Scand J Med Sci Sports 2015: : –
doi: 10.1111/sms.12633
Two-dimensional knee valgus displacement as a predictor of
patellofemoral pain in adolescent females
S. Holden1, C. Boreham1,2, C. Doherty1, E. Delahunt1,2
1
School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland, 2Institute for Sport and
Health, University College Dublin, Dublin, Ireland
Corresponding author: Sinead Holden, A101 School of Public Health, Physiotherapy and Sports Science, Health Sciences Centre,
University College Dublin, Belfield, Dublin 4, Ireland. Tel.: 00 353 1 7166671, Fax: 00 353 1 716 6501, E-mail:
sinead.holden@ucdconnect.ie
Accepted for publication 6 November 2015
Patellofemoral pain (PFP) is a prevalent lower limb
musculo-skeletal injury in adolescent females. Female
athletes with PFP display increased frontal plane knee
joint motion in comparison to control subjects. The current
investigation aimed to determine prospectively whether
two-dimensional knee valgus displacement during landing
could predict the risk of developing PFP. Seventy-six
injury-free adolescent female athletes (age = 12.9 
0.35 years) participated. At baseline participants
performed three drop vertical jump trials from a 31-cm
box. A standard video camera was used to record frontal
plane knee joint kinematics. Over the 24-month follow-up,
Patellofemoral pain (PFP) is a prevalent lower limb
musculo-skeletal injury in adolescent females (Myer
et al., 2010; Rathleff et al., 2013a, b). Up to one-
third of all adolescents experience knee pain with a
large proportion of this attributable to PFP (Mol-
gaard et al., 2011; Rathleff et al., 2013a, b). An even
higher prevalence is reported in adolescent female
athletes (Barber Foss et al., 2012). In general,
females experience a higher incidence and prevalence
of PFP in comparison to males (Taunton et al.,
2002; Boling et al., 2010).
PFP is characterized by diffused retro-patellar
and/or peri-patellar knee pain which is aggravated
during many activities of daily living such as stair
ascent/descent, prolonged sitting or running (Fagan &
Delahunt, 2008; Witvrouw et al., 2014). Symptoms
are highly persistent in adolescent females, with a
high proportion experiencing recurrent pain in both
short- and long-term follow-up (Nimon et al., 1998;
Stathopulu & Baildam, 2003; Rathleff et al., 2013a),
which can result in both localized and distal hyperal-
gesia (Rathleff et al., 2013c). The debilitating effect
of PFP is magnified by its detrimental influence on
physical activity (Stathopulu & Baildam, 2003) and
its association with patellofemoral osteoarthritis
ª 2015 John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
eight participants developed PFP, as diagnosed by a
Chartered Physiotherapist. Knee valgus displacement was
significantly increased in those who developed PFP
compared to those who did not (mean difference = 7.79°;
P = 0.002; partial eta squared = 0.07). Knee valgus
displacement ≥10.6° predicted PFP with a sensitivity of
0.75 and specificity of 0.85. The associated positive
likelihood ratio was 5. These results have clinical utility
suggesting that two-dimensional analysis could be
implemented to screen for increased risk of PFP in
adolescent female athletes.
(Utting et al., 2005; Thuillier et al., 2013; Hinman
et al., 2014). Early identification of risk factors and
ultimately prevention of PFP is therefore critical to
maintain knee joint health and function in adolescent
athletes.
Previous investigations have demonstrated that
females with PFP display altered knee joint kinemat-
ics in comparison to non-injured control subjects.
Particularly, symptomatic PFP patients exhibit
increased frontal plane knee joint motion and loads
during dynamic activities such as squatting, running,
jumping, and stepping (Levinger et al., 2007; Willson &
Davis, 2008; Nakagawa et al., 2012, 2013, 2015).
