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Running has become an increasingly popular form of physical activity due to the
associated health benefits22 such as reducing the risk of cardiovascular disease,47 type II
diabetes88 and obesity.39 Apart from the health benefits, running is also easily accessible and does
not require special equipment or location, making it even more appealing to the general
population as a form of exercise. Running is also a source of stress relief and social interaction.
Habitual runners report feeling happier and more energetic, as well as have reported adopting
healthier eating and sleep habits and decreasing the use of alcohol and tobacco.5,30,31
In 2015, it was reported that approximately 48.5 million Americans run75 and while
associated with numerous health benefits, running can potentially lead to injury. In fact, it is
estimated that 27% to 70% of recreational and competitive distance runners experience an
overuse injury per year.22 With the growing popularity of running as a form of physical activity,
Injury can result in a decrease in running participation and in some cases, complete
cessation. As a result of being unable to run or participate fully, feelings of guilt, irritability,
depression and decreased energy have been reported.5,31 In addition, as a rapidly increasing form
of physical activity for the general population, being unable to participate in running can lead to
overall decreases physical activity. Therefore, further understanding of the risk factors of
running-related injuries is an avenue to ensure that individuals can continue to enjoy being
physically active.
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normal joint kinematics that occur while running. The gait cycle can be divided into two distinct
phases, stance and swing. The stance phase is defined as the time in which the foot is in contact
with the ground. The swing phase is the time in which the foot is in the air and the leg is
advancing forward. The time spent in each of these phases is dependent on speed. During
running, the stance phase constitutes approximately 35% of the gait cycle, while 65% of the gait
cycle is spent in swing phase.61 Because of the impact experienced when the foot comes in
contact with the ground, kinematics during the stance phase are focused on.
When the foot strikes the ground, it does so in a more supinated position. As the stance
phase continues, the foot pronates until midstance. Foot pronation allows for shock absorption to
be attenuated over a longer period of time and accommodates for uneven surfaces. Peak
pronation is typically experienced by midstance. After midstance, it is necessary for the foot to
supinate in order to produce a stable lever for the runner to propel forward off of. Because of the
tight articulation of the talus and the tibia, pronation is accompanied by internal rotation of the
tibia. Conversely, foot supination is accompanied by external rotation of the tibia. At the knee,
initial contact indicates that the limb is being loaded. In response, the knee flexes to
approximately 45 as body weight is being accepted onto the single limb. In order for normal
knee flexion to occur, the tibia must internally rotate to allow the knee to unlock and flex. The
knee is also in an abducted position and remains abducted for most of the stance phase. After
midstance, knee flexion is reduced to 15 and the knee externally rotates. The hip, at initial
contact is flexed to approximately 30 and remains in this position until midstance. Internal
rotation and adduction also occurs. Hip adduction during the stance phase serves as shock
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absorbing mechanism. After midstance, the hip externally rotates and hip adduction decreases to
a neutral position at the end of stance.17 After midstance, hip flexion decreases and is fully
Running injuries can be classified as acute traumatic or overuse. While acute traumatic
injuries, such as an ankle sprain or muscle strains do occur, overuse injuries are more prevalent.
Overuse injuries result from repeated stress placed on the body, without sufficient rest periods in
between, that when combined over time, exceed the bodys injury threshold. In other words, the
body is not able to repair itself quickly enough before more breakdown occurs; the rate of
breakdown exceeds the rate of repair. While the exact cause of running overuse injuries is
difficult to pinpoint, risk factors can be categorized as training errors, anatomical variables and
abnormal biomechanics. Training errors include running distance, training intensity, increasing
weekly mileage or intensity too quickly and stretching habits. Anatomical risk factors include
excessive foot arch height, ankle range of motion, leg length discrepancies and lower extremity
alignment such as, genu varum, excessive Q-angle and rear foot varus.14 Abnormal biomechanics
A systematic review on running injury incidence reported that the knee is the most
common site for overuse injury and accounts for up to half of all running injuries.72,83 The lower
leg is the second most common site for injury (9-32%), followed by the foot (5.7-39.3%), upper
leg (3.4-38.1%), ankle (3.9-16.6%) and hip/pelvis (3.3-11.5%). Overuse running injuries include
patellofemoral pain syndrome (PFPS), iliotibial band syndrome (ITBS), plantar fasciitis, Achilles
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tendonitis and medial tibial stress syndrome.22 However, because of the prevalence of PFPS and
Etiology
Patellofemoral pain syndrome (PFPS) is the most common overuse running injury and is
characterized by aching pain under or around the knee cap. While running, the pain usually starts
when running has ceased and worsens over the next 1-12 hours. Pain is exacerbated by sitting for
extended periods of time, squatting, climbing stairs and jumping. While the cause of pain is still
debated, one explanation is increased stress on the patellofemoral joint from patella
malalignment. Individuals with PFPS often deal with chronic and recurring pain. In a
retrospective case-control study, 91% of subjects initially diagnosed with PFPS had reoccurring
symptoms 4-18 years later, with 36% of the subjects restricting their level of physical activity.81
Under normal alignment conditions, the femur is aligned vertically over tibia and the
patella articulates with the trochlear groove of the femur. The patella is anchored to the femur via
the quadriceps tendon and to the tibia via the patellar tendon. Because the forces exerted on the
patella at these attachment sites are not collinear, the patella is predisposed to lateral forces when
the quadriceps contract. Originally, it was thought that patellar misalignment resulted from the
patella moving in relation to the femur and ultimately resulted in PFPS. Therefore, treatment for
PFPS focused on limiting motion of the patella and included strengthening of the quadriceps or
bracing/taping the patella. While this holds true for non-weight bearing activity, use of magnetic
resonance imaging during a weight bearing activities has shown that the femur actually internally
rotates in relation to the patella. Using magnetic resonance imaging, Powers et al. compared
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patellofemoral joint kinematics between a non-weight bearing knee extension exercise and a
weight-bearing single-leg squat exercise in females with PFPS. During the non-weight bearing
knee extension exercise, lateral patellar displacement was greater than during the weight-bearing
single-leg squat exercise. Internal femoral rotation was significantly greater during the weight-
bearing single-leg exercise compared to the non-weight bearing exercise.68 Also using magnetic
resonance imaging, Souza et al. compared patellofemoral joint kinematics during a single-limb
squat in females with PFP to a healthy control group. Outcome measures included femur and
patella rotation, lateral patella tilt and lateral patella displacement at 45, 30, 15 and 0 of knee
flexion. Compared to the control group, females with PFPS exhibited greater lateral patella
displacement at all angles of knee flexion during the single-leg squat. Greater lateral patella tilt at
30, 15 and 0 and similar to results of Powers et al., increased medial femoral rotation at 45,
15 and 0 degrees were seen in the symptomatic group.79 It has been shown that as little as five
degrees of femoral internal rotation increases shear stress, subsequently increasing lateral patella
facet pressure.48 Rather than focusing solely on the knee, researchers have become interested in
how the knee can be affected proximally by hip mechanics and distally by foot mechanics.
