Cobb SC, Joshi MN, Cashin SE, Earl JE. Normalizing hip muscle strength: establishing body-size-independent measurements. Arch Phys Med Rehabil. Jan 2011;92(1):76-82. Neumann DA. Kinesiology of the hip: a focus on muscular actions. J Orthop Sports Phys Ther. 2010;40(2):82-94.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 669
ORIGINAL RESEARCH
RELATIONSHIP BETWEEN HIP STRENGTH AND TRUNK, HIP, AND KNEE KINEMATICS DURING A JUMPLANDING TASK IN INDIVIDUALS WITH PATELLOFEMORAL PAIN Michelle Boling, PhD, ATC1 Darin Padua, PhD, ATC2
ABSTRACT Background/Purpose: Decreased strength of the hip musculature and altered mechanics of the lower extremity have been identified in individuals with patellofemoral pain (PFP). The aim of this study was to determine if a relationship exists between hip muscle strength and transverse and frontal plane motion at the hip and knee, and ipsilateral trunk flexion during a jump-landing task in individuals with PFP. Methods: Fifteen individuals (10 females, 5 males) with PFP participated in this investigation. A threedimensional motion analysis system was utilized to assess trunk, hip, and knee kinematics during a jumplanding task. An isokinetic dynamometer was utilized to assess concentric and eccentric strength of the hip musculature. Simple correlation analyses were performed to determine the relationships between hip muscle strength and peak frontal and transverse plane hip and knee kinematics and ipsilateral trunk flexion. Results: Decreased eccentric strength of the hip external rotators and abductors was significantly correlated to increased frontal plane motion at the hip and trunk, respectively (P0.05), which may be driven by the low subject numbers; however, due to the lack of gender differences, the correlational analyses were performed without regard to gender. Also, due to the moderate r-values reported for our significant findings, the results do not appear to be influenced by the low subject number. However, the lack of significant findings for the additional kinematic and hip muscle strength variables may be attributed to the low subject number. For example, the results for ipsilateral trunk flexion may be viewed as clinically meaningful, although not statistically significant, as all r-values show a negative relationship and range from 0.43-0.49. A final limitation of this investigation was the range of motion limits and positioning utilized for assessing strength of the hip musculature. As previously stated, the rationale for assessing concentric and eccentric contractions was to replicate how the muscles contract during functional tasks, however, it should be noted that our testing procedures did not exactly replicate the range of motion and joint positions that occurred during the jump-landing task. The range of motions used during strength testing was decided upon based on the level of comfort of the participant during pilot testing. Although there may be limits in the ability to generalize these results to functional tasks due to the small range of motion used to assess strength, the authors feel that the internal validity of the results is high due to all subjects performing the tests through the same arcs of motion. Future investigations should determine if set ranges of motion during strength testing influences the relationship between strength and lower extremity kinematics. CONCLUSION The findings of this investigation support an association between eccentric strength of the hip musculature and frontal plane motion at the trunk and hip. Based on these results and the results from prior studies reporting alterations in lower extremity strength and kinematics in individuals with PFP, it is important for clinicians to evaluate strength of the hip musculature along with lower extremity mechanics during dynamic tasks in indviduals with
PFP.9-15,22,23 It is also important to note the r-values for significant correlations were moderate in this study. Thus, future research should investigate additional biomechanical variables, such as neuromuscular control, in order to better understand the multiple factors that influence faulty mechanics in individuals with PFP. Gaining a clear understanding of all biomechanical factors influencing lower extremity mechanics during dynamic tasks will aid clinicians in developing more effective intervention programs for individuals with PFP. REFERENCES 1. Devereaux M, Lachman S. Patellofemoral arthralgia in athletes attending a sports injury clinic. Br J Sports Med. 1984;18:18-21. 2. DeHaven KE, Lintner DM. Athletic injuries: Comparison by age, sport, and gender. Am J Sports Med. 1986;14:218-224. 3. Milgrom C, Kerem E, Finestone A, Eldad A, Shlamkovitch N. Patellofemoral pain caused by overactivity. A prospective study of risk factors in infantry recruits. J Bone Joint Surg. 1991;73A 10411043. 4. Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G. Intrinsic risk factors for the development of anterior knee pain in an athletic population: A two-year prospective study. Am J Sports Med. 2000;28(4):480-489. 5. Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33(11):639-646. 6. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):4251. 7. Huberti HH, Hayes WC. Patellofemoral contact pressures. The influence of Q angle and tendofemoral contact. J Bone Joint Surg. 1984;66A (5):715-724. 8. Lee T, Morris G, Csintalan R. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. 2003;33(11):686-693. 9. 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(1):12-18. 10. Boling MC, Padua DA, Alexander CR. Concentric and eccentric torque of the hip musculature in
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 668
11.
