Gait & Posture 43 (2016) 120–124

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Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Full length Article

Sagittal plane pelvis motion influences transverse plane motion of the

femur: Kinematic coupling at the hip joint
Jennifer J. Bagwell a,*, Thiago Y. Fukuda b, Christopher M. Powers a
a
Jacquelin Perry Musculoskeletal Biomechanics Laboratory, Division of Biokinesiology & Physical Therapy, University of Southern California, Los Angeles,
CA 90089, USA
b
Knee and Hip Rehabilitation, Trata Institute, Department of Physical Therapy, Santa Casa of São Paulo, São Paulo , SP, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Previous studies have suggested that internal femur rotation can influence sagittal pelvis motion. This
Received 10 May 2015 indicates that there may be kinematic ‘‘coupling’’ of these two segments. The purpose of the current
Received in revised form 31 August 2015 study was to determine whether there is a consistent and predictable kinematic relationship between
Accepted 14 September 2015
the pelvis and the femur. Sixteen healthy subjects (nine females, seven males) performed three trials of
maximum anterior and posterior pelvis tilt at four different hip flexion angles (08, 308, 608, and 908).
Keywords: Ordinary least squares regressions were used to calculate the ratio of transverse femur motion to sagittal
Kinematic coupling
pelvis motion using the mean kinematic curves during maximum anterior and posterior pelvis tilting. R2
Hip
Femur rotation
values were used to assess the strength of the kinematic relationship between these segments at each
Pelvis tilt hip flexion angle. The ratios of transverse femur motion to sagittal pelvis motion were consistent across
all hip flexion angles during anterior and posterior pelvis tilting (range 0.23–0.32; R2 values greater than
0.97). On average, for every 58 of anterior pelvis tilt there was 1.2–1.68 of internal femur rotation and the
converse was true for posterior pelvis tilt and external femur rotation. Our findings suggest that altered
pelvis movement in the sagittal plane may influence transverse femur motion. The observed coupling
behavior between the pelvis and femur may have implications for musculoskeletal conditions in which
excessive internal femur rotation has been deemed contributory to symptoms (i.e. femoroacetabular
impingement).
ß 2015 Elsevier B.V. All rights reserved.

1. Introduction
The hip joint is a complex anatomical structure comprised of
the pelvis and the femur. The inherent stability of the hip occurs
secondary to the ball and socket bony morphology, the thick
capsule and ligaments [1,2], and the strong muscles surrounding
the joint [1]. As a result of the highly congruent nature of this joint
and the closely approximated joint surfaces [1,3] it is likely that
movement of one segment may influence the other.
Previous studies have suggested a potential relationship
between transverse plane femur and sagittal plane pelvis motions
[4–7]. Duval et al. [4] reported that internal rotation of the lower
extremity during standing resulted in an anterior pelvis tilt and
external rotation of the lower extremity resulted in a posterior
* Corresponding author. Present address: Department of Physical Therapy,
Creighton University, 2500 California Plaza, Omaha, NE 68178, USA.
Tel.: +1-402-280-5188; fax: +1 402 280 5692.
E-mail address: jennybagwell@creighton.edu (J.J. Bagwell).
pelvis tilt. These authors proposed that this kinematic relationship
occurred as a direct result of bony approximation between the
femoral head and the acetabulum [4]. Further support for
kinematic coupling between the pelvis and the femur comes from
studies in which calcaneal wedging was used to induce foot
pronation [5–7]. These studies revealed that calcaneal eversion
resulted in internal tibia rotation, internal femur rotation, and
anterior pelvis tilting [5–7]. The kinematic relationship between
the pelvis and femur has been shown to exist during bilateral [5,6]
and unilateral standing [6,7].
The fact that transverse plane motion of the femur can influence
sagittal plane motion of the pelvis is suggestive of kinematic
coupling between these two segments. Coupling arises when a
force or torque in one direction causes motion in another direction
[8]. At the foot–ankle complex, for example, there is a well-studied
relationship between calcaneal eversion and internal tibia rotation
[9,10]. In the cervical spine, axial rotation has been shown to be
coupled with ipsilateral lateral flexion [11,12]. While previous
research supports the premise that internal femur rotation
contributes to anterior pelvis tilt [4–7], it is not clear if the same