However, due to the observational and retrospective
nature of these investigations, it is unclear whether
these abnormal frontal plane knee joint kinematics
cause PFP or occur secondary to knee pain. It is the-
orized that increased valgus load during dynamic
activities increases laterally directed forces on the
patellofemoral joint, which could be an intrinsic risk
factor precipitating the onset and development of
PFP (Powers, 2003). One prospective study has iden-
tified a relationship between increased frontal plane
moments and PFP (Myer et al., 2010); however, in
order to quantify knee abduction moments, the use
1
Holden et al.
of sophisticated three-dimensional (3D) analysis is
required, which is both costly and inaccessible to
most sports settings outside of the research environ-
ment. Measurement of frontal plane knee joint kine-
matics by two-dimensional (2D) video analysis has
previously been validated (McLean et al., 2005) and
may present a more time and cost-effective screening
methodology.
The current investigation developed as a corollary
to a longitudinal investigation of the development of
adolescent knee joint jump landing kinematics and
aimed to determine whether altered knee joint land-
ing kinematics could be used to predict the risk of
developing PFP in this population. We hypothesized
that increased knee valgus displacement, as mea-
sured by 2D analysis during jump landing, would be
increased in those who developed PFP relative to
those who did not.
Although 2D analysis has previously been vali-
dated against 3D motion analysis (McLean et al.,
2005), we utilized a modified method for calculating
knee valgus displacement. Therefore, validation of
this protocol was conducted in conjunction with this
study in order to ensure this modified method main-
tained correlation with 3D measures of knee valgus
displacement.
Materials and methods
Participants
Seventy-six adolescent female athletes were recruited from
three secondary schools in the University catchment area
as part of a longitudinal study on the development of ado-
lescent knee joint jump landing kinematics. Participants
were included in the study if they were currently participat-
ing in high school sports and free from lower limb injury.
Participants were engaged in a variety of sports, including
court or field-based sports (e.g., field hockey, Gaelic foot-
ball, basketball, etc.), track and field athletics, or athletic
dance (e.g., gymnastics, cheerleading). Exclusion criteria
were a current injury or previous history of major lower
limb surgery and/or knee injury. Written informed parental
consent for each participant was obtained prior to testing,
with participant assent obtained on the day of testing. All
testing was undertaken in the relevant schools’ gymnasium.
Participants were tested at baseline and at 6-, 12-, 18-, and
24-month intervals. Baseline characteristic (age, height,
body mass) are displayed in Table 1. The study was
approved by the University Human Research Ethics
Committee.
Table 1. Mean (SD) participant descriptives for the control and PFP
groups; PFP = patellofemoral pain
Control PFP
Participants (N) 68 8 pain of insidious onset, provoked by at least two of the follow-
Age (years) 12.91 (0.34) 13.12 (0.42)
Height (m) 1.59 (0.07) 1.61 (0.05)
Body mass (kg) 49.61 (8.32) 46.75 (7.90)
2
Baseline drop vertical jump landing kinematics
Upon recruitment to the study, each participants’ 2D landing
kinematics were assessed. This baseline assessment is part of a
longitudinal study investigating the development of knee joint
jump landing kinematics in adolescent athletes. For the cur-
rent investigation, the baseline (pre-injury) data were used.
Performance of the drop vertical jump (DVJ) was initially
explained and demonstrated to participants by one of the
investigators. Participants initially stood with feet shoulder
width apart and hands on their hips on top of a 31-cm box.
They were then required to drop directly off the box and upon
landing immediately perform a maximum effort vertical jump.
Participants performed a minimum of three to five practice
repetitions until they were comfortable with the technique
required to correctly execute the DVJ. Each participant then
performed three DVJ test trials. Trials were not included if the
participant removed their hands from their hips or lost their
balance during landing. Two-dimensional frontal plane knee
joint kinematics was captured by a standard video camera
(Canon Legria HF R306, Canon Inc, Tokyo, Japan) with an
acquisition rate of 50 Hz. The camera was positioned at a
height of 1.03 m. Retro-reflective markers (Vicon Motion Sys-
tems Ltd, Oxford, United Kingdom) were placed on the
greater trochanter, lateral knee joint line, and lateral malleolus
of both legs of participants during data acquisition. Markers
were placed directly onto the skin of participants and as such,
required them to wear athletic shorts which were taped in a
manner that exposed skin around the greater trochanter of the
hip so the marker could be visually identified and digitized
during the data processing. All markers were placed by the
same researcher.
