Biomechanical differences between military patients with patellar tendinopathy and asymptomatic controls during single-leg squatting and gait – A statistical parametric mapping study

  • Andrew Houston
    Affiliations
    Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK
    Search for articles by this author
  • Daniel T.P. Fong
    Affiliations
    National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, UK
    Search for articles by this author
  • Alexander N. Bennett
    Affiliations
    Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK

    National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, UK
    Search for articles by this author
  • Vanessa Walters
    Affiliations
    Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK

    Versus Arthritis Centre for Sport, Exercise and Osteoarthritis Research, University of Bath, Bath, UK
    Search for articles by this author
  • Robert M. Barker-Davies
    Correspondence
    Corresponding author at: Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough LE12 5QW, UK.
    Affiliations
    Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK

    National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, UK
    Search for articles by this author

      Highlights

      • Statistical parametric mapping reduced the number of significant results compared to prior work.
      • Cases demonstrated increased knee abduction at various points of a single-leg squat.
      • No kinematic or kinetic differences were observed during walking.
      • Hip-focused exercises to stabilise the knee are justified in this population.

      Abstract

      Background

      Prior identification of biomechanical differences between patients with patellar tendinopathy and healthy controls has utilised time-discrete analysis which is susceptible to type I error when multiple comparisons are uncorrected. We employ statistical parametric mapping to minimise the risk of such error, enabling more appropriate clinical decision-making.

      Methods

      Lower-limb biomechanics of 21 patients with patellar tendinopathy and 22 controls were captured during walking and three types of squats. A statistical parametric mapping two-sample t-test was used to identify kinematic and kinetic differences between groups for each joint. Paired t-tests were used to compare pain before and after tasks, in patients with patellar tendinopathy.

      Findings

      During walking, cases demonstrated reduced knee joint power during initial contact and hip joint power during terminal stance. In squatting, cases demonstrated increased knee abduction angles at various time points of the small knee bend and single-leg squat. Cases demonstrated reduced knee internal rotation moment during the deepest portion of the single-leg squat and single-leg decline squat.

      Interpretation

      Gait appears unaffected by patellar tendinopathy, likely due to low task difficulty. Elevated knee abductions angles during squatting were confirmed as a key difference in patients with patellar tendinopathy. Reduced knee internal rotation moments in patients were attributed to a potential reduction in hip external rotator strength and possible pain avoidance strategy; however further evidence is required to substantiate these claims. Findings provide a clear rationale for rehabilitation programs to focus on knee stabilisation and strengthening of the muscles surrounding the hip.