http://dx.doi.org/10.1016/j.gaitpost.2015.09.010
0966-6362/ß 2015 Elsevier B.V. All rights reserved.
 J.J. Bagwell et al. / Gait & Posture 43 (2016) 120–124 121

coupling relationship occurs reciprocally (i.e. whether sagittal

plane pelvis motion influences transverse plane femur motion).
Additionally, research in this area has focused on upright standing
postures [4–7], so it is not known if the same coupling behavior
exists at greater hip flexion angles similar to those that occur
during functional tasks.
The purpose of the current study was to systematically explore
whether there is a consistent and predictable kinematic relation-
ship between sagittal plane motion of the pelvis and transverse
plane motion of the femur during anterior and posterior pelvis
tilting. It was hypothesized that sagittal plane pelvis motion and
transverse plane femur motion would be significantly correlated at
various hip flexion angles. It also was hypothesized that the ratio
between transverse femur motion and sagittal pelvis motion
would be similar between anterior and posterior pelvis tilting. The
presence of kinematic coupling at the hip joint may have
implications for musculoskeletal conditions in which internal
femur rotation has been shown to be contributory to pathology (i.e.
femoroacetabular impingement).

2. Methods

2.1. Participants
Sixteen subjects consisting of 9 females (28.0  7.6 years;
60.8  7.5 kg; 164.6  5.2 cm) and 7 males; (29.3  4.8 years;
76.1  10.4 kg; 178.0  4.7 cm) participated in this study. Partici-
pants had no history of hip pain, no previous hip surgery, and no
complaints of lower extremity or low back pain during the preceding
6 months. Data collection occurred in the Jacquelin Perry Musculo-
skeletal Biomechanics Research Laboratory at the University of
Southern California. Prior to participation, all subjects were informed
of the purpose of the study and provided written informed consent.
2.2. Procedures
Three-dimensional kinematics were collected at 250 Hz using
an 11-camera Qualisys motion analysis system (Qualisys AB,
Göteborg, Sweden). Reflective markers (11 mm diameter) were
placed on the most distal aspect of the second toes, the first and
fifth metatarsal heads, the medial and lateral malleoli, the medial
and lateral femoral epicondyles, the greater trochanters, the iliac
crests, and the L5–S1 junction. Semi-rigid plastic plates with
mounted tracking markers were secured to the heels, shanks, and
thighs (Fig. 1). Prior to data collection, a standing calibration trial
was collected to determine the segmental coordinate systems and
the joint centers. All markers were then removed with the
exception of the semi-rigid clusters and the markers on the iliac
crests, and the L5–S1.
Subjects were instructed to stand upright with the feet
stationary, shoulder width apart, toes pointing forward with
shoulders flexed to 908. Participants then performed a maximum
anterior and posterior pelvis tilt without moving at the trunk or
flexing the knees. Subjects practiced this motion at a set pace of
20 beats-per-minute in each direction (maximum anterior pelvis
tilt to maximum posterior pelvis tilt) until they were comfortable
with the task. Approximately 5 to 15 practice trials were
performed.
Following familiarization with the movement, five continuous
repetitions of this task were performed. Subjects then performed a
bilateral squat to 308 of hip flexion as determined using a
goniometer. Starting from this position, subjects again performed
five repetitions of maximum anterior and posterior tilt of the pelvis
at the same pace described above. This task subsequently was
performed at hip flexion angles of 608 and 908 (Fig. 2). All subjects
Fig. 1. Marker set utilized for static trial.
were able to successfully perform the desired pelvis motions for all
knee flexion conditions.
2.3. Data analysis
Three-dimensional kinematic data were processed with Visual
3D software (C-motion, Inc., Germantown, MD). Kinematic data
were low-pass filtered at 6 Hz using a 4th-order Butterworth filter.
The middle three repetitions at each hip flexion angle for each
subject were averaged. The femur and pelvis angles were
calculated as the orientation of the femur and pelvis segments
relative to the global coordinate system. The average of the three
repetitions for each hip flexion angle was calculated from the
individual participant’s data. The individual means for the
16 participants were then averaged at each hip flexion angle to
create the average angle–angle plot.
2.4. Statistical analysis
The ratio of femur transverse motion to pelvis sagittal motion
was calculated at each hip flexion angle as the unstandardized
coefficient of the linear regression of the average data during the
period of anterior pelvis tilt and during the period of posterior
pelvis tilt using PASW software (SPSS, Inc., Chicago, IL). This
provided an estimate of the change in femur transverse rotation
per degree of pelvis sagittal tilt. The R2 value for the mean femur
transverse angles and the mean pelvis sagittal angles throughout
this motion also was calculated for each hip flexion angle.
3. Results
All kinematic variables of interest demonstrated acceptable
normality with skewedness and kurtosis values less than 0.5 and
2, respectively. Mean transverse plane femur excursions during the
08, 308, 608, and 908 hip flexion angle conditions were 7.4  4.38,
7.0  5.58, 5.6  4.28, and 5.3  2.88, respectively. Mean sagittal plane
pelvis excursions during the 08, 308, 608, and 908 hip flexion angle
conditions were 23.4  7.58, 20.8  12.28, 20.3  11.98, and
16.6  8.98, respectively. The average femur transverse motion to
122 J.J. Bagwell et al. / Gait & Posture 43 (2016) 120–124

