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Is hip strength a risk factor for patellofemoral pain?
A systematic review and meta-analysis
M S Rathleff,1,2 C R Rathleff,1 K M Crossley,3 C J Barton4,5,6,7
1
Orthopaedic Surgery Research ABSTRACT internal rotation, especially during weight-bearing
Unit, Research and Innovation Objective To evaluate and synthesise the literature on activities, may lead to altered knee and patellofe-
Center, Aalborg University
Hospital, Aalborg, Denmark
hip strength among patients with patellofemoral pain moral joint (PFJ) kinematics with subsequent
2
Institute of Clinical Medicine, (PFP) to address the following: (1) differentiate between increase in lateral PFJ stress.17 Recent prospective
Aarhus University, Aarhus, hip strength as a risk factor and associated deficit in studies support this hypothesis, reporting increased
Denmark PFP; (2) describe hip strength in men and women with peak hip internal rotation angle during landing in
3
Division of Physiotherapy, PFP across different age ranges; (3) investigate the military recruits,6 and greater peak hip adduction
School of Health and
Rehabilitation Sciences, effects of hip strengthening on biomechanical knee angle in recreational female runners18 to be risk
University of Queensland, variables associated with PFP development. factors for PFP development. These altered move-
Brisbane, Queensland, Methods MEDLINE, CINAHL, Web of Science, ment patterns may result from impaired hip muscle
Australia SportDiscus and Google Scholar were searched in function.6 18
4
Complete Sports Care,
Melbourne, Victoria, Australia
November 2013 for studies investigating hip strength Lower hip muscle strength has been explored in
5
Pure Sports Medicine, among patients with PFP. Two reviewers independently people with PFP. The most recent systematic review
London, UK assessed papers for inclusion and quality. Means and of hip strength included a search completed in
6
Centre for Sport and Exercise SDs were extracted from each included study to allow January 2008, and focused only on women.19 This
Medicine, Queen Mary effect size calculations and comparisons of results. review concluded that women demonstrated lower
University of London
7
Musculoskeletal Research Results Moderate-to-strong evidence from prospective hip abduction, external rotation and extension
Centre, La Trobe University, studies indicates no association between isometric hip strength in the affected side compared to asymp-
Melbourne, Australia strength and risk of developing PFP. Moderate evidence tomatic individuals.19 However, no prospective
from cross-sectional studies indicates that men and research was identified to allow evaluation of a
Correspondence to
Dr Michael Skovdal Rathleff, women with PFP have lower isometric hip musculature causal relationship between hip muscle function
Orthopaedic Surgery Research strength compared to pain-free individuals. Limited and PFP.20 Since the publication of this systematic
Unit, Research and Innovation evidence indicates that adolescents with PFP do not review, many studies, including those with pro-
Center, Aalborg University have the same strength deficits as adults with PFP. spective designs, have evaluated the link between
Hospital, Soendre Skovvej 15,
Conclusions This review highlights a possible hip strength and PFP, and it is timely to conduct an
Aalborg 9000, Denmark;
michaelrathleff@gmail.com discrepancy between prospective and cross-sectional updated high-quality (HQ) systematic review in this
research. Cross-sectional studies indicate that adult men field.
Accepted 5 March 2014 and women with PFP appear to have lower hip strength In line with the belief that impaired hip muscle
Published Online First compared to pain-free individuals. Contrary to this, a function is associated with PFP, the clinical effects
31 March 2014
limited number of prospective studies indicate that there of hip muscle strengthening programmes have
may be no association between isometric hip strength recently been evaluated.21–24 However, in order to
and risk of developing PFP. Therefore, reduced hip gain a deeper understanding of the role of hip
strength may be a result of PFP rather than the cause. muscle strength in PFP, an evaluation of the rela-
tionship between hip strengthening interventions
and changes in knee biomechanics are required.