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Clinical Biomechanics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Barker-Davies R.M.
        • Roberts A.
        • Bennett A.N.
        • Fong D.T.P.
        • Wheeler P.
        • Lewis M.P.
        Single leg squat ratings by clinicians are reliable and predict excessive hip internal rotation moment.
        Gait Posture. 2018; 61: 453-458https://doi.org/10.1016/j.gaitpost.2018.02.016
        • Barker-Davies R.M.
        • Roberts A.
        • Watson J.
        • Baker P.
        • Bennett A.N.
        • Fong D.T.P.
        • Wheeler P.
        • Lewis M.P.
        Kinematic and kinetic differences between military patients with patellar tendinopathy and asymptomatic controls during single leg squats.
        Clin. Biomech. (Bristol, Avon). 2019; 62: 127-135https://doi.org/10.1016/j.clinbiomech.2019.02.001
        • Barton C.J.
        • Levinger P.
        • Menz H.B.
        • Webster K.E.
        Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review.
        Gait Posture. 2009; 30: 405-416
        • Buckwalter J.A.
        Osteoarthritis and articular cartilage use, disuse, and abuse: experimental studies.
        J. Rheumatol. Suppl. 1995; 43: 13-15
        • Claiborne T.L.
        • Armstrong C.W.
        • Gandhi V.
        • Pincivero D.M.
        Relationship between hip and knee strength and knee valgus during a single leg squat.
        J. Appl. Biomech. 2006; 22: 41-50https://doi.org/10.1123/jab.22.1.41
        • Ferretti A.
        Epidemiology of jumper’s knee.
        Sports Med. 1986; 3: 289-295https://doi.org/10.2165/00007256-198603040-00005
        • Florit D.
        • Pedret C.
        • Casals M.
        • Malliaras P.
        • Sugimoto D.
        • Rodas G.
        Incidence of Tendinopathy in team sports in a multidisciplinary sports Club over 8 seasons.
        J. Sports Sci. Med. 2019; 18: 780-788
        • Ford K.R.
        • Nguyen A.-D.
        • Dischiavi S.L.
        • Hegedus E.J.
        • Zuk E.F.
        • Taylor J.B.
        An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus.
        Open Access J. Sport. Med. 2015; 6: 291-303https://doi.org/10.2147/OAJSM.S72432
        • Guilak F.
        Biomechanical factors in osteoarthritis.
        Best Pract. Res. Clin. Rheumatol. 2011; 25: 815-823https://doi.org/10.1016/j.berh.2011.11.013
        • Haddara R.
        • Harandi V.J.
        • Lee P.V.S.
        Anterior cruciate ligament agonist and antagonist muscle force differences between males and females during perturbed walking.
        J. Biomech. 2020; 110: 109971https://doi.org/10.1016/j.jbiomech.2020.109971
        • Haddara R.
        • Harandi V.J.
        • Lee P.V.S.
        Effect of prophylactic knee bracing on anterior cruciate ligament agonist and antagonist muscle forces during perturbed walking.
        Orthop. J. Sport. Med. 2021; 9 (2325967120981641)https://doi.org/10.1177/2325967120981641
        • Heino Brechter J.
        • Powers C.M.
        Patellofemoral stress during walking in persons with and without patellofemoral pain.
        Med. Sci. Sports Exerc. 2002; 34: 1582-1593https://doi.org/10.1097/00005768-200210000-00009
        • Herrington L.
        Knee valgus angle during single leg squat and landing in patellofemoral pain patients and controls.
        Knee. 2014; 21: 514-517https://doi.org/10.1016/j.knee.2013.11.011
        • Kaufman K.R.
        • Brodine S.
        • Shaffer R.
        Military training-related injuries: surveillance, research, and prevention.
        Am. J. Prev. Med. 2000; 18: 54-63https://doi.org/10.1016/s0749-3797(00)00114-8
        • Khan K.M.
        • Bonar F.
        • Desmond P.M.
        • Cook J.L.
        • Young D.A.
        • Visentini P.J.
        • Fehrmann M.W.
        • Kiss Z.S.
        • O’Brien P.A.
        • Harcourt P.R.
        • Dowling R.J.
        • O’Sullivan R.M.
        • Crichton K.J.
        • Tress B.M.
        • Wark J.D.
        Patellar tendinosis (jumper’s knee): findings at histopathologic examination, US, and MR imaging. Victorian Institute of Sport Tendon Study Group.
        Radiology. 1996; 200: 821-827https://doi.org/10.1148/radiology.200.3.8756939
        • Khan K.M.
        • Maffulli N.
        • Coleman B.D.
        • Cook J.L.
        • Taunton J.E.
        Patellar tendinopathy: some aspects of basic science and clinical management.
        Br. J. Sports Med. 1998; 32: 346-355https://doi.org/10.1136/bjsm.32.4.346
        • Lee T.Q.
        • Morris G.
        • Csintalan R.P.
        The influence of tibial and femoral rotation on patellofemoral contact area and pressure.
        J. Orthop. Sports Phys. Ther. 2003; 33: 686-693https://doi.org/10.2519/jospt.2003.33.11.686
        • Malliaras P.
        • Cook J.
        • Purdam C.
        • Rio E.
        Patellar Tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations.
        J. Orthop. Sports Phys. Ther. 2015; 45: 887-898https://doi.org/10.2519/jospt.2015.5987
        • Malloy P.J.
        • Morgan A.M.
        • Meinerz C.M.
        • Geiser C.F.
        • Kipp K.
        Hip external rotator strength is associated with better dynamic control of the lower extremity during landing tasks.
        J. Strength Cond. Res. 2016; 30: 282-291https://doi.org/10.1519/JSC.0000000000001069
