The American Journal of Sports

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Knee Angular Impulse as a Predictor of Patellofemoral Pain in Runners

Darren J. Stefanyshyn, Pro Stergiou, Victor M. Y. Lun, Willem H. Meeuwisse and Jay T. Worobets
Am J Sports Med 2006 34: 1844
DOI: 10.1177/0363546506288753
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http://ajs.sagepub.com/content/34/11/1844

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Knee Angular Impulse as a Predictor

of Patellofemoral Pain in Runners
Darren J. Stefanyshyn,* PhD, Pro Stergiou, MSc, Victor M. Y. Lun, MSc,

Willem H. Meeuwisse, MD, PhD, and Jay T. Worobets, BSc

From the Human Performance Laboratory and the Sport Medicine Centre,
University of Calgary, Calgary, Alberta, Canada

Background: Identification of mechanical factors associated with patellofemoral pain, the most prevalent running injury, is
necessary to help in injury prevention, but unfortunately they remain elusive.
Hypothesis: Runners who develop patellofemoral pain have increased knee joint angular impulse in the frontal plane.
Study Design: Case control study; Level of evidence, 3.
Methods: A retrospective study compared knee abduction impulses of 20 patellofemoral pain patients with those of 20 asymptomatic patients. A second prospective study quantified knee angular impulses during the stance phase of running of 80 runners
at the beginning of the summer running season. Epidemiologic data were then collected, recording the type and severity of injury
of these runners during a 6-month running period.
Results: The patellofemoral pain patients in the retrospective study had significantly higher (P = .026) knee abduction impulses
(17.0 8.5 Nms) than did the asymptomatic patients (12.5 5.5 Nms). Six patients developed patellofemoral pain during the
prospective study. The prospective data showed that patients who developed patellofemoral pain had significantly higher (P =
.042) knee abduction impulses (9.2 3.7 Nms) than did matched patients who remained uninjured (4.7 3.5 Nms).
Conclusion: The data indicate that increased knee abduction impulses should be deemed risk factors that play a role in the
development of patellofemoral pain in runners.
Clinical Relevance: Footwear and running style can influence knee angular impulse, and the appropriate manipulation of these
variables may play a preventive role for patients who are predisposed to patellofemoral pain.
Keywords: joint loading; biomechanics; injuries; locomotion

Patellofemoral pain is a debilitating injury that has been

reported as the most common athletic injury, affecting up
to a quarter of all persons active in sporting activities.9,22
Patellofemoral pain is especially common in sports that
involve running, occurring twice as frequently as the second
most common running injury (iliotibial band friction syndrome or tibial stress syndrome, depending on the study).5,32
Patellofemoral pain is a chronic injury that can persist and
affect athletic activity indefinitely. In fact, even with treatment, up to 75% of affected athletes must modify their athletic activity, as they continue to be plagued by pain for
several years.3,20

Patellofemoral pain commonly develops on the lateral

aspect of the patella.8,12 This finding suggests that frontal
plane loading, in particular internal knee abduction
moments, may play a large role in the development of
patellofemoral pain in runners. Increased knee abduction
moments during running could be generated by increased
muscle forces, increased soft tissue forces, or a combination
of the two. It has been suggested that increases in these
forces overpower the vastus medialis, which acts as a medial
stabilizer for the patella.15 When this occurs, lateral tracking of the patella and increased lateral stress can occur.6
Increases in values for these moments would, therefore,
likely reflect as increases in loads and stresses on the lateral
facet of the patella, which in turn can result in the activation of nociceptive (pain) fibers in the bone and/or synovium11 and the development of patellofemoral pain.
Patellofemoral pain is typically classified as an overload
or overuse injury, as large stresses are exacerbated by
repetitive loading, leading to a cumulative effect.27,33
Because cumulative loading is best quantified with impulse
variables, it was hypothesized that runners who develop