INTRODUCTION The gaps in the literature call for the investigation
The incidence and prevalence of patellofemoral of the following: (1) differentiate between hip
pain (PFP) are high in both adolescent and adult strength as a risk factor and associated deficit in
populations.1–7 Importantly, despite the implemen- PFP; (2) association of hip strength with PFP in men
tation of conservative rehabilitation, the long-term and women across different age ranges and (3) the
prognosis for PFP is poor, with only one-third being effects of hip strengthening on biomechanical knee
pain-free, 1 year after the initial diagnosis.8–11 variables associated with PFP development.
Identifying modifiable risk factors will facilitate tar-
geted rehabilitation and prevention strategies for METHODS
PFP, thus reducing the burden of PFP.12 Search strategy
The aetiology of PFP is thought to be multifac- MEDLINE, EMBASE, CINAHL, Web of Science,
torial.13 Local factors, such as lower knee extension Google Scholar, SportDiscus databases were
strength,14 delayed onset of vastus medialis relative searched from inception until November 2013. No
to vastus lateralis,4 greater knee abduction impulse data limits were used during searching. Without
during running15 and knee abduction moment any modification, the search strategy from a
during drop jump landing16 have been associated Cochrane systematic review on exercise therapy for
with increased risk of PFP development. While all PFP was used for diagnostic search terms (see
To cite: Rathleff MS, factors can contribute to PFP and are likely to be online supplementary appendix 1).25 The diagnos-
Rathleff CR, Crossley KM, interrelated, recently much attention has been paid tic search terms were then combined with the
et al. Br J Sports Med to the relationship between hip function and PFP.12 terms: strength, torque, force, moment, isokinetic,
2014;48:1088–1088. It is proposed that greater hip adduction and isometric, eccentric, concentric, power, isotonic,

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endurance, kinematics, moments and kinetics. Reference lists In addition a PFP diagnosis checklist was used.30 The diagno-
and citing articles of included papers were also screened. sis checklist is a seven-item scale summarising the reporting of
Additionally a cited reference search for each included paper key inclusion and exclusion criteria for the diagnosis of PFP,
was completed in Google Scholar for additional publications of with higher scores indicating a greater number of desired cri-
interest. Unpublished work was not sought in this review. This teria is reported. Each scale was applied by two reviewers (MSR
could potentially lead to publication bias because significant and CRR) with discrepancies resolved during a consensus
results are more likely to be published.26 In addition, it would meeting, and a third reviewer was available (CJB) if needed.
have been unfeasible to contact all institutions and authors
around the world for unpublished work. No review protocol Study analysis
exists. Sample sizes, participant demographics, population sources and
pain duration were extracted by MSR and checked by CRR.
Inclusion and exclusion criteria Sample sizes, means and SDs of all outcomes were extracted or
Data from prospective studies investigating risk factors for PFP sought from original authors to allow calculation of the standar-
were included to answer objective 1. Cross-sectional and pro- dised mean difference (SMD) as a measure of effect size. MSR
spective studies evaluating hip strength were considered for extracted all outcomes from the papers into a spreadsheet. After
inclusion to answer objective 2 if they contained data on hip the content of the spreadsheet was checked by CRR and CJB
strength from a comparison between (1) participants with PFP for data accuracy, the SMDs were calculated using a random
and pain-free individuals or (2) women and men with PFP. Data effects model in Review Manager V.5.2 (Copenhagen: The
from prospective and randomised trials investigating the effect Nordic Cochrane Centre, The Cochrane Collaboration).
of hip strengthening on knee kinematics were included to help Following the methodology used by Hume et al,30a the individ-
answer objective 3. Hip strength in all six movement directions ual or pooled SMDs were categorised as small (≤0.59), medium
was included (flexion, extension, abduction, adduction, internal (0.60–1.19) or large (≥1.20). These criteria were chosen to be
rotation and external rotation). The inclusion criteria required more stringent than traditional criteria.31 Furthermore these cri-
patients to be diagnosed with PFP, anterior knee pain or chon- teria have been used in previous systematic reviews on PFP,
dromalacia patellae. Studies including participants with other which facilitates comparison.32 33 Forest plots were used to
knee conditions such as patellar tendinopathy or osteoarthritis, allow easy visualised comparisons between studies and out-
where individuals with PFP could not be separately analysed, comes. The level of statistical heterogeneity for pooled data was
were excluded. Studies using manual assessment of hip strength established using the χ2 and I2 statistics. The χ2 and I2 statistics
without a dynamometer or similar (ie, manual muscle tests) describe heterogeneity or homogeneity of the comparisons with
were excluded. p<0.05 indicating a significant heterogeneity. The χ2 and I2 sta-
tistics are presented together with levels of evidence in the
Review process Result section. Definitions for ‘levels of evidence’ were guided
Titles and abstracts identified in the search were downloaded by recommendations made by van Tulder et al34.