Proximal joints, such as the hip, have been hypothesized to have influence on PFPS. The
hip and knee share a common bone, the femur. Therefore, excessive femoral movement has been
suggested to affect knee kinematics because of the articulation between the femur and the patella.
Specifically, increased hip adduction and hip internal rotation have been hypothesized as
potential risk factors for PFPS, however results are inconsistent. A study comparing lower
extremity mechanics in females with and without PFPS assessed lower extremity mechanics
across three different tasks. Each task was progressively more demanding than the previous and
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was designed to elicit greater responses to external demands. Tasks included single-leg squat,
running and single-leg jump. In all three tasks, females with PFPS experienced increased hip
adduction. Hip internal rotation was not increased in this study. Authors hypothesize that the
decrease in hip internal rotation was a compensatory mechanism to decrease pain.89 Similar
results were produced in another study comparing hip kinematics in female runners with and
without PFPS. In addition to increased hip adduction, the PFPS group also demonstrated
increased internal rotation.58 In a prospective study that followed 400 female runners over two
years, females who developed PFPS demonstrated increased hip adduction compared to female
runners who did not develop PFPS. Contrary to retrospective evidence, increased hip internal
rotation was not found.57 Decreased hip muscle strength has been proposed to cause abnormal
Decreases in hip strength have been suggested to result in abnormal hip kinematics and
subsequently altered knee kinematics. A limitation to the aforementioned studies is that muscle
strength was not measured. Rather, muscle strength was only hypothesized to cause the abnormal
kinematics. When hip strength and kinematics were evaluated together, results again are
inconsistent. During a stair descent task, females with PFPS demonstrated 24% less hip external
rotator torque and 26% less abductor torque compared to the control group. However, no
differences in hip adduction, internal rotation or knee valgus were found. Authors speculate that
absence of kinematic differences may have been because the stair descent task was not difficult
enough to challenge the hip musculature.4 Hip kinematics and muscle strength were assessed
during running, drop jump and step-down tasks in females with PFPS. When averaged across all
three tasks, the PFPS group demonstrated greater hip internal rotation that was accompanied by
14% decrease in hip abductor strength and 17% decrease in hip extensor strength when
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compared to the control group. Significant differences were not seen in hip adduction between
the two groups.80 During a single-leg squat task, males and females with PFPS demonstrated
increased hip adduction and knee abduction along with reduced eccentric hip abduction and hip
external rotation strength compared to the control groups. Increased hip internal rotation was
only found in females with PFPS.52 Similar results were found during a step-down task. Males
and females with PFPS demonstrated increased hip adduction and knee abduction compared to
the control groups. Isometric hip abductor torque also reduced.53 During a run to fatigue task,
combined male and female runners with PFPS demonstrated decreased hip abduction strength
and hip external rotation strength both at the beginning of the run and at the end of the run
compared to the control group. However, at the beginning of the run, decreased hip abduction
strength was not associated with increased hip adduction. Only at the end of the run, when
subjects were in a fatigued state, did the relationship become significant. No association between
decreased hip external rotation strength and hip internal rotation was found for the PFPS group at
the beginning or end of the run.7 A recent systematic review and meta-analysis investigating hip
strength as a risk factor for PFPS in both males and females found conflicting results between
relationship between PFPS and decreased isometric hip muscle strength, moderate-to-strong
prospective evidence suggests no association between hip strength and risk of developing PFPS.