        • Mündermann A.
        • Dyrby C.O.
        • Hurwitz D.E.
        • Sharma L.
        • Andriacchi T.P.
        Potential strategies to reduce medial compartment loading in patients with knee osteoarthritis of varying severity: reduced walking speed.
        Arthritis Rheum. 2004; 50: 1172-1178https://doi.org/10.1002/art.20132
        • Nakagawa T.H.
        • Moriya E.T.U.
        • Maciel C.D.
        • Serrão F.V.
        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: 491-501https://doi.org/10.2519/jospt.2012.3987
        • Naouma H.
        • Pataky T.C.
        A comparison of random-field-theory and false-discovery-rate inference results in the analysis of registered one-dimensional biomechanical datasets.
        PeerJ. 2019; 7e8189https://doi.org/10.7717/peerj.8189
        • Nieuwenhuys A.
        • Papageorgiou E.
        • Desloovere K.
        • Molenaers G.
        • De Laet T.
        Statistical parametric mapping to identify differences between consensus-based joint patterns during gait in children with cerebral palsy.
        PLoS One. 2017; 12e0169834https://doi.org/10.1371/journal.pone.0169834
        • Owens B.D.
        • Wolf J.M.
        • Seelig A.D.
        • Jacobson I.G.
        • Boyko E.J.
        • Smith B.
        • Ryan M.A.K.
        • Gackstetter G.D.
        • Smith T.C.
        Risk factors for lower extremity tendinopathies in military personnel.
        Orthop. J. Sport. Med. 2013; 1 (2325967113492707)https://doi.org/10.1177/2325967113492707
        • Pataky T.C.
        • Robinson M.A.
        • Vanrenterghem J.
        Vector field statistical analysis of kinematic and force trajectories.
        J. Biomech. 2013; 46: 2394-2401https://doi.org/10.1016/j.jbiomech.2013.07.031
        • Powers C.M.
        • Perry J.
        • Hsu A.
        • Hislop H.J.
        Are patellofemoral pain and quadriceps femoris muscle torque associated with locomotor function?.
        Phys. Ther. 1997; 77 (discussion 1075-8): 1063-1075
        • Powers C.M.
        • Heino J.G.
        • Rao S.
        • Perry J.
        The influence of patellofemoral pain on lower limb loading during gait.
        Clin. Biomech. (Bristol, Avon). 1999; 14: 722-728https://doi.org/10.1016/s0268-0033(99)00019-4
        • Powers C.M.
        • Chen P.-Y.
        • Reischl S.F.
        • Perry J.
        Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain.
        Foot Ankle Int. 2002; 23: 634-640https://doi.org/10.1177/107110070202300709
        • Robon M.J.
        • Perell K.L.
        • Fang M.
        • Guererro E.
        The relationship between ankle plantar flexor muscle moments and knee compressive forces in subjects with and without pain.
        Clin. Biomech. (Bristol, Avon). 2000; 15: 522-527https://doi.org/10.1016/s0268-0033(00)00007-3
        • Roper J.L.
        • Harding E.M.
        • Doerfler D.
        • Dexter J.G.
        • Kravitz L.
        • Dufek J.S.
        • Mermier C.M.
        The effects of gait retraining in runners with patellofemoral pain: a randomized trial.
        Clin. Biomech. (Bristol, Avon). 2016; 35: 14-22https://doi.org/10.1016/j.clinbiomech.2016.03.010
        • Salsich G.B.
        • Long-Rossi F.
        Do females with patellofemoral pain have abnormal hip and knee kinematics during gait?.
        Physiother. Theory Pract. 2010; 26: 150-159https://doi.org/10.3109/09593980903423111
        • Sole G.
        • Pataky T.
        • Tengman E.
        • Häger C.
        Analysis of three-dimensional knee kinematics during stair descent two decades post-ACL rupture - data revisited using statistical parametric mapping.
        J. Electromyogr. Kinesiol. 2017; 32: 44-50https://doi.org/10.1016/j.jelekin.2016.12.005
        • van der Straaten R.
        • Wesseling M.
        • Jonkers I.
        • Vanwanseele B.
        • Bruijnes A.K.B.D.
        • Malcorps J.
        • Bellemans J.
        • Truijen J.
        • De Baets L.
        • Timmermans A.
        Functional movement assessment by means of inertial sensor technology to discriminate between movement behaviour of healthy controls and persons with knee osteoarthritis.
        J. Neuroeng. Rehabil. 2020; 17: 65https://doi.org/10.1186/s12984-020-00694-2
        • Willy R.W.
        • Scholz J.P.
        • Davis I.S.
        Mirror gait retraining for the treatment of patellofemoral pain in female runners.
        Clin. Biomech. (Bristol, Avon). 2012; 27: 1045-1051https://doi.org/10.1016/j.clinbiomech.2012.07.011
        • Winter D.A.
        • Sidwall H.G.
        • Hobson D.A.
        Measurement and reduction of noise in kinematics of locomotion.
        J. Biomech. 1974; 7: 157-159https://doi.org/10.1016/0021-9290(74)90056-6
        • Woltring H.J.
        A Fortran package for generalized, cross-validatory spline smoothing and differentiation.
        Adv. Eng. Softw. 1986; 8: 104-113https://doi.org/10.1016/0141-1195(86)90098-7
        • Zawadka M.
        • Smolka J.
        • Skublewska-Paszkowska M.
        • Lukasik E.
        • Bys A.
        • Zielinski G.
        • Gawda P.
        Sex-dependent differences in single-leg squat kinematics and their relationship to squat depth in physically active individuals.
        Sci. Rep. 2020; 10: 19601https://doi.org/10.1038/s41598-020-76674-2