into Endnote V.X4 (Thomson Reuters, Carlsbad, California, Strong evidence: pooled results derived from three or more
USA), cross-referenced, and duplicates deleted. All potential studies, including a minimum of two HQ studies, which are stat-
publications were independently assessed for inclusion by two istically homogenous ( p>0.05)—may be associated with a statis-
reviewers (MSR and CRR), and full texts were obtained if tically significant or non-significant pooled result.
necessary. Any discrepancies were resolved during a consensus Moderate evidence: statistically significant pooled results
meeting, and a third reviewer was available (CJB) if needed. derived from multiple studies, including at least one HQ study,
which are statistically heterogeneous ( p<0.05); or from mul-
Quality assessment and risk of bias tiple low-quality (LQ) studies which are statistically homogenous
Included papers were assessed for methodological quality by (p>0.05).
two independent raters (MSR and CRR), with any disagree- Limited evidence: results from multiple LQ studies which are
ments resolved by consultation with a third party. Title, journal statistically heterogeneous ( p<0.05); or from one HQ study.
and author details were removed to de-identify articles prior Very limited evidence: results from one LQ study.
to rating. Quality ratings were performed using the Conflicting evidence: pooled results insignificant and derived
Epidemiological Appraisal Instrument (EAI)27 using similar from multiple studies regardless of quality, of which some show
methodology as Nix et al.28 The EAI was designed as ‘a critical statistical significance individually, which are statistically hetero-
appraisal system rooted in epidemiological principles’ for use in geneous ( p<0.05, ie, inconsistent).
systematic reviews and meta-analysis, and developed by a team To evaluate the robustness of our meta-analysis, two sensitiv-
of epidemiologists, physicians and biostatisticians. The robust ity analyses were completed. One was completed with LQ
development consisted of an eight-step process including studies removed, and one where studies with a score of 5 or
content and criterion validation, consultation with individuals below on the diagnosis checklist were excluded.
outside the research team, two associated revised versions and
establishment of the scales reliability.27 Utilising the method RESULTS
described by Nix et al,28 the EAI was adjusted to the intended The initial search produced 1947 unique citations. Following
purpose of this review and 26 of the original 43 items were application of the selection criteria to titles and abstracts this
used. Items relating to interventions, randomisation, follow-up was reduced to 77. The primary reason for exclusion of studies
period or loss to follow-up that were not applicable to three included lack of a control group for strength measurements.
individual objectives were excluded by MSR and CJB. Identical After reading full texts the number was reduced to 27 (see
to Nix et al,29 we used a median approach to divide included figure 1). An additional three citations were later excluded due
studies into higher and lower quality groups, that is, describing to data duplication. Results of the diagnostic checklist and the
50% as higher quality and 50% as lower quality based on the EAI scale are shown in tables 1 and 2. Agreement between
scores from the EAI. quality assessors, calculated as a weighted κ was 0.90 (95% CI

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Figure 1 PRISMA flowchart.

0.88 to 0.93). Online supplementary tables S1 and S2 summar- well as a trend for lower isometric hip external rotation (2 HQ
ise the main methodological details and results for the included and 5 LQ studies: SMD: −0.38, 95% CI −0.77 to 0.02, I2=60%,
studies. Three studies were prospective6 35 36 while the remain- p=0.02)37–39 41 44 47 48 in individuals with PFP. Limited evidence
ing 21 studies used a cross-sectional design. Four studies used from one HQ study indicates no difference in isometric hip
concentric and/or eccentric isokinetic strength testing while the internal rotation, (SMD: −0