Authors of this review concluded that hip strength deficits may be a result of PFPS rather than
the cause.69
Normal movement during gait includes subtalar joint pronation occurring during the first
30% of stance phase. In response, the tibia internally rotates 6 to 10.26,71 When pronation is
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prolonged or the amount of pronation is excessive, pronation is deemed abnormal. The coupling
motion between the tibia and subtalar joint has led to the assumption that increased pronation
leads to increased tibial internal rotation which in turn stresses the tissues at the knee joint. While
this chain of events may be true for the tibiofemoral joint, increased tibial rotation actually
decreases the Q-angle and thus the lateral forces acting on the patella. In order for the
patellofemoral joint to be affected, the femur must implicated.66 Tiberio et al. described a
situation in which excessive pronation and increased tibial rotation would affect the
patellofemoral joint. In order for the patellofemoral joint to be affected by excessive internal
tibial rotation, compensatory internal rotation of the femur would have to occur, causing
abnormal patellar tracking with the trochlear groove of the femur. A situation in which
compensatory internal rotation of the femur would occur is when the foot is unable to supinate
during midstance as it is supposed to which subsequently causes the tibia to remain internally
rotated. For normal knee extension to occur, the tibia must externally rotate. In an effort to
compensate for the tibia remaining internally rotated, the femur internally rotates to align with
the tibia so that knee extension can occur.85 This may explain why studies investigating foot
mechanics in individuals with PFPS have not found significant results. In 36 runners, Messier et
al. found no significant differences in maximum pronation, maximum pronation velocity or total
rearfoot movement in comparison to the control group.50 Similarly, Powers et al. found no group
differences in magnitude and timing of peak foot pronation and tibial rotation when comparing
24 females with PFP to 17 controls.67 Noehren and colleagues compared 16 female runners with
PFP to 16 healthy female runners and found no differences in foot mechanics. Interestingly, the
PFP group demonstrated greater internal tibial rotation despite absence of increased foot
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pronation. Authors hypothesized that the increased internal rotation of the tibia may have been
the result of the abnormal hip mechanics also demonstrated in the PFP group.58
Females are twice as likely to develop PFPS, resulting in the majority of studies utilizing
females as their subjects, however males with PFPS also demonstrate abnormal kinematics, but
not in the same manner as females. Willy et al. investigated the differences in movement patterns
between males and females with and without PFPS while running and performing single-leg
squats. Results showed that males with PFP ran and performed single-leg squats with greater
peak knee adduction when compared to females with PFP and a healthy male population. When
differences between genders were considered, males demonstrated less hip adduction and greater
knee adduction. This study suggests that males run and perform single-leg squats in with an
excessive knee varum alignment90, placing stress on the medial aspect of the patellofemoral
joint,36 as opposed to females with PFPS who demonstrate increased knee valgus alignment,90
which places stress on the lateral aspect of the patellofemoral joint.36 These results suggest that
treatment for PFPS may need to be tailored to the individual, depending on gender.
Muscle strengthening
To improve control of lower extremity kinematics associated with PFPS, both hip and
strengthening has been considered standard practice for treating PFPS. However with the high
evidence that the femur rotates in relation to the patella during weight-bearing activity,
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interventions have shifted their focus more proximally to include strengthening of the hip
musculature.
Various methods have been implemented to understand the efficacy of hip musculature
strengthening protocols in improving pain, function and hip strength. These methods include
investigating the effects of a hip strengthening only protocol in a single cohort44,86, comparing the
effects of protocols that combine hip and quadriceps strengthening to quadriceps strengthening
Khayambashi et al. found that pain, health status and hip abductor and external rotator strength
improved in the group participating in the hip strengthening protocol compared to a no exercise
control group. Pain and health status remained improved 6-months after the intervention. Hip
abduction and external rotation strength were not reassessed, therefore it cannot be concluded
that the continued improvements in pain and health status resulted from improved muscle
strength.44 After a 6-week hip musculature strengthening and flexibility protocol, Tyler et al.
found that pain decreased in 66% of the participants. Decrease in pain was accompanied by
increases in iliopsoas and iliotibial band flexibility and hip flexion, abduction and adduction
strength. No control group was included in this study, but for further analysis, participants were
decreases in pain. Interestingly, improvements in hip abduction and adduction strength were
found to be unrelated to success. Rather success was attributed to increases in flexibility of the
provide greater benefit than quadriceps strengthening alone. For example, several studies have
demonstrated the ability of additional hip strengthening to reduce pain in a more efficient
manner. In a randomized clinical trial, 33 females with PFPS underwent either an initial 4-week
included pain, function and hip strength. Authors hypothesized that the group initially focused on
hip strengthening would show quicker improvements in symptoms and be better prepared for the
functional weight-bearing exercise protocol. After the 8-week intervention, both groups
experienced similar improvements in pain, function, and hip external rotator strength, however,
the hip strengthening group reported significant decreases in pain after only 4 weeks. Hip
abduction strength also increased significantly in the hip strengthening group. The initial
quadriceps strengthening group did not experience the same decrease in pain until the end of the
8-week protocol. 8 Studies conducted by Nakagawa et al. and Ismail et al. found that pain was
significantly reduced with the combined hip and quadriceps muscle strengthening in comparison
to a quadriceps only strengthening protocol. However neither of these studies found increased
hip strength in addition to the greater reductions in pain.38,54 With the inclusion of a no exercise
control group, in addition to a combined hip and quadriceps strengthening protocol and a
quadriceps only strengthening protocol and a no exercise control group, both rehabilitation
groups experienced increases in function and decreases in pain. In line with previous studies, the
combined hip and quadriceps strengthening group experienced greater reductions in pain during
the stair descent task. Strength was not measured in this study.21 In a follow-up study, the
combined hip and quadriceps strengthening group demonstrated greater function and less pain
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compared to the quadriceps strengthening only group. At 3, 6 and 12 months post-intervention,
the combined hip and quadriceps maintained improvements in pain and function at 3, 6 and 12
pain only at 3 months and 6 month post-intervention. To date, this is the only study with a 1 year
follow-up and while it is only one study, it provides further support for the inclusion of hip
strengthening. Similar to results found from studies adding hip muscle strengthening to a
quadriceps strengthening protocol, Ferber et al. found that after a 6-week intervention, both
hip/core strengthening group experienced a reduction in pain earlier than the quadriceps
strengthening group accompanied by greater improvements in hip abduction and hip extension
strength.13 These results agree with Khayambashi et al. who also found that improvements were
still present at 6-months post-intervention. As in the short term results, both groups maintained in
improvements at 6-months, but those who participated in the hip muscle strengthening
demonstrated superior results.45 While the aforementioned studies show the benefits of proximal
hip musculature strengthening in improving pain, function and strength, a limitation is that
changes in lower extremity kinematics were not investigated. It was speculated that by increasing
muscle strength, lower extremity kinematics would also be affected, particularly in the frontal
and transverse planes of the hip and knee. In some studies, strength was not assessed, meaning
no conclusions could be drawn about the relationship between hip muscle strength and lower
extremity kinematics.