Data reduction
Knee joint valgus angles were measured and averaged across
the three test trials for both the dominant and non-dominant
limbs of participants. Knee joint valgus angle was calculated
from the video frame just prior to initial contact (IC) by digi-
tizing the reflective markers on the hip, knee, and ankle in
order to calculate the angle formed between the three markers
(see Fig. 1 for marker placement). IC was defined as the frame
in which the participants’ toes initially came in contact with
the force plate and was visually identified by watching the
video of the jump frame by frame. This process was repeated
to measure knee valgus angle at the video frame representing
maximum frontal plane knee joint motion. Knee valgus dis-
placement was then calculated as the difference in angle
between the two time points (displacement = IC
angle peak angle).
Follow-up
Athletes were prospectively followed at 6 months intervals for
2 years. At each subsequent test session, participants were
questioned regarding any injuries obtained since the last test-
ing session. If knee pain was reported, participants were clini-
cally evaluated by a Chartered Physiotherapist for the
presence of PFP. Diagnosis was based on the following and is
in agreement with previously published criteria in the litera-
ture (Stefanyshyn et al., 2006; Boling et al., 2009; Rathleff
et al., 2013d): long-standing anterior knee or retro-patellar
ing activities: prolonged sitting or kneeling, squatting, run-
ning, hopping, or stair walking; negative findings on
examination of knee ligament, menisci, bursa, and synovial
plica. In addition, the PFP group could not have had a previ-

Fig. 1. Marker placement for measurement of 2D knee val-
gus displacement.
ous episode of PFP. The mechanism of injury could not be
related to a traumatic blow to the knee joint or an acute injuri-
ous incident. A total of eight subjects developed new PFP
during the follow-up period.
Concurrent validation
Participants
Seven participants were recruited for the validation (five
males, two females). Participants reported to the University
biomechanics laboratory for a single testing session, including
collection of 2D and 3D measures during the DVJ on both
limbs of all participants. This enabled the use of 14 limbs for
concurrent validation. Written informed consent was obtained
on the day of testing.
Drop vertical jump
Similar to the prospective investigation, participants com-
pleted three to five practice trials of the DVJ, or until they felt
comfortable executing the movement. The participant was
required to begin on top of a 31-cm box with their feet shoul-
der width apart and their hands on their hips. They were then
required to drop of the box and upon contact with the labora-
tory force plates, immediately perform a maximal effort verti-
cal jump. After familiarization with this protocol, participants
performed three DVJ trials while concurrent 3D and 2D data
were collected.
CODA motion kinematics
Participants were instrumented with the Codamotion (Leice-
ster, United Kingdom) bilateral lower limb gait setup prior to
validation trials. This included recording specific anthropo-
metric details for the calculation of hip, knee, and ankle joint
centers, and the placement of lower limb makers and wands as
outlined in Monaghan et al. (2007). All anthropometrics and
marker/wand placement were undertaken by the same
researcher. Subsequent to marker and wand placement, a neu-
tral stance trial was used to align the participant with the labo-
ratory coordinate system and to function as a reference
position for subsequent kinematic analysis. During the valida-
tion trials, 3D kinematic data acquisition was made at 200 Hz
using 3 Codamotion cx1 units (Codamotion, Leicester, United
Kingdom), while kinetic data acquisition was made using two
Knee valgus: a risk factor for knee pain
AMTI (Watertown, Massachusetts, USA) walkway-
embedded force plates sampling at 1000 Hz. The CODA
mpx1 units were time synchronized with the force plates.
Kinematic data were analyzed using the Codamotion soft-
ware. Dynamic valgus has previously been described as a med-
ial collapse of the knee during dynamic movement
(Krosshaug et al., 2007; Paterno et al., 2010). Therefore, esti-
mated hip, knee, and ankle joint centers were used to calculate
frontal plane knee joint angular displacement during landing;
a method which has been demonstrated to be sensitive to
injury (Paterno et al., 2010). Knee joint angular displacement
was calculated for the frontal plane only. The point at which
the vertical ground reaction force exceeded a 10N threshold
was defined as IC. The frontal plane knee angle was recorded
at 20 ms pre-IC and at the point of maximum frontal plane
knee motion in order to calculate frontal plane angular dis-
placement. Valgus angular displacement was defined
as positive, while varus angular displacement was defined as
negative.