*Address correspondence to Darren J. Stefanyshyn, PhD, Human

Performance Laboratory, University of Calgary, 2500 University Drive NW,
Calgary, Alberta T2N 1N4, Canada (e-mail: darren@kin.ucalgary.ca).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 34, No. 11
DOI: 10.1177/0363546506288753
2006 American Orthopaedic Society for Sports Medicine

1844

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Vol. 34, No. 11, 2006

Knee Angular Impulse

1845

Figure 1. Schematic illustration showing the resultant knee abduction moment and the calculation of the knee abduction impulse
during the stance phase of running. The knee abduction impulse (shaded region) represents the area under the moment-time curve.

patellofemoral pain have higher knee joint angular impulse in

the frontal plane than do runners who do not develop patellofemoral pain. Abduction moments represent the torque or
twisting loads on the knee in the frontal plane, and the
impulse is the total twisting load experienced during the
stance phase, calculated by multiplying the load with the
length of time it is applied (Figure 1). The analysis of knee
abduction impulse for patients with and without patellofemoral pain may provide information about biomechanical
factors responsible for the onset of this pain. Furthermore,
to truly assess this hypothesis and determine whether knee
abduction moments are causally related to patellofemoral
pain, a prospective study is required.
Therefore, the purposes of this investigation were to determine (1) whether knee joint angular impulse in the frontal
plane is associated with patellofemoral pain in runners with
the use of a retrospective case control study and (2) whether
knee joint angular impulse in the frontal plane is causally
related to the onset of patellofemoral pain in a group of
recreational runners with the use of a prospective study.

METHODS
Retrospective Case Control Study
Two groups of runners were analyzed using a case control
study design. These groups included the following:
1. Patellofemoral pain group (PFP group): group of
patients with patellofemoral pain at time of study,
with no other injuries to the lower extremity in the
past 3 months.

TABLE 1
Patient Characteristics of the 40 Runners Who
Participated in the Retrospective Studya
Group

Age, y

Height, cm

Mass, kg

ASYMP
PFP

20
20

34.4 (10.3)
34.6 (9.8)

176.5 (9.4)
170.0 (9.4)

70.8 (13.4)
66.8 (12.5)

Values are presented as mean (SD). ASYMP, asymptomatic;

PFP, patellofemoral pain.

2. Asymptomatic group (ASYMP group): group of

patients who never had patellofemoral pain, with
no other injuries to the lower extremity in the past
3 months.
Data were collected on 40 patients (PFP group, n = 20;
ASYMP group, n = 20). The mean anthropometric data for
the patients can be found in Table 1.
Patellofemoral pain volunteers were recruited via medical
records from a sports medicine clinic. Potential patients
were contacted by telephone and asked whether they would
be willing to participate. Asymptomatic volunteers were
recruited through advertisements placed at local running
shoe stores with organized running programs. Before the
study, all volunteers read and signed a subject consent form
approved by the university ethics committee. Entry criteria
for the ASYMP group included having maintained a minimum weekly running distance of 20 km for at least the 6
months before the study. All patients were between 20 and
50 years old, had no injuries to the testing leg, had no prior
knee surgery, and had no diagnosis of joint disease. Entry

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The American Journal of Sports Medicine