Fig. 2. Subject performing maximum posterior pelvis tilt (left) to maximum anterior pelvis tilt (right) at 608 of hip flexion. This task was repeated at hip flexion angles of 08,
308, and 908.

Table 1
Coupling ratios during maximum pelvis sagittal plane excursion for periods of anterior and posterior pelvis tilt.

08 Hip flexion 308 Hip flexion 608 Hip flexion 908 Hip flexion

Internal femur rotation:Anterior pelvis tilt 0.32:1 0.30:1 0.23:1 0.26:1

External femur rotation:Posterior pelvis tilt 0.31:1 0.31:1 0.25:1 0.29:1

pelvis sagittal motion ratios ranged from 0.23 to 0.32 and from 0.25 to
0.31 for anterior and posterior tilting, respectively (Table 1 and Figs.
3 and 4). The R2 values between femur transverse and pelvis sagittal
motion indicated a strong, linear relationship at each hip flexion angle
tested (R2 values of 0.97 or greater; Figs. 3 and 4).
4. Discussion
A consistent pattern of kinematic coupling of anterior pelvis tilt
and internal femur rotation (and, conversely, posterior pelvis tilt
and external femur rotation) was observed at each hip flexion
angle evaluated. All 16 participants demonstrated this coupling
behavior at the 08 hip flexion condition, and 15 out of the
16 participants demonstrated the coupling behavior in the 308, 608,
and 908 hip flexion conditions. When averaged across all hip
flexion angles, there was 1.2–1.68 of internal femur rotation for
every 58 of anterior pelvis tilt. Similarly, there was 1.2–1.68 of
external femur rotation for every 58 of posterior pelvis tilt. This
relationship was consistent across hip flexion angles and during
periods of both anterior and posterior tilt, suggesting that
kinematic coupling between these segments is robust.
Our findings confirm and expand upon previous reports of
kinematic coupling between the femur and the pelvis [4–7].
Consistent with the current study, Duval et al. [4] found a
significant relationship between internal femur rotation and
anterior pelvis tilt. Contrary to the findings of the current study,
however, these authors reported that the relationship between
external femur rotation and posterior pelvis tilt was less
pronounced than that between internal femur rotation and
anterior pelvis tilt [4]. The findings of the current study reveal
that coupling was nearly identical during anterior pelvis tilting and
posterior pelvis tilting.
To the best of our knowledge, this is the first study to
demonstrate that motion of the pelvis in the sagittal plane can
influence motion of the femur in the transverse plane. While it is
beyond the scope of this paper to explain the mechanism
underlying the observed coupling, several possibilities exist.
Motion at any joint is heavily influenced by bony anatomy. The
hip joint, in particular, is highly congruent with closely approxi-
mated joint surfaces [1,3] secondary to its thick capsule [1,2],
strong musculature [1], and the negative pressure within the joint
space [13]. As such, it is logical that motion of one segment would
have a predictable influence on the other. Many highly congruent
joints exhibit kinematic coupling. For example, the relationship at
the foot–ankle complex between calcaneal eversion and tibial
internal rotation has been well documented [9,10].