2D kinematics
As previously described, 2D frontal plane kinematics were
captured simultaneously with a standard digital video camera
(Canon Legria HF R306) with an acquisition rate of 50 Hz.
Cameras were positioned on a tripod at a height of 1.03 m.
Retro-reflective markers (20 mm; Vicon Motion Systems Ltd)
were placed on the greater trochanter, lateral joint line, and
lateral malleolus to enable calculation of the 2D knee valgus
displacement. The video recordings were analyzed using a
commercial software package (Dartfish Motion Analysis Soft-
ware; Dartfish, Fribourg, Switzerland) as previously
described.
Statistical analysis
Prospective investigation
Statistical means and standard deviations of all variables of
interest were calculated from the three trials of the DVJ. A
between-groups multivariate analysis of variance (MANOVA)
was used to investigate the effect of group (control vs PFP) on
knee valgus displacement and participant characteristics (age,
height, and body mass). Four participants acquired unilateral
PFP, with the symptomatic knee being included in the PFP
group for subsequent analyses and four participants acquired
bilateral PFP, with both knees being included in the PFP
group. Therefore, a total of 12 knees developed new PFP dur-
ing the follow-up period and were included in the PFP group
for analysis. The control group consisted of the uninjured
knees of the total tested population (n = 140).
Logistic regression analysis was used to determine whether
knee valgus displacement could predict PFP injury risk. The
predictive accuracy was quantified with the use of the C-statis-
tic, which measures the area under the receiver operating char-
acteristic curve (ROC). Significance was set a priori at
P < 0.05.
A chi-square test for independence was undertaken to
examine the relationship of activity level and PFP. The cate-
gorical variables used were development of PFP (yes or no)
and number of sports played (one, two, or three).
Concurrent validation
The average knee valgus angular displacement was calculated
from three trials for both limbs of all participants. Therefore,
3
Holden et al.
the average values for 14 limbs were used to examine the con- Concurrent validation
current validity of the 2D measures of knee valgus angular
displacement. Pearson product correlation coefficients were There was a strong significant correlation between 2D
used to determine the relationship between the 2D values to and 3D measured knee valgus angular displacement
those obtained from the 3D motion analysis system. A Bland– (r = 0.946; r2 = 0.894; P < 0.001). The Bland–Altman
Altman plot was also used to examine the concurrent reliabil-
ity of the 2D values to the 3D derived values. Significance was
plot confirmed there were no systematic differ-
set a priori at P < 0.05. ences between the two systems (Fig. 3). A scatterplot
of the 2D vs 3D results can be seen in Fig. 4.
Results
Prospective investigation Discussion
The cumulative incidence risk of developing PFP in The incidence of PFP reported in the current investi-
this population was 10.5%. There were no significant gation (10.5%) is slightly higher than that which has
differences between the PFP group and control been previously reported in prospective investiga-
group for participant characteristics of age, height, tions of adult populations (Stefanyshyn et al., 2006;
or body mass (P > 0.05; Table 1). Knee valgus dis- Boling et al., 2009). This is probably reflective of the
placement was significantly different between groups high incidence of PFP in adolescent females as these
at baseline (mean difference = 7.79°; 95% CI: 3.26– studies examined adult populations which included
12.32°; P ≤ 0.001; partial eta squared = 0.071). males in their analyses. Myer et al. (2010) prospec-
Specifically, knee valgus displacement was increased tively investigated a population of adolescent females
in the PFP group (10.88  2.2°; Fig. 2) in compar- of the same age as the current investigation and
ison to the control group (3.09  0.64°). Receiver reported a comparable cumulative incidence of
operating curve (ROC) analysis demonstrated
that knee valgus displacement was a significant pre-
dictor of PFP (C-statistic = 0.77; P = 0.002). Knee
valgus displacement ≥10.6° predicted PFP with a
sensitivity of 75% and specificity of 85%. The
associated positive likelihood ratio (sensitivity/1
specificity) was 5. The chi-square test indicated no sig-
nificant association between the development of PFP
and number of sports played (v2 = 2.96; P = 0.23;
phi = 0.19).

