Patellar maltracking correlates with vastus medialis activation delay in patellofemoral pain patients

Saikat Pal, Christine E Draper, Michael Fredericson, Garry E Gold, Scott L Delp, Gary S Beaupre, Thor F Besier, Saikat Pal, Christine E Draper, Michael Fredericson, Garry E Gold, Scott L Delp, Gary S Beaupre, Thor F Besier

Abstract

Background: Delayed onset of vastus medialis (VM) activity compared with vastus lateralis activity is a reported cause for patellofemoral pain. The delayed onset of VM activity in patellofemoral pain patients likely causes an imbalance in muscle forces and lateral maltracking of the patella; however, evidence relating VM activation delay to patellar maltracking is sparse. The aim of this study was to investigate the relationship between VM activation delay and patellar maltracking measures in pain-free controls and patellofemoral pain patients.

Hypothesis: Patellar tilt and bisect offset, measures of patellar tracking, correlate with VM activation delay in patellofemoral pain patients classified as maltrackers.

Study design: Case control study; Level of evidence, 3.

Methods: Vasti muscle activations were recorded in pain-free (n = 15) and patellofemoral pain (n = 40) participants during walking and jogging. All participants were scanned in an open-configuration magnetic resonance scanner in an upright weightbearing position to acquire the position of the patella with respect to the femur. Patellar tilt and bisect offset were measured, and patellofemoral pain participants were classified into normal tracking and maltracking groups.

Results: Correlations between VM activation delay and patellar maltracking measures were statistically significant in only the patellofemoral pain participants classified as maltrackers with both abnormal tilt and abnormal bisect offset (R(2) = .89, P < .001, with patellar tilt during walking; R(2) = .75, P = .012, with bisect offset during jogging). There were no differences between the means of activation delays in pain-free and all patellofemoral pain participants during walking (P = .516) or jogging (P = .731).

Conclusion: There was a relationship between VM activation delay and patellar maltracking in the subgroup of patellofemoral pain participants classified as maltrackers with both abnormal tilt and abnormal bisect offset.

Clinical relevance: A clinical intervention such as VM retraining may be effective in only a subset of patellofemoral pain participants-namely, those with excessive tilt and excessive bisect offset measures. The results highlight the importance of appropriate classification of patellofemoral pain patients before selection of a clinical intervention.

Figures

Figure 1
Figure 1
Raw and filtered electromyography (EMG) activations of the vastus lateralis (VL) and vastus medialis (VM) muscles during a representative walk trial. Toe-off (TO; at left) marks the initiation of swing phase, which was the beginning of data collection. Trial time was adjusted to represent heel strike (HS) as time zero. The arrows indicate measured EMG onset times determined when activations crossed onset threshold, the greater of 3 standard deviations of resting EMG, and 2% of the larger peak activation between the VM and VL muscles.
Figure 2
Figure 2
Axial-plane patellofemoral joint kinematics illustrating (A) bisect offset (BO) index, a measure of the percentage of the patella lateral to the midline of the femur, and (B) patellar tilt (°), the angle formed by lines joining the posterior femoral condyles and the maximum width of the patella. Anatomical landmarks used to compute each measurement are indicated by the black dots. M, medial; L, lateral.
Figure 3
Figure 3
Distributions of (A) patellar tilt and (B) bisect offset values for men (controls and patellofemoral pain, n = 28) and women (controls and patellofemoral pain, n = 27) measured during weightbearing at full extension.
Figure 4
Figure 4
Relationship between patellar tilt and bisect offset in (A) male and (B) female pain-free controls and patellofemoral pain (PFP) participants measured during weightbearing at full extension. The dashed lines represent gender-specific thresholds for classification of maltrackers based on abnormal tilt and abnormal bisect offset values.
Figure 5
Figure 5
Relationship between vastus medialis (VM) activation onset delay and patellar tilt during walking using two classifications: A, pain-free controls and patellofemoral pain (PFP) participants; B, PFP participants classified according to maltracking measures. Negative VM delay indicates activation of VM before vastus lateralis. The regression line represents a significant relationship (R2 = .89, P <.001) in patients classified as maltrackers with both abnormal tilt and abnormal bisect offset (BO).
Figure 6
Figure 6
Relationship between vastus medialis (VM) activation onset delay and patella bisect offset (BO) during walking using two classifications: A, pain-free controls and patellofemoral pain (PFP) participants; B, PFP participants classified according to maltracking measures. Negative VM delay indicates activation of VM before vastus lateralis.

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