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Muscle strengthening to control lower extremity kinematics, such as hip adduction and
hip internal rotation, have become a popular treatment option for individuals with PFPS. This
being said, studies actually investigating kinematic changes in response to muscle strengthening
protocol are limited. Earl et al. investigated the effects of a proximal strengthening program on
hip strength, core endurance, pain, function and lower extremity running biomechanics. Nineteen
females with PFPS participated in an 8-week proximal stability program focused on improving
strength and neuromuscular control of hip and core musculature. After the intervention,
significant improvements were seen in pain, functional ability, hip abductor and external rotator
strength and lateral core endurance. Changes in lower extremity biomechanics included a
reduction in knee abduction moment. No differences were observed in joint range of motion for
rear foot eversion, knee abduction, hip abduction or hip external rotation. Absence of kinematic
differences after the intervention was unexpected because of the association between hip muscle
weakness and excessive joint motion. At the 6-month follow-up, 4 participants reported that
their pain level remained decreased, while 4 participants reported a slight increase in pain, but
still below pre-intervention pain levels.9 Ferber et al. investigated changes in knee biomechanics
after a 3-week hip-abductor strengthening protocol in runners with PFPS. Compared to the
increased hip abductor strength and reduced pain and decreased stride-to-stride knee joint
variability while running. Interestingly, no changes in peak knee genu valgum were observed,
suggesting that evaluation of peak joint angles may not a sufficient measure to gauge progress
after an intervention15 Lastly, a randomized clinical trial investigated the effects of a functional
stabilization training protocol on pain, lower extremity and trunk kinematics during a single-leg
squat, trunk endurance and eccentric torque. Thirty-one females with PFPS were randomly
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assigned to an 8-week functional stabilization protocol or quadriceps strengthening protocol. The
functional stabilization protocol combined hip and knee strengthening with verbal feedback on
correct lower extremity alignment during functional exercise. Females assigned to the functional
stabilization protocol demonstrated greater improvements in pain, physical function, lower limb
and trunk kinematics, trunk muscle endurance and eccentric strength of the hip and knee
musculature when compared to females who participated in the quadriceps only strengthening
protocol. In this study, changes in kinematics associated with PFPS were seen in response to hip
abductor, extensor and lateral rotator muscle strengthening after the functional stabilization
training protocol. Specifically, during the single-leg squat task, decreased contralateral pelvic
depression, hip adduction and knee abduction movement were observed. At the 3-month follow-
up, the functional stabilization group experienced greater decreases in pain than the quadriceps
strengthening group. The incorporation of verbal feedback in the functional stabilization protocol
makes the findings of this study unique and brings to question the benefits of including verbal
kinematics during a single-leg squat were seen, it is not possible to determine if the functional
stabilization exercises were responsible for the changes in kinematic or if the addition of verbal
Gait retraining
Gait retraining has also been used to correct abnormal kinematics in individuals with
PFPS. Using real-time kinematic feedback of hip adduction angle, subjects with PFPS and
excessive hip adduction underwent 8 gait retraining sessions. While on a treadmill, each subjects
hip adduction angle was projected on a computer screen. Subjects were instructed to keep their
hip adduction angle within the grey region of the curve, which represented a normal hip
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adduction angle. Verbal cues including contract gluteal muscles, run with their knees pointing
forward and maintain a level pelvis were also included in the retraining sessions. Based on a
faded feedback protocol, visual feedback was provided continuously for the first 4 sessions and
then gradually removed for the last 4 sessions. Learning was assessed by skill transfer of altered
mechanics to a single-leg squat. Results showed that all subjects were able to reduce hip
adduction and contralateral pelvic drop and maintain reductions at 1-month follow up. Only
reduction in hip adduction transferred to the single-leg squat. Impact loading was also reduced.60
Using both visual and auditory feedback, 10 female runners with patellofemoral pain ran on a
treadmill with a full length mirror placed in front of them to provide visual feedback on lower
extremity alignment. Verbal instructions were given which included run with knees apart and
with knee caps pointing straight ahead and to squeeze buttocks. At the first training session,
each subject was shown a video of themselves running and were educated on their abnormal hip
mechanics. For training sessions 1 through 4, run time and visual and verbal feedback time were
gradually increased from 15 minutes to 30 minutes. For training sessions 4 through 8, visual and
verbal feedback were gradually removed. Results showed that all subjects were able to reduce
hip adduction, contralateral pelvic drop and hip abduction moment and maintain improvements
at 1 month and 3 month follow-ups. Skill transfer to an untrained functional task was assessed
through performance of a single leg squat and step descent. Improvements in hip adduction,
contralateral pelvic drop and hip abduction moment were also seen during performance of
single-leg squat and stair descent and were maintained at 1-month and 3-month follow-ups.