Fig. 3. Bland–Altman plot for knee valgus displacement.

Fig. 2. Representative landing of participant who went on

to acquire bilateral PFP. PFP = patellofemoral pain. Fig. 4. Scatterplot of 2D vs 3D knee valgus displacement.

4

9.66%. It has long been postulated that female ado-
lescents may be at higher risk of developing PFP
than their male and/or adult counterparts and as
such, may be the best sample to target from an injury
prevention perspective.
There were no observed differences between the
PFP and control group for baseline measures of age,
height, body mass, or number of sports partici-
pated in. However, in the current investigation, we
observed that baseline measures of knee valgus dis-
placement ≥10.6°, as measured by 2D analysis, were
predictive of PFP with high sensitivity and speci-
ficity. The high sensitivity found for this threshold
indicates that it correctly identified 75% of the knees
that went on to develop PFP (i.e., 8 of 12), while the
specificity means that this threshold value was cor-
rectly negative for 85% of people who did not
develop PFP. The positive likelihood ratio was 5,
indicating a 30% increased probability of developing
PFP if above the 10.6° of knee valgus displacement
during the DVJ (McGee, 2002). Myer et al. (2010)
reported that high school females who developed
PFP displayed significantly higher frontal plane knee
abduction moments than those who did not; how-
ever, the predictive capacity of this was not statisti-
cally evaluated. The addition of logistic regression
analysis, with associated sensitivity, specificity, and
positive likelihood ratio in the current investigation
strengthens the evidence for decreased frontal plane
control of the knee joint as a risk factor for develop-
ing PFP.
Knee valgus displacement measured in the current
investigation may in fact be a manifestation of fron-
tal and transverse plane motions at the hip. Dynamic
knee valgus has been described to be attributable to
a combination of femoral adduction and internal
rotation as well as tibial abduction and external rota-
tion (Powers, 2003; Levinger et al., 2007). This is in
agreement with previous investigations which identi-
fied a relationship between hip adduction and inter-
nal rotation and the development of PFP, both
prospectively (Boling et al., 2009; Noehren et al.,
2013) and retrospectively (Souza & Powers, 2009;
Noehren et al., 2012a, b; Nakagawa et al., 2015).
Additionally, a randomized control trial by Baldon
et al. (2014) reported that a functional training pro-
gram which targeted hip strengthening and control
reduced hip adduction and internal rotation. This
hip focused intervention was more beneficial in
improving pain and function than standard training
which consisted of stretching, as well as traditional
weight-bearing and non-weightbearing exercises
emphasizing quadriceps strengthening. Considering
the effect of hip adduction and internal rotation on
patellofemoral joint pressures, it is easy to conceptu-
alize how repetitive valgus loading during sporting
activities could cause PFP. Lee et al. (2003) reported
Knee valgus: a risk factor for knee pain
that more than 30° of femoral internal rotation
results in a significant increase in patellofemoral joint
contact pressures while Huberti and Hayes (1984)
discovered that a 10° increase in Q-angle increase
peak contact forces on the lateral aspect of the patel-
lofemoral joint by 45%.
In order to develop appropriate injury prevention
strategies, there is a need to identify predisposing
risk factors for PFP and develop clinically applicable
tools that will aid in the detection of such risk fac-
tors. The results of the current study are in agree-
ment with research from Myer et al. (2010) which
established a relationship between knee abduction
moment during landing and the development of PFP
in adolescent females. In their cohort they found that
a peak external knee abduction moment ≥15.4 Nm
was associated with a 6.8% risk of developing PFP.
