Kinematic and Kinetic Gait Characteristics in People with Patellofemoral Pain: A Systematic Review and Meta-analysis

Abstract Background Patellofemoral pain (PFP) is a prevalent knee condition with many proposed biomechanically orientated etiological factors and treatments. Objective We aimed to systematically review and synthesize the evidence for biomechanical variables (spatiotemporal, kinematic, kinetic) during walking and running in people with PFP compared with pain-free controls, and determine if biomechanical variables contribute to the development of PFP. Design Systematic review and meta-analysis. Data sources We searched Medline, CINAHL, SPORTDiscus, Embase, and Web of Science from inception to October 2021. Eligibility criteria for selecting studies All study designs (prospective, case–control [± interventional component, provided pre-intervention data were reported for both groups], cross-sectional) comparing spatiotemporal, kinematic, and/or kinetic variables during walking and/or running between people with and without PFP. Results We identified 55 studies involving 1300 people with PFP and 1393 pain-free controls. Overall pooled analysis identified that people with PFP had slower gait velocity [moderate evidence, standardized mean difference (SMD) − 0.50, 95% confidence interval (CI) − 0.72, − 0.27], lower cadence (limited evidence, SMD − 0.43, 95% CI − 0.74, − 0.12), and shorter stride length (limited evidence, SMD − 0.46, 95% CI − 0.80, − 0.12). People with PFP also had greater peak contralateral pelvic drop (moderate evidence, SMD − 0.46, 95% CI − 0.90, − 0.03), smaller peak knee flexion angles (moderate evidence, SMD − 0.30, 95% CI − 0.52, − 0.08), and smaller peak knee extension moments (limited evidence, SMD − 0.41, 95% CI − 0.75, − 0.07) compared with controls. Females with PFP had greater peak hip flexion (moderate evidence, SMD 0.83, 95% CI 0.30, 1.36) and rearfoot eversion (limited evidence, SMD 0.59, 95% CI 0.03, 1.14) angles compared to pain-free females. No significant between-group differences were identified for all other biomechanical variables. Data pooling was not possible for prospective studies. Conclusion A limited number of biomechanical differences exist when comparing people with and without PFP, mostly characterized by small-to-moderate effect sizes. People with PFP ambulate slower, with lower cadence and a shortened stride length, greater contralateral pelvic drop, and lower knee flexion angles and knee extension moments. It is unclear whether these features are present prior to PFP onset or occur as pain-compensatory movement strategies given the lack of prospective data

Is impaired knee confidence related to worse kinesiophobia, symptoms, and physical function in people with knee osteoarthritis after anterior cruciate ligament reconstruction?

Objectives: To compare knee confidence and kinesiophobia (fear of re-injury) in those with and without knee osteoarthritis following anterior cruciate ligament reconstruction, and determine whether poorer knee confidence is associated with greater kinesiophobia, worse knee-related symptoms, and functional impairments in those with knee osteoarthritis

Medical Interventions for Patellofemoral Pain and Patellofemoral Osteoarthritis

Patellofemoral pain (PFP) and patellofemoral osteoarthritis (PFOA) are common, persistentconditions that may lie along a pathological spectrum. While evidence supports exercise-therapyas a core treatment for PFP and PFOA, primary care physicians commonly prescribe medication,or refer for surgical consults in persistent cases. We conducted a systematic review of medicalinterventions (pharmaceutical, nutraceutical, and surgical) for PFP and PFOA to inform primarycare decision making. Methods: Following protocol registration, we searched seven databasesfor randomized clinical trials of our target interventions for PFP and PFOA. Our primary outcomewas pain. We assessed risk of bias, calculated standardized mean differences (SMDs) and determinedthe level of evidence for each intervention. Results: We included 14 publications investigatingpharmaceutical or nutraceutical interventions, and eight publications investigating surgicalinterventions. Two randomized control trials (RCTs) provided moderate evidence of patellofemoralarthroplasty having similar pain outcomes compared to total knee arthroplasty in isolated PFOA,with SMDs ranging from−0.3 (95% CI−0.8, 0.2, Western Ontario McMaster Pain Subscale, 1 yearpost-surgery) to 0.3 (−0.1, 0.7, SF-36 Bodily Pain, 2 years post-surgery). Remaining studies provided,at most, limited evidence. No efficacy was demonstrated for oral nonsteroidal anti-inflammatoriesor arthroscopic surgery. Conclusions: Pharmaceutical and nutraceutical prescriptions, and surgicalreferrals are currently being made with little supporting evidence, with some interventions showinglimited efficacy. This should be considered within the broader context of evidence supportingexercise-therapy as a core treatment for PFP and PFOA