12.
13.
14.
individuals with and without patellofemoral pain. J Athl Train. 2009;44(1):7-13. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33 (11):671-676. Piva SR, Goodnite EA, Childs JD. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2005;35(12):793-801. Robinson RL, Nee RJ. Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2007;37(5):232-238. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-19.
15. Cichanowski HR, Schmitt JS, Johnson RJ, Niemuth PE. Hip strength in collegiate female athletes with patellofemoral pain. Med Sci Sports Exerc. Aug 2007;39(8):1227-1232. 16. Jacobs CA, Uhl TL, Mattacola CG, Shapiro R, Rayens WS. Hip abductor function and lower extremity landing kinematics: sex differences. J Athl Train. JanMar 2007;42(1):76-83. 17. Willson JD, Ireland ML, Davis I. Core strength and lower extremity alignment during single leg squats. Med Sci Sports Exerc. May 2006;38(5):945-952. 18. Claiborne TL, Armstrong CW, Gandhi V, Pincivero DM. Relationship between hip and knee strength and knee valgus during a single leg squat. J Appl Biomech. 2006;22(1):41-50. 19. Hollman JH, Ginos BE, Kozuchowski J, Vaughn AS, Krause DA, Youdas JW. Relationships between knee valgus, hip-muscle strength, and hip-muscle recruitment during a single-limb step-down. J Sport Rehabil. Feb 2009;18(1):104-117. 20. Lawrence RK, 3rd, Kernozek TW, Miller EJ, Torry MR, Reuteman P. Influences of hip external rotation
21.
22.
23.
24.
25.
26.
27.
28.
29.
strength on knee mechanics during single-leg drop landings in females. Clin Biomech (Bristol, Avon). Jul 2008;23(6):806-813. Baldon RD, Lobato DFM, Carvalho LP, Santiago PRP, Benze BG, Serrao FV. Relationship Between Eccentric Hip Torque and Lower-Limb Kinematics: Gender Differences. J Appl Biomech. Aug 2011;27(3):223-232. 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(8):448-456. Willson JD, Davis IS. Lower extremity strength and mechanics during jumping in women with patellofemoral pain. J Sport Rehabil. Feb 2009;18(1):76-90. Dempsey AR, Lloyd DG, Elliott BC, Steele JR, Munro BJ. Changing sidestep cutting technique reduces knee valgus loading. Am J Sports Med. Nov 2009;37(11):2194-2200. Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. J Arthroscopic Rel Surg. 1993;9 (2):159-163. 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 Rehab. 2004;85 815-822. Hawkey TJ, Halverson SD, Padua DA, Guskiewicz KM. Reliability of three different strength testing protocols for hip abduction, extension, and external rotation strength. J Athl Train. 2004;39 (2):S116. Bazett-Jones DM, Cobb SC, Joshi MN, Cashin SE, Earl JE. Normalizing hip muscle strength: establishing body-size-independent measurements. Arch Phys Med Rehabil. Jan 2011;92(1):76-82. Neumann DA. Kinesiology of the hip: a focus on muscular actions. J Orthop Sports Phys Ther. 2010;40(2):82-94.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 669