Reductions in hip internal rotation were not observed.91 Altering foot strike pattern has also been
proposed as a gait retraining protocol to reduce PFPS. Approximately 75% of shod runners are
considered rear foot strikers. Runners with a rear foot strike have been found to be a greater risk
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for developing knee pain than rear foot strikers. Additionally, rear foot strikers report less injury
to the knee. This discrepancy between forefoot strikers and rear foot strikers is thought be the
result of greater shock and loading rate associated with a rear foot strike. Use of a forefoot strike
is also associated with decreased patellofemoral contact force and stress. Therefore, Roper et al.
investigated if runners with PFPS benefitted from gait retraining that altered their foot mechanics
from a rear foot strike to a forefoot strike. Runners with PFPS assigned to the experimental
group participated in 8 training sessions in which mirror feedback, similar to Willy et al., was
used to allow participants to see themselves running with a forefoot strike. Verbal cues were also
provided such as run on your toes and/or run on the balls of your feet. Continuous feedback
was provided during the first 4 gait retraining sessions and gradually removed over the last 4
sessions. Runners assigned to the control group also participated in 8 training sessions with
mirror feedback and verbal cues. However the verbal cues were designed not to modify gait.
Instead, verbal cues provided encouragement and included keep it up or nice job. Participants
in the experimental group reported significant reductions in PFP compared to the control group.
Decreases in pain were also associated with a decrease in knee abduction angle and an increase
in knee flexion angle at initial contact. Dynamic knee abduction has been shown to contribute to
PFPS, while increases in knee flexion most likely resulted in reduced knee loading. As a result of
decreased knee abduction, patellofemoral joint contact force and patellofemoral stress were also
Overall, gait retraining appears to be an effective treatment for PFPS, but there is a need
for longer follow-up periods to determine how long improvements last. Currently the longest
follow-up period is 3 months. Longer follow-up periods will allow for better determination of
gait retraining effectiveness. Additionally, these studies were performed in a laboratory setting
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with special equipment including gait analysis equipment and a screen in which to project real-
time hip adduction angle feedback on. Equipment requirements alone may reduce the practicality
positive changes may be difficult to maintain once running outside where terrain can be uneven
and unpredictable and speed is not controlled by the speed of moving treadmill belt. The use of
verbal cues such as run with knees apart and with knee caps pointing straight ahead and to
squeeze buttocks may provide sufficient stimulus to induce change in lower extremity
kinematics, however in the previous studies, verbal cues have been in addition to other types of
determine the effect of just verbal cues, such as the examples mentioned previously, on gait
kinematics. Use of verbal cues would be a more convenient method of altering gait kinematics,
as opposed to use of real-time feedback. Other aspects of gait retraining that require further
investigation include the effect of changes in kinematics on running economy and likelihood that
new gait patterns will be adopted and used outside of the gait retraining sessions. Changes in gait
that are difficult to maintain or do not feel natural may decrease adherence. Similarly, gait
changes that are unnatural or deviate too far from the normal gait pattern for a person may
increase the difficulty of running. Alongside with investigating whether new gait patterns are
adopted or not is determining if any adverse side effects result from altering gait characteristics.
For example, while rear foot striking is associated with running injuries, forefoot striking can
place more stress on the ankle joint and possibly result in injury. Roper et al. did investigate
adverse effects associated with changing foot strike patterns, but only for a short time period.
Immediately after the invention, participants in the experimental group experienced calf soreness
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during the gait retraining sessions, but the pain subsided by the end of the intervention. At the 1-
month follow-up, two participants reported ankle soreness, but the pain was not enough to deter
them from running. Longer follow-up periods are necessary to investigate whether changes in
foot strike pattern led to any injury. Noehren et al. and Willy et al. did not assess whether
Etiology
Iliotibial band syndrome (ITBS) is the second most common running injury and accounts
for approximately 8% of running injuries.84 In individuals with ITBS, a sharp, burning pain on
the lateral side of the knee is experienced and worsens as running continues.10 Pain is typically
relieved by keeping the knee in a fully extended position. Two theories exist explaining the cause
of ITBS. The first theory, developed by Orchard et al. suggested that ITBS results from friction.
As the knee repetitively flexes and extends, as seen during running, the IT band moves forward
and backward across the lateral femoral epicondyle.62 This theory was challenged by researchers
who argued that the IT band is securely anchored to its attachment sites and is not capable of
moving anteriorly and posteriorly across the lateral femoral epicondyle.11,12 Using MRI
technology, Fairclough et al. found that at 30 of knee flexion, the IT band compresses against
the lateral femoral condyle. Regardless of mechanism, both theories agree that ITBS results from
irritation and inflammation of the bursa sac located between the IT band and the lateral femoral
epicondyle.
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Onset of lateral knee pain at 20-30 of knee flexion led researchers to believe that an
impingement zone existed. Naturally, sagittal plane biomechanics at the knee were investigated
in runners with ITBS. Despite the suggested impingement zone, no differences in sagittal plane
knee kinematics were found between runners with ITBS compared to their non-injured leg.