criteria for the patellofemoral pain patients included the

above criteria plus their patellofemoral pain was not related
to an acute injury but was overuse in nature. Proper diagnoses of the injured patients were performed by 1 of 2 sports
medicine physicians (12 patients were diagnosed by 1 physician, whereas the remaining 8 were diagnosed by the other
physician). Common symptoms and signs used to diagnose
patellofemoral pain by the sports medicine physicians were
pain on palpation of the medial or lateral border of the
patella, pain on deep knee flexion (ie, deep knee bend, walking up or down stairs), and/or pain on the posterior surface
of the patella when the quadriceps muscles were contracted
with the knee in full extension. Patients were excluded if
their knee pain was found to be related to patellar tendinitis, quadriceps tendinitis, or prepatellar bursitis.
Three-dimensional kinematics of the affected limb were
quantified for the PFP group. For the ASYMP group, the left
or right leg was randomly selected for analysis. The upper leg,
the lower leg, and the foot segments were prepared using 9
reflective markers (3 per segment) attached to the skin with
adhesive tape. The markers were attached at the following
locations: proximal lateral upper leg, midanterior upper leg,
distal lateral upper leg, proximal lateral lower leg, midtibial
crest, distal lateral lower leg, posterior shoe heel, distal shoe
heel, and the lateral side of the shoe below the lateral malleolus. The 3-dimensional spatial positions of the markers were
collected using 4 electronically shuttered, high-speed video
cameras (NAC MOS-TV, V-14B, Japan) equipped with 12.5- to
75-mm zoom lenses (Cosmicar, Japan) and a VP310 video
processor (Motion Analysis Corp, Santa Rosa, Calif). The sampling frequency was set at 200 frames per second, and the
exposure time was set at 1/2500 seconds. System calibration
was achieved using a calibration frame containing 8 control
points. The calibration volume closely matched the volume of
interest. The raw data were stored on a SUN 3/280 computer.
Simultaneous 3-dimensional force data were collected
using a force platform (Kistler AG, Winterthur, Switzerland)
mounted flush with the floor in the center of a 30-m runway.
Force data were sampled at 1000 Hz. Patients were given
several practice trials to ensure that the foot landed with
a natural running style on the force platform. In all of the
cases, the natural running style was one of a heel-toe strategy. Running speed was controlled (4.0 0.2 m/s) using 2
photocells, 1.9 m apart, at shoulder height.
Positions of the markers to establish the defined neutral
position were identified in a standing trial using the video
system (200 Hz, 2-second sample). The patient was asked to
stand in a position with feet pointing anteriorly and approximately hip width apart. The knee and hip were in a fully
extended position, with the ankle joint at approximately a
90 angle. Six markers were used to identify joint centers in
the standing neutral trial. The hip joint center was identified
by markers placed on the greater trochanter and on the anterior leg just below the anterior superior iliac spine, the knee
joint center was identified by markers on the lateral knee
and at the center of the patella, and the ankle joint center
was identified by markers on the lateral malleolus and on
the anterior talus. For each joint, the lateral marker defined
the joint centers anterior-posterior and superior-inferior
coordinates, and the anterior marker defined the joint

centers mediolateral coordinate. This information was

necessary to make a transformation file relating the markerbased coordinate system to a meaningful anatomical segmental coordinate system for the lower and upper leg using a
singular value decomposition method.31
Video data were processed using Expert Vision ThreeDimensional software (Motion Analysis Corp). A direct linear
transformation was performed to determine 3-dimensional
spatial coordinates of each marker from the 2-dimensional
data collected. Data were tracked for a period corresponding
to 10 frames before and after contact with the force plate.
Before calculation, the kinematic data were smoothed using
a second-order low-pass Butterworth filter with a cutoff frequency of 12 Hz, and the kinetic data were smoothed using a
second-order low-pass Butterworth filter with a cutoff frequency of 100 Hz. Both the kinematic and kinetic data were
imported into Kintrak 4.0 (Motion Analysis Corp) for further
analysis.
Three-dimensional joint attitude and angular motions were
determined using a joint coordinate system implemented
in Kintrak 4.0. This joint coordinate system consisted of the
proximal segments (thigh segment for the knee joint calculations) flexion-extension axis, the distal segments (shank segment for the knee joint calculations) longitudinal axis, and
a third floating axis calculated as the cross-product of the
flexion-extension and longitudinal axes. Knee joint kinematics (3-dimensional) was calculated for the period of stance as
the relative movement of the lower leg with respect to the
upper leg. Resultant joint moments in the frontal plane were
calculated about the floating axis for the stance phase of running in Kintrak using a standard inverse dynamics approach.
Abduction moments represent the torque or twisting loads on
the knee in the frontal plane. Internal abduction impulse was
quantified by integrating the moment-time curve and represents the cumulative twisting load during the entire stance
phase. Means were calculated for 5 trials per patient. A
1-tailed t test was used to compare the knee abduction
impulse between the injured and uninjured patients with a
level of significance set at = .05.