Fig. 3. Average angle-angle diagram of the femur transverse plane kinematics versus the pelvis sagittal plane kinematics at hip flexion angles of 08, 308, 608, and 908 while
performing a maximum anterior pelvis tilt from a maximum posterior pelvis tilt. Star indicates starting point.
 J.J. Bagwell et al. / Gait & Posture 43 (2016) 120–124
Fig. 4. Average angle-angle diagram of the femur transverse plane kinematics versus the pelvis sagittal plane kinematics at hip flexion angles of 08, 308, 608, and 908 while
performing a maximum posterior pelvis tilt from a maximum anterior pelvis tilt. Star indicates starting point.
Duval et al. [4] suggested that internal rotation of the femur
causes the femoral head to rotate posteriorly into the posterior
acetabulum which pushes the pelvis into an anterior tilt.
Conversely, it is possible that anterior tilt of the pelvis rotates
the acetabulum antero-inferiorly into the anterior femoral head,
which pushes the femur into internal rotation. Other factors, such
as muscle activation, soft tissue length, and bony alignment (i.e.
femoral or acetabular version or inclination) also may influence
intersegmental coupling [4].
Understanding contributory factors to hip joint motion is
important in populations where abnormal kinematics have been
implicated. In persons with femoroacetabular impingement, for
example, anterior pelvis tilt and femur internal rotation increase
approximation of the femoral head-neck junction with the
acetabulum [14,15]. Such abutment is hypothesized to contribute
to labral damage [16–18], chondral damage [16,17,19], and hip
osteoarthritis [20,21]. Additionally, kinematic studies have identi-
fied differences in sagittal [22–25] and transverse plane hip and
pelvis kinematics [23,25] between persons with and without
femoroacetabular impingement. Our findings indicate that altered
sagittal plane pelvis kinematics in persons with femoroacetabular
impingement may influence hip rotation.
There are certain limitations of this study that should be
considered when interpreting the results. Skin markers were used
to assess segment position and may have been subject to soft tissue
movement artifact. Marker artifact error was minimized however
through use of thigh clusters comprised of four markers [26], and
the fact that we studied of a relatively slow movement with
minimal inertial effects [27]. Another limitation is that only
isolated intentional motion of the pelvis was examined. The ratio of
femur to pelvis motion may vary during more dynamic tasks that
involve greater excursions and muscular demands. The ratio
between femur rotation and pelvis tilt also may differ between
weightbearing and non-weightbearing tasks. Furthermore, the
coupling behavior only was evaluated in healthy participants. The
reported coupling ratios may differ in persons with hip or back
pain. The ratios also may differ in the presence of abnormal bony
morphology of the hip.
5. Conclusions
To the best of our knowledge, this study is the first to
systematically explore the coupling behavior between the pelvis
and femur during a dynamic task, across varying degrees of hip
flexion. A consistent pattern of kinematic coupling of anterior
pelvis tilt and internal femur rotation and, conversely, posterior
pelvis tilt and external femur rotation, was observed at hip flexion
angles ranging from 0–908. For every 58 of anterior pelvis tilt there
was 1.2–1.68 of internal femur rotation and for every 58 of posterior
123
pelvis tilt there was a similar 1.2–1.68 of external femur rotation.
Our findings suggest that altered pelvis control or positioning in
the sagittal plane has the potential to influence transverse plane
motion of the femur. Our findings may have clinical applications,
particularly for populations that exhibit altered pelvis or femur
kinematics.
Conflict of interest statement
There are no conflicts of interest to disclose.
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