Specifically, no differences were seen in peak knee flexion angle, knee flexion angle at heel
strike or in the percent of time spent in knee flexion. Results suggested that kinematics in the
The IT band originates proximally at the hip from the fascia of the gluteus maximus,
gluteus medius and the tensor fascia latae. This thick band of fibrous connective tissue extends
down the lateral thigh and inserts into the lateral femoral condyle and Gerdys tubercle on the
tibia.76 Its primary functions include acting as both a hip and knee stabilizer by resisting hip
adduction and knee internal rotation.16,46,92 As a result of its attachment points to both the femur
and the tibia, abnormal kinematics of the hip and foot have been suggested to contribute to the
kinematics in 35 female runners with a history of ITBS to a group of 35 female runners with no
history of running-related injuries. It was hypothesized that female runners with a history of
ITBS would exhibit increased peak rear foot eversion, knee internal rotation, knee flexion and
hip adduction angles during stance. Results showed that runners with a history of ITBS
demonstrated greater peak knee internal rotation angles and greater peak hip adduction angles
compared to the control group and remained in greater hip adduction and knee internal rotation
throughout the stance phase. Similar to previous studies investigating sagittal plane knee
mehcanics62, no differences were seen in peak knee flexion angle or peak rear foot eversion
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angle.18 As part of a large prospective study investigating lower extremity injuries in female
runners, a group of healthy female recreational runners underwent a 3D gait analysis and were
then followed over a period of two years. Kinematics of individuals who developed ITBS were
compared to an age and mileage matched control group. Authors hypothesized that the
participants who developed ITBS would show increased hip adduction, increased knee internal
rotation and increased rear foot eversion angles. Knee flexion angles were not expected to differ
between groups. Results from this prospective study showed that the ITBS group demonstrated
greater hip adduction and knee internal rotation compared to the control group. Contrary to the
authors hypothesis, rear foot eversion did not differ between groups.56 These results are in
agreement with the retrospective study conducted by Ferber et al.18 A continuation of this study
was conducted by Hamill et al. to compare pre-existing strain, strain rate and duration of
impingement in the IT band between female runners who develop ITBS and healthy controls
who did not go on to develop any injury. Using the same kinematic data as Noehren et al.56, it
was hypothesized that runners who developed ITBS would demonstrate greater strain throughout
the stance period of running, particularly at touchdown and maximum knee flexion. Strain rate
and duration of impingement were also expected to be greater in the ITBS group compared to the
healthy group. IT band strain was calculated specific to each subject using a model of the lower
extremity produced by SIMM software. Compared to the control group and the unaffected limb,
strain rate was significantly greater in the limb experiencing ITBS suggesting that increased
strain may lead to the development of ITBS.28 Strength, flexibility and running mechanics were
assessed in males only with ITBS. Compared to a control group, males with ITBS exhibited
increased hip internal rotation and knee adduction angles during the early stance phase. Hip
for weakness of this muscle to lead to increased hip adduction. In a study using healthy
recreational runners who manipulated their step width to increase hip adduction, results showed
that a narrower step width was associated with significantly greater IT band strain and strain rate
than with a preferred step width and a wider step width. Calculation of effect sizes suggests that
step width has a moderate to large effect on IT band strain and small to moderate effect on IT
band strain rate. Without sufficient gluteus medius strength, the tensor fascia latae and the IT
band must compensate to stabilize the knee during dynamic movement, potentially increasing the
strain on the IT band.49 Fredericson et al. compared hip abductor strength in long distance
runners with ITBS to the unaffected limb and to a control group. Hip abductor muscle strength
was significantly reduced in runners with ITBS compared to their unaffected limb and the
control group.19 While not focused specifically on ITBS, Niemeth et al. reported reduced hip
abductor muscle strength in runners with various musculoskeletal injuries, including ITBS. This
finding further supports association between hip abductor strength and ITBS.55 However, not all
studies support the association between hip abductor weakness and ITBS. Grau et al. compared a
group of runners with ITBS to a control group and found no differences in concentric, eccentric
or isometric peak torque of the hip abductors and adductors nor was any difference found in the
concentric endurance quotient. This measure assesses the difference between dynamic hip
abduction and adduction with the normal population experiencing stronger adductors. In the
current study, both groups of runners had similar ratios that indicated they had stronger
abductors, compared to the normal population suggesting that as a group runners exhibit stronger
hip abductors compared to hip adductors. Authors concluded at this time, hip abductor muscle
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Knowledge Evidence Essay
weakness was not involved in the etiology of ITBS in runners. However it is important to note,
Gait kinematics in males and females with ITBS were compared in an effort to determine if
differences existed based on gender. It was hypothesized that females with ITBS would
demonstrate greater frontal and transverse plane knee kinematics compared to males with ITBS.
In comparison to males with ITBS, females demonstrated greater hip external rotation angles.64
Muscle strengthening
In comparison to PFPS, interventions to improve running mechanics associated with ITBS are
scarce. After determining that hip abductor strength was significantly reduced in long distance
runners with ITBS, Fredericson et al. employed a 6-week rehabilitation program targeting the
gluteus medius. The rehabilitation protocol consisted of two IT band stretches, side-lying hip
abduction exercises and pelvic drops performed once per week under supervision of a physical
rehabilitation protocol. After completion, increases in hip abductor strength of the injured limb
were demonstrated in both males and females. Twenty-two of the 24 runners were able to return
to running pain free and remained pain free at the 6-month follow-up. A limitation to this study
was that no kinematics were assessed. Authors did assess hip abductor strength before and after
the intervention, but investigation of the effect of hip abductor strengthening on running
Gait retraining
While strengthening of hip abductor musculature to improve ITBS symptoms is supported, it has
been suggested that muscle strengthening alone may not be sufficient enough to improve running
mechanics. Therefore, a running retraining protocol was implemented to determine the effects on
pain, function and lower-extremity biomechanics in a female recreational runner with ITBS.