Prospective Study
The data collected in this investigation consisted of 2 parts.
The first aspect was a detailed kinematic and kinetic analysis during the stance phase of running for 140 runners at
the beginning of the summer running season. The second
aspect was an epidemiologic study quantifying the type
and severity of injury of these runners as they undertook a
6-month running period. As the patients constituted a relatively experienced group of runners, 89% reported at least
1 previous running-related injury. However, all runners were
free from pain or injury at the onset of the study. Eighty
patients (Table 2) fully completed the study with detailed
running logs and injury data after the 6-month period.
Informed written consent in agreement with the university
ethics committees policy was obtained from all patients.
Using similar methodology as in the retrospective case
control study, force and movement data were collected in the
laboratory at a running speed of 4.0 0.2 m/s. Although
training paces of the patients varied, all patients were

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TABLE 2
Patient Characteristics of the 80 Runners Who
Completed the Prospective Investigationa

Women
Men

Age, y

Height, cm

Mass, kg

39
41

35.9 (8.0)
39.8 (8.9)

166.9 (7.7)
179.1 (7.1)

61.5 (8.8)
77.3 (10.6)

1847

TABLE 3
Comparison of the Patient Characteristics of the
6 Patients Who Developed Patellofemoral Pain
and the Uninjured Patients Who Were Used
as Matched Controls in the Prospective Study
Patient

Injured
Leg

Gender

Mileage,
km

Experience,
y

Mass,
kg

40
40
55
60
12
15
40
35
30
30
15
15

1.5
4.0
20.0
15.0
1.0
0.7
16.0
14.0
1.5
4.0
1.0
2.0

79.1
84.0
82.5
75.2
65.5
59.0
59.3
63.5
76.0
74.1
76.6
76.2

32.0
32.5

6.8
6.6

73.2
72.0

Values are presented as mean (SD).

comfortable at this pace. One small modification was made to

the data collection protocol for the prospective study. The knee
joint center was calculated as the midpoint between markers
placed on the lateral and medial epicondyles, as opposed to on
the patella. This change was made in conjunction with newly
presented data from Ferber et al,10 showing that knee abduction moments are highly repeatable using this methodology.
All patients had data collected on both right and left legs while
wearing their own running shoes. Internal abduction impulse
was quantified by integrating the moment-time curve, and
means were calculated for 3 trials per patient.
After completion of the kinematic and kinetic data collection, patients began a 6-month running period (approximately May-October, depending on the patient). During the
running period, patients were required to document daily
running distance and intensity in a log book that was collected monthly. Any lower extremity pain or injury that was
thought to be running related was documented in the log
book. Although the patients did not meet regularly with the
investigators, they were encouraged to contact the investigators if they had any questions. Moreover, a weekly injury
clinic was organized at which 2 sports medicine physicians
were available to assess injuries requiring medical attention.
During the study, 6 patients who were seen by the physicians were diagnosed with patellofemoral pain. None of the
6 patients previously had patellofemoral pain. Diagnosis of
patellofemoral pain was based on meeting all of the following historical and physical examination criteria:
History
1. Nontraumatic unilateral and/or bilateral peripatellar
or retropatellar knee pain
2. Patellofemoral knee pain with and/or after activity
3. Inactivity patellofemoral pain and/or stiffness,
especially with sitting with knees held in flexed
posture
4. No history of knee surgery

1 injured
Match 1
2 injured
Match 2
3 injured
Match 3
4 injured
Match 4
5 injured
Match 5
6 injured
Match 6