Clinical findings in patellofemoral osteoarthritis compared to individually-matched controls: A pilot study

Objective To explore clinical characteristics in individuals with patellofemoral osteoarthritis (PFOA) compared to individually-matched asymptomatic controls. We also explored associations between functional performance and patient-reported symptoms with patellofemoral alignment. Methods We assessed 15 individuals with PFOA and 15 individually-matched asymptomatic controls. In addition to physical examination and patient-reported questionnaires, we evaluated functional performance, lower extremity strength and range of motion, and patellar alignment (using MRI). We analysed group differences with Wilcoxon's matched-pairs signed rank tests, and within-group associations with Spearman's rank correlations. Results We included 24 (80%) women with median (IQR) age of 56 (9) years and BMI of 22.8 (5.9) kg/m 2. Individuals with PFOA reported lower quality of life (8/100 points lower EQ-5D-5L, p=0.02), and performed worse on two functional tests: repeated one-leg rises (median 16 fewer rises, p=0.04) and timed stair climb (1.2 s slower, p=0.03). There were no differences in strength tests performed or range of motion. Patellar proximal translation correlated with worse functional performance and worse patient-reported pain, function and self-efficacy, while lateral translation and lateral tilt correlated with worse knee-related quality of life (Spearman's r ranging from 0.5 to 0.7). Conclusion Functional performance was worse in individuals with PFOA, despite those individuals having no significant differences on lower extremity strength testing. Patellofemoral alignment was associated with worse functional performance as well as worse patient-reported outcomes, and it may represent one mechanism underpinning PFOA-related symptoms

Developing Clinical and Research Priorities for Pain and Psychological Features in People With Patellofemoral Pain:An International Consensus Process With Health Care Professionals

OBJECTIVE: To decide clinical and research priorities on pain features and psychological factors in persons with patellofemoral pain. DESIGN: Consensus development process. METHODS: We undertook a 3-stage process consisting of (1) updating 2 systematic reviews on quantitative sensory testing of pain features and psychological factors in patellofemoral pain, (2) an online survey of health care professionals and persons with patellofemoral pain, and (3) a consensus meeting with expert health care professionals. Participants responded that they agreed, disagreed, or were unsure that a pain feature or psychological factor was important in clinical practice or as a research priority. Greater than 70% participant agreement was required for an item to be considered important in clinical practice or a research priority. RESULTS: Thirty-five health care professionals completed the survey, 20 of whom attended the consensus meeting. Thirty persons with patellofemoral pain also completed the survey. The review identified 5 pain features and 9 psychological factors—none reached 70% agreement in the patient survey, so all were considered at the meeting. Afte the meeting, pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy were the only factors considered clinically important. All but the therma pain tests and 3 psychological factors were consid ered research priorities. CONCLUSION: Pain catastrophizing, pain self-efficacy, and fear-avoidance beliefs were factors considered important in treatment planning, clinical examination, and prognostication. Quantitative sensory tests for pain were not regarded as clinically important but were deemed to be research priorities, as were most psychological factors.</p

Post-traumatic knee osteoarthritis after anterior cruciate ligament reconstruction: Psychological, functional and biomechanical factors and the effect of a targeted brace

© 2015 Dr. Harvi HartPost-traumatic knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) is prevalent in younger adults and has the potential to cause substantial knee-related symptoms and limit physical function. Physical and psychological impairments are likely to adversely affect quality of life and work participation. Knowledge of modifiable risk factors associated with knee OA post-ACLR has the greatest capacity to lead to new interventions that could change the natural history of knee OA. What are the modifiable factors associated with knee OA post-ACLR? Section A of this thesis describes the results of two cross-sectional studies which revealed that individuals with knee OA five to 12 years post-ACLR have worse knee confidence and greater kinesiophobia compared with individuals who have no OA five to 12 years post-ACLR. In individuals with knee OA five to 20 years post-ACLR, those with worse knee confidence have worse knee-related symptoms, poorer function, greater kinesiophobia, and poorer perceived self-efficacy and health-related quality of life. Section B of this thesis investigated knee biomechanics during walking in individuals post-ACLR. Pooled data from a systematic review revealed that, compared to healthy controls and uninjured contralateral knees, ACLR knees have abnormal knee biomechanics, particularly in the sagittal plane. Systematic review findings also revealed that the type of graft (hamstring or patellar) and time post-surgery could also influence knee biomechanics. A cross-sectional study also evaluated biomechanics in people with lateral knee OA post-ACLR. Compared to healthy controls, individuals with lateral knee OA five to 20 years post-ACLR had greater knee flexion and lower knee internal rotation angles, as well as greater pelvic anterior tilt, and hip flexion angles. Is there a potential intervention for modifiable risk factors associated with knee OA post-ACLR? A targeted knee brace was investigated for individuals with knee OA post-ACLR. First, a within-subject randomized study investigated the immediate and four-week effects of a targeted knee brace on knee-related symptoms and function in individuals with knee OA post-ACLR. The brace produced improvements in knee-related symptoms immediately and following four weeks of intervention. Second, a within-subject randomized study evaluated the immediate effects of varus bracing on gait characteristics in individuals with lateral knee OA post-ACLR. Results revealed that the unloader brace significantly altered gait characteristics associated with lateral knee OA post-ACLR. Overall, this thesis sheds light on some of the modifiable risk factors associated with knee OA post-ACLR, and investigated one targeted intervention with the potential to improve quality of life of individuals with knee OA post-ACLR. Targeting psychological, functional and biomechanical risk factors in individuals post-ACLR may aid in optimal recovery, and slowing disease progression in individuals with knee OA post-ACLR