Nevertheless, 3D motion analysis does not provide a
feasible method to facilitate screening adolescents
for knee injury risk. 2D analysis of dynamic knee
valgus has provided a surrogate measure of knee
joint control in the frontal plane (Levinger et al.,
2007; Willson & Davis, 2008). Research has shown
that it is valid, reliable, and sensitive to altered kine-
matics both in patients with symptomatic PFP and
post-intervention. However, prior to the current
investigation, no study had evaluated whether 2D
analysis would be able to prospectively identify those
who may be at risk of developing PFP. Although 2D
analysis has previously been validated against 3D
motion analysis (McLean et al., 2005), we utilized a
modified method for calculating knee valgus displace-
ment. The modification entails digitizing retro-reflective
markers placed on specific anatomic landmarks rather
than joint centers, due to the variability associated
with estimating joint centers on video images. How-
ever, high levels of adiposity (e.g., on the hips) may
influence the angle measured from markers placed
on the skin. Therefore, angular displacement (i.e.,
change in angle) during the deceleration phase of
landing was used to control for this. The direction
and magnitude in the change of angle will be the
same, irrespective of whether it is measured from
joint centers or markers placed on the skin. The
modified technique outlined in the current investiga-
tion demonstrates excellent correlation with mea-
sures from 3D motion analysis and has previously
been shown to have excellent reliability (Holden
et al., 2015). By measuring valgus angular displace-
ment, we quantified dynamic valgus (which is
described as medial collapse of the knee), rather than
the static “Q-angle” which is a measure of anatomic
alignment. A previous study found no relationship
between standing Q-angle and knee valgus angle dur-
ing dynamic activity (Pantano et al., 2005). Target-
ing the deficits associated with dynamic valgus may
therefore offer the opportunity for intervention if
5
Holden et al.
people “at risk” are subjected to exercise-based neu-
romuscular training which minimizes aberrant lower
limb mechanics.
Future investigation should evaluate whether
interventions which aim to reduce knee valgus dis-
placement could prevent PFP in adolescent females.
Prevention programs that focus on improving neuro-
muscular control of the knee have been effective in
the reduction of ACL injury incidence in female ath-
letes (Gagnier et al., 2013) and in reducing “high-
risk” movements such as dynamic valgus during
functional tasks (Myer et al., 2013a). Adolescent
females appear to be more receptive to such interven-
tions than adult females (Myer et al., 2013b). As the
incidence of PFP in adolescence is much higher than
the incidence of ACL injury, theoretically, it should
require smaller sample sizes to determine the efficacy
of such injury prevention programs on the incidence
of PFP.
The current investigation is not without limita-
tions. Although there is good correlation between
3D and 2D analysis, 3D analysis represents the
gold standard for kinematic analyses. As dynamic
knee valgus can be influenced by both proximal
(hip adduction/internal rotation) and distal (tibial
abduction) factors to the knee it is important to
consider the entire kinetic chain in efforts to pre-
vent knee joint injuries. Moreover, the predictive
capacity of knee valgus displacement found in this
study is specific to adolescent females. It has been
suggested that there may be subgroups of PFP
(Witvrouw et al., 2014) and that the underlying
etiology of PFP may be sex specific (Nakagawa
et al., 2012; Willy et al., 2012). As females athletes
are typically characterized by increased valgus dur-
ing dynamic activities which may predispose them
to PFP and/or ACL injury, screening and preven-
tion efforts may need to be specialized according
to sex.
Perspective
This study is the first to prospectively identify the
link between clinical measures of knee valgus and
risk of developing PFP. Although previous research
has identified increased knee valgus as a characteris-
tic of patients presenting with PFP, it was hard to
determine whether this precipitated the condition or
was as a result of it. The identification of increased
knee valgus displacement as a predictor for PFP has
important implications for the implementation of
neuromuscular control training in adolescent female
athletes in order to minimize aberrant lower extremity
kinematics, and thereby reduce the risk of developing
PFP. Additional research is needed to design, imple-
ment, and assess the efficacy of such individualized
programs.
Key words: Adolescent, patellofemoral pain, risk factor,
biomechanics, kinematics, prospective.

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