Right

Male

Left

Male

Left

Female

Left

Female

Right

Male

Right

Female

Mean
Injured
Noninjured

first analysis compared the 6 injured patients to the 74

patients who did not develop patellofemoral pain. This
analysis is confounded by the fact that some of the patients
who did not develop patellofemoral pain during this study
(1) had a previous history of patellofemoral pain and/or (2)
developed other running injuries such as iliotibial band syndrome or tibial stress syndrome. Therefore, a second analysis was performed in which the 6 injured patients were
matched to 6 patients who remained injury free (ASYMP
group) throughout the study, 1-to-1 case-to-control matching.13 Patients were matched according to weekly training
distance, years of running experience, mass, and gender
(Table 3), variables that have been proposed to be associated
with injury and/or that can have an influence on resultant
joint moments.25,34 All matching was performed solely on the
variables listed, with the researchers blinded to the outcome
variables. None of the 6 asymptomatic patients had a previous patellofemoral injury. For both comparisons, a 1-tailed
paired t test was used to compare the knee abduction
impulse between the injured and uninjured patients. The
level of significance was set at = .05.

RESULTS
Physical examination
1. No or minimal articular or periarticular effusion or
bursitis
2. No significant joint line tenderness
3. No intra-articular ligamentous instability
4. Peripatellar tenderness mild inferior patellar
pole tenderness
5. No patellar apprehension
To analyze the knee joint impulses of the injured (PFP
group) patients, 2 different analyses were performed. The

Retrospective Case Control Study

Resultant knee joint moments in the frontal plane were
primarily abduction throughout the stance phase. The
mean resultant knee abduction moments showed similar
patterns but different magnitudes for the PFP and ASYMP
groups (Figure 2). The PFP group patients had significantly higher (P = .026) knee abduction impulses (17.0
8.5 Nms) than did the ASYMP patients (12.5 5.5 Nms)
(Figure 3).

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Stefanyshyn et al

The American Journal of Sports Medicine

Figure 2. Mean (SE) resultant knee abduction moments for

the 20 patellofemoral pain (PFP) and 20 asymptomatic
(ASYMP) patients. The shaded regions represent the knee
abduction impulses.

Figure 4. Knee abduction impulse for the patellofemoral pain

(PFP) patients. Comparison is made to the asymptomatic
(ASYMP) patients where zero represents the mean of the
ASYMP group. A positive value indicates the PFP patient had
knee abduction impulses that were higher than the mean of
the ASYMP group.

to the retrospective study. There was no significant difference

(P = .230) in knee abduction impulses when comparing the
PFP group patients (9.2 3.7 Nms) to all the other patients
who did not develop patellofemoral pain (7.7 4.8 Nms)
(Figure 6). When matched according to running mileage, running experience, gender, and mass, the PFP group patients
had significantly higher (P = .042) knee abduction impulses
(9.2 3.7 Nms) than did the matched ASYMP patients (4.7
3.5 Nms) (Figure 7). Individual results for the knee joint
moments are presented in Figure 8. Five of the 6 patellofemoral pain patients had higher knee abduction impulses
than did their asymptomatic matched controls.
Figure 3. Mean (SD) knee abduction impulses for the 20
patellofemoral pain (PFP) and 20 asymptomatic (ASYMP)
patients.

Individual results for the knee joint impulses are presented in Figure 4. Individual values for each PFP group
patient are compared with the mean knee abduction
impulse of the ASYMP group. There is an approximately
equal distribution of PFP group patients who had knee
abduction impulses higher and lower than the mean of the
ASYMP group. However, 10 of 20 patients had more than
50% larger abduction impulses compared to the ASYMP
group, with 6 patients having impulses that were more
than 100% larger. In contrast, only 1 patient within the
ASYMP group had more than a 50% larger impulse than
the ASYMP group mean.