OARSI year in review 2018: rehabilitation and outcomes

Objective: Conduct a systematic review of systematic reviews and randomised controlled trials (RCTs) from the past year evaluating rehabilitation for people with osteoarthritis, and provide narrative synthesis of findings focused on core recommended treatments for osteoarthritis (exercise, education, biomechanical interventions, weight loss). Design: A comprehensive search strategy was used to search PubMed, EMBASE and Cochrane databases (16 May 2017 to 22 March 2018). Search terms included 'osteoarthritis', 'rehabilitation', 'systematic review', and 'randomised controlled trial'. Inclusion criteria were: (i) RCT, or systematic review of RCTs; (ii) human participants with osteoarthritis (any joint); (iii) evaluation of rehabilitation intervention; and (iv) at least one patient-reported measure. Methodological quality was evaluated using the AMSTAR tool (systematic reviews) and PEDro rating scale (RCTs). Narrative synthesis mapped findings to core recommendations from existing osteoarthritis clinical guidelines. Results: From 1994 records, 13 systematic reviews and 36 RCTs were included. 73% of these evaluated knee osteoarthritis (36 studies). The remaining studies evaluated hand osteoarthritis (6 studies), hip, hip/knee and general osteoarthritis (each 2 studies), and neck osteoarthritis (1 study). Exercise was the most common intervention evaluated (31%). Updated recommendations for exercise prescription and preliminary guidance for psychological interventions are provided. Conclusion: Level 1 and 2 osteoarthritis rehabilitation literature continues to be dominated by knee osteoarthritis studies. Consistent with current clinical guidelines, exercise should be a core treatment for osteoarthritis, but future studies should ensure that exercise programs follow published dose guidelines. There is a clear need for research on rehabilitation for hip, hand, foot/ankle, shoulder and spine osteoarthritis

Bracing of the reconstructed and osteoarthritic knee during high dynamic load tasks

Purpose: Lateral compartment osteoarthritis accompanied by abnormal knee biomechanics is frequently reported in individuals with knee osteoarthritis after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to evaluate changes in knee biomechanics produced by an adjusted and unadjusted varus knee brace during high dynamic loading activities in individuals with lateral knee osteoarthritis after ACLR and valgus malalignment. Methods: Nineteen participants who had undergone ACLR 5 to 20 yr previously and had symptomatic and radiographic lateral knee osteoarthritis with valgus malalignment were assessed. Quantitative motion analysis experiments were conducted during hopping, stair ascent, and descent under three test conditions: (i) no brace, (ii) unadjusted brace with sagittal plane support and neutral frontal plane alignment, and (iii) adjusted brace with sagittal plane support and varus realignment (valgus to neutral). Sagittal, frontal, and transverse plane knee kinematics, external joint moment, and angular impulse data were calculated. Results: Relative to an unbraced knee, braced conditions significantly increased knee flexion and adduction angles during hopping (P = 0.003 and P = 0.005; respectively), stair ascent (P = 0.003 and P G 0.001, respectively), and descent (P = 0.009 and P G 0.001, respectively). In addition, the brace conditions increased knee flexion (P G 0.001) and adduction (P = 0.001) angular impulses and knee stiffness (P G 0.001) during hopping, as well as increased knee adduction moments during stair ascent (P = 0.008) and flexion moments during stair descent (P = 0.006). There were no significant differences between the adjusted and the unadjusted brace conditions (P 9 0.05). Conclusion: A knee brace, with or without varus alignment, can modulate knee kinematics and external joint moments during hopping, stairs ascent, and descent in individuals with predominant lateral knee osteoarthritis after ACLR. Longer-term use of a brace may have implications in slowing osteoarthritis progression