After baseline collection of 3D gait kinematics, the participants symptomatic limb was
compared to her unaffected limb. In comparison to the unaffected limb, the symptomatic limb
demonstrated reduced pelvic external rotation, increased knee external rotation and external
rotation foot progression angles. While these biomechanical abnormalities differ from previous
literature which has reported increased hip adduction and knee internal rotation in individuals
with ITBS, tension on the IT band is still increased. Based on the results of the gait analysis, the
gait retraining protocol focused on increasing pelvic rotation angle. Using both visual and
auditory feedback, gait retraining sessions took place over the span of 4 weeks with 2 sessions
per week during the first 3 weeks and 3 session per week during the final week. Real-time visual
feedback of pelvic rotation angle was provided on a computer monitor placed in front the
treadmill. Auditory feedback was provided by an alarm that buzzed when the amount of pelvic
rotation deviated 1 SD from the amount of normal pelvic rotation. Verbal cues were also
provided such as keep the knee pointing forward, reduce the arm swing and keep the foot
pointing forward. Feedback was gradually removed using a faded feedback design to decrease
reliance on feedback to alter gait and promote internalization of the task. After completion of
running retraining sessions, the participant was instructed to return to running 3 times per week
using the new gait pattern and gradually increasing running time. Results from the post-
intervention showed that the amount of pelvic external rotation did not improve and remained
Amanda Estep
Knowledge Evidence Essay
decreased. However, knee external rotation angle and external rotation foot progression angle
improved by decreasing and moving towards a more internally rotated position. At the one-
month follow-up, pelvic external rotation decreased even more, while knee external rotation and
external rotation foot progression angles continued to decrease and become more internally
rotated. Pain and function were also improved in response to the gait retraining intervention.
Limitations to this study are similar to the limitations seen in the gait retraining studies for
individuals with PFPS. A laboratory setting with specific equipment is needed to carry out the
gait retraining sessions, which limits the practicality of this type of intervention. Side effects of
altering gait kinematics were monitored during the intervention, but only during the intervention.
It was not made clear if the researchers investigated any negative side effects at the 1-month
follow-up and no follow-up beyond 1-month was conducted. During the intervention, the
participant did report stiffness in her thoracic spine after the second training session, but these
symptoms disappeared by the third training session with no complaints being reported for the
remainder of the intervention. Researchers also investigated the time it took for the participant to
easily alter her running gait pattern, which the participant reported being able to do by the fourth
training session. However, this change was not maintained at the end of the intervention or at the
1-month follow. It is known whether the participant continued to incorporate altered gait pattern
beyond 1-month post-intervention.37 Another case study investigated the effects of step rate
manipulation on a 36 year old female recreational runner presenting with ITBS. Previous
literature, not specific to ITBS, has demonstrated that increases in step rate above preferred
cadence are associated with decreases in joint loading at the hip and knee joint6,34, decreases in
peak hip adduction and knee internal rotation angles34 and increases in muscle firing of the
gluteus medius and gluteus maximus.35 Because ITBS has been associated with increased hip
Amanda Estep
Knowledge Evidence Essay
adduction and internal rotation angles and hip muscle weakness, authors hypothesized that
individuals with ITBS may benefit from increasing running cadence above their preferred rate.
Based on the participants preferred running speed, the goal of the intervention was to increase
step rate by 5%. To increase step rate, a metronome was used while running to provide auditory
feedback. The metronome was used until the participant felt like she could easily and
consistently match the beat of the metronome. The participant was also instructed to run
quietly and let your feet strike under your body as you fall forward. After 6 weeks of gait
retraining combined with hip strengthening and flexibility exercises, the participant was able to
return to running pain free while incorporating the increased running cadence. When visually
inspecting her gait using video analysis, the participants running form had improved and
included striking the ground closer to her center of mass and a slightly forward trunk lean, both
of which have been shown to decrease impact forces. Additionally, contralateral pelvic was
improved and the participant demonstrated greater control over dynamic knee valgus. At 4-
months post-intervention, running mileage had increased to 13.1 miles with maintenance of
increased running cadence. The primary focus of the intervention was on increasing running
cadence, but the intervention also included hip muscle strengthening exercises as well as IT band
flexibility exercises. As a result, improvements in pain, contralateral pelvic drop and control of
dynamic knee valgus cannot solely be attributed to increasing running cadence. Increases in hip
muscle strength were also demonstrated which may have contributed to the participants
increased control of dynamic valgus. Verbal cues were also given, such as let your feet strike
under your body as you fall forward that potentially influenced running form and subsequently
may also have contributed to observed improvements.1 While both of the aforementioned studies
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Knowledge Evidence Essay
were case studies, results do support the use of gait retraining in the treatment of ITBS. Future
studies including larger sample sizes are needed to further determine effectiveness.
Movement variability
defined as normal variations that occur in motor performance across multiple repetitions of a
task. As it relates to the gait cycle, no two steps taken are the exact same.82
Traditionally, increased variability has been viewed as a negative aspect of human movement
and considered to be error. Less variability was associated with stability and mastery of a
task.77,78 However, the incorporation of dynamic systems theory and optimal variability theory,
into how movement is studied, has changed the way variability is viewed.
environment and allows for the same task to be completed in multiple ways.29 The ability to
complete the same task in multiple ways is suggested to decrease repeated stress placed on the
body.27 Optimal variability theory states than an ideal amount of variability exists and deviating
away from this value represents pathology. Whether increased or decreased variability is
associated with pathology is dependent on the task.29 For example, variability demonstrated in
the interbeat interval in the human heartbeat represents healthy, normal function. Absence of
variability is indicative of cardiac disease.24 Within postural control, variability can be healthy
and exploratory, as long as basic postural stability can be achieved. In a study comparing center
of pressure (COP) excursion between young subjects and healthy older adults during quiet
Amanda Estep
Knowledge Evidence Essay
standing, results showed that older adults demonstrated less COP excursion. In addition, older
adults were unable to lean as far forward relative to their base of support compared to younger
subjects and at the maximum lean condition, postural variability was greater. Authors concluded
that the younger subjects met basic postural stability demands and as result, were able to lean
farther forward relative to their base of support and remain stabilized. The greater COP
excursions shown during quiet standing represented an exploratory form of variability. The older
adults were unable to meet basic postural stability demands and when asked to lean forward, they
became unstable, resulting in detrimental greater variability in the maximal lean condition. In
order to complete the quiet standing task, COP excursion was reduced, resulting in decreased
variability.87 Within human gait, variability of certain stride characteristics have been found to be
indicators of pathology. Increased stride duration variability is associated with risk of falling in
the elderly population. In addition, increased stride duration variability has also been
Variability can be measured using both linear and non-linear methods. Using linear measures,
such as standard deviation and coefficient of variation, data is averaged together and a mean
variability. Non-linear measures of variability provide insight into the structure and evolution of
variability over time. Methods of non-linear measures include approximate entropy, detrended
regularity and predictability. Typically, approximate entropy values range from 0-2 with higher
values illustrating greater irregularity/less predictability in the time series signal. Conversely,
lower values are reflective of increased regularity or smoothness for the given signal.65
of the time series. Weaker long range correlations indicate more flexibility.63 Lyapunov exponent
of zero shows that trajectories are not converging or diverging. Instability arises from trajectories
A number of studies have addressed variability during walking and running in regards to
spatio-temporal features. Hausdorff et al. was the first to determine that stride interval
fluctuations demonstrated while walking were not random noise. Instead, these fluctuations
represented long-range correlations, meaning that stride intervals at any point in time series is
dependent on previous stride intervals.33 Long-range correlations have also been found in stride
interval of running,41 stride length, step interval and step length while walking and running.
Furthermore, the amount and structure of variability appear to be dependent on speed. While
walking and running at a preferred speed and speeds above and below, the amount of variability
for stride interval, step interval, stride length and step length decreased as speed increased. When
looking at the structure of variability, deviations away from preferred walking and running speed
range correlations represents greater predictability and less adaptability and variability. The
opposite is true for reduced strength in long-range correlations. This may suggest that walking
and running above and below preferred speed introduces a biological stress to the body and thus
degrees of freedom are reduced in order to complete the task. Walking and running at a preferred
experiencing a running injury. Using continuous relative phase to measure joint coordination,
healthy runners, across entire gait cycle for joint couplings including thigh flexion/extension and
tibial rotation, thigh abduction/adduction and tibial rotation, tibial rotation and foot
inversion/eversion and femoral rotation and tibial rotation.27 In another study of individuals with
patellofemoral pain, joint coordination was obtained using a modified vector coding technique.
Joint coordination for each subjects injured limb was compared to their healthy limb. When
averaged across the entire gait cycle, no differences were seen between injured limb and healthy
limb. However, when the gait cycle was broken down into phases and analyzed, reduced
variability for thigh/leg rotation coupling was demonstrated in the limbs with patellofemoral pain
relative phase, between runners with a history of iliotibial band syndrome and a healthy control
group during an exhaustive run showed decreased variability for thigh adduction/abduction and
foot inversion/eversion joint coupling. This difference was only demonstrated when the entire
gait cycle was analyzed. Interestingly, runners with a history of iliotibial band syndrome
coupling during stance and swing phases.10 Using approximate entropy, sagittal plane knee
variability was examined in 10 individuals who had experienced an anterior cruciate ligament
rupture. Each individuals ACL deficient knee was compared to the intact contralateral knee
while walking at different speeds on a treadmill. Authors hypothesized that the ACL deficient
Amanda Estep
Knowledge Evidence Essay
knee would exhibit less variability compared to the intact contralateral knee. In line with the
authors hypothesis, the ACL deficient knee demonstrated significantly less variability across all
walking speeds compared to the contralateral intact knee. Results of this study suggest that the
ACL deficient knee is less adaptable to unexpected changes in the environment and may be more
What is next?
A gap exists in the literature when trying to identify the mechanisms behind
individuals experiencing a running injury. When the relationship between muscle strength and
changes in kinematics is investigated, results are not only limited, but they are also inconclusive.
For example, Earl et al. investigated the effects of a proximal strengthening program on hip
strength, core endurance, pain, function and lower extremity running biomechanics. Increases in
hip strength were demonstrated, however joint kinematics remained the same. Ferber et al.
runners with PFPS. Compared to the control group, individuals who participated in hip-abductor
strengthening protocol demonstrated increased hip abductor strength and reduced pain and
decreased stride-to-stride knee joint variability while running. Interestingly, no changes in peak
knee genu valgum were observed. The investigation of changes in variability, as opposed to
solely relying on peak joint angles, provided a more sensitive measure to detect changes in
kinematics. Incorporating the use of non-linear dynamics, such as approximate entropy, when
evaluating kinematic changes after an intervention to improve abnormal kinematics may provide
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Knowledge Evidence Essay
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