Prospective Study
Six patients (3 men and 3 women) were clinically diagnosed
with patellofemoral pain. The mean resultant knee joint
moments during running showed similar patterns (Figure 5)

DISCUSSION
The first purpose of this investigation was to determine
whether knee angular impulses in the frontal plane are associated with patellofemoral pain. The data from the retrospective case control study showed that abduction impulses are
related to patellofemoral pain, as mean knee abduction
moments in the PFP group were significantly higher than
those in the ASYMP group by 36%. The second purpose was
to determine whether these abduction impulses are causally
related to the onset of patellofemoral pain. In the prospective
study, the patients who developed patellofemoral pain had
knee abduction impulses that were, on average, 19% higher
than those in the remaining runners who did not develop
patellofemoral pain. These differences were not significantly
different; however, they were confounded by various factors.
The main confounding factor was that some of the patients,
although currently uninjured, had a history of patellofemoral
pain. Another confounding factor was that some of these
patients developed other running injuries such as iliotibial
band syndrome or tibial stress syndrome. It may be that these
runners modified their training programs or running styles
as a result of these injuries, thus preventing the onset of
patellofemoral pain. Consequently, an attempt was made to

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Figure 5. Mean (SE) resultant knee abduction moments for

the 6 patients who developed patellofemoral pain (PFP) and
the 6 asymptomatic matched controls (ASYMP). The shaded
regions represent the knee abduction impulses.

1849

Figure 7. Mean (SD) knee abduction impulses for the 6

patients who developed patellofemoral pain (PFP) and the
6 asymptomatic matched controls (ASYMP).

Figure 6. Mean (SD) knee abduction impulses for the 6

patients who developed patellofemoral pain (PFP) and the 74
patients who did not develop PFP. ASYMP, asymptomatic.

Figure 8. Mean (SD) knee abduction impulse for each of the

6 patients who developed patellofemoral pain (PFP) in comparison to their asymptomatic matched controls (ASYMP).

compare the patients with patellofemoral pain in the prospective study to similar (matched on the basis of gender, running
mileage, running experience, and mass) uninjured patients.
Research has shown that joint moments are influenced by
mass and gender25; thus, it was important to match for these
criteria. Furthermore, injury has been related to weekly running distance and years of running experience34; thus, it was
deemed necessary to match for these criteria as well. The
prospective data show that the patients who developed
patellofemoral pain had significantly higher (97%) knee
abduction impulses before injury than did uninjured matched
controls. Thus, the hypothesis that runners characterized
by increased knee abduction impulses are predisposed to
patellofemoral pain was supported. The data from these 2
studies indicate that knee abduction impulses should be
deemed risk factors that play a role in the development of
patellofemoral pain in runners.
Although several studies1,16,17 have quantified patellofemoral loads and pressures in vitro, it is obviously difficult

to determine these parameters in vivo. Therefore, resultant

knee joint moments have been used to look at in vivo
patellofemoral joint loading. Scott and Winter29 studied
internal forces at the knee joint during running. They used
knee joint moments as inputs into a 2-dimensional sagittal
plane model to calculate patellofemoral joint contact force
over the stance phase of running. Mean patellofemoral joint
contact forces equated to 7.6 times body weight. Other
authors have also indicated that these patellofemoral forces
can be several times body weight18,28 and have, therefore,
speculated that this large force substantiates why this joint
has such a high injury frequency rate. Recently, Powers
et al26 showed that increases in knee extensor moments lead
to increases in contact forces and stress in the patellofemoral
joint. However, extensor moments account for only part of
the joint loading. Glitsch and Baumann14 found that for
patients running at 5 m/s, moments in the frontal plane contributed significantly to the 3-dimensional intersegmental
knee joint moment. Initial foot placement during running

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Figure 9. Schematic illustration showing how increased hip

adduction (right) results in increased knee abduction moments
with identical ground reaction forces.

necessitates the hip being in an adducted position during

the stance phase. Consequently, the positioning of the
ground-reaction force results in an external adduction
moment at the knee, which can be quite large, up to 50% of
the knee extension moments,21 and must be counteracted
by an internal abduction moment. A comparison with a
2-dimensional approach showed that there was an underestimation of the internal loads by up to 60%, suggesting that
a 3-dimensional approach including frontal and transverse
plane moments should be used to get a clear picture of the
loads acting on the knee joint.
Frontal plane knee moments have been linked to disorders
other than patellofemoral pain. A study done by
Andriacchi2 showed that a higher than normal abduction
moment at the knee joint may be related to progressive
degenerative changes at the knee joint. It was suggested
that this factor may influence surgical outcome in patients
treated for varus deformities. Hurwitz et al19 found that
the abduction moment during walking was the single best
predictor of knee joint bone mineral content measured by
radiograph absorptiometry. This finding suggests that
an increase in value for this moment may equate to an
increase in load and may have important implications
for the progression of degenerative joint disease. It has

also been shown30 that there was a significant relationship

between abduction moments and severity of osteoarthritis.
Knee joint moments and impulses in the frontal plane can
be influenced by footwear and running style. Different
authors have shown that medially or laterally wedging
footwear can influence peak knee moments in the frontal
plane. Inverted orthotics posted between 15 and 25 significantly increase peak knee abduction moments during running.36 Medial wedges of 10 were also found to significantly
increase peak knee abduction moments during walking.35 In
contrast, lateral wedges significantly reduced peak knee
abduction moments7,35 with wedges as small as 5. Running
mechanics such as hip adduction will also influence the knee
abduction moment. Greater hip adduction will result in
increased knee joint moments as the lever arm between the
line of action of the ground-reaction force and the knee joint
center increases (Figure 9). In addition, foot contact position
and angle can influence the point of application of the groundreaction force and, subsequently, the knee joint moment. It
appears that even relatively small changes in footwear and
running mechanics can have significant influences on knee
loading in the frontal plane.
Limitations and errors associated with determining resultant joint moments have been well documented.4,23 However,
Ferber et al10 showed knee abduction moments to be highly
repeatable with within-day and between-day interclass correlation coefficients of 0.98. Despite the use of slightly different methods, the resultant knee joint moments found in this
investigation showed similar patterns and peak magnitudes
to those previously reported.24 There were some discrepancies
in the absolute magnitudes of the abduction impulses
between the retrospective and prospective studies. These discrepancies can be primarily attributed to different methods of
selecting the knee joint centers, as discussed in the Methods
section; however, this does not affect the repeatability of the
measurements. A main limitation of this investigation was the
small group of injured patients in the prospective study. Six of
80 patients (those who completed the study) developed
patellofemoral pain during a 6-month period for an annual
injury incidence of 15%. This finding was slightly lower than
the reported values of 16% to 25%.5,32 Another limitation is
that patellar loading was not directly quantified. To fully
understand the cause of patellofemoral pain, it is important
to directly quantify the loading of the patellofemoral joint.
However, this procedure is extremely invasive and is difficult
to perform in vivo. Thus, the exact mechanical link between
increased frontal plane knee joint angular impulse and
patellofemoral pain cannot be conclusively defined. However,
the results indicate that knee joint abduction impulse may be
a useful predictor of persons who may be predisposed to
developing patellofemoral pain during running.
In conclusion, despite a substantial amount of research on
patellofemoral pain during the past 25 years, it still remains
the number one running injury,32 suggesting that little
progress has been made in prevention. Prevention is obviously difficult if the risk factors remain unknown. Runners
who have patellofemoral pain have significantly higher
knee abduction impulses than do asymptomatic runners.
Furthermore, runners who developed patellofemoral pain
during a 6-month running season had higher knee abduction

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Knee Angular Impulse

impulses than did patients with similar characteristics

who remained uninjured. The increased knee joint loading,
as indicated by the increased joint impulses, may result in
higher local stresses and, therefore, pain after repetitive
cycles. Footwear and running style can have a substantial
influence on the knee joint moments, and the appropriate
manipulation of these variables may play a preventive role
for patients who are predisposed to injury.

ACKNOWLEDGMENT
This work was supported by the Canadian Fitness and
Lifestyle Research Institute. The authors thank Darren
Hinton for his assistance in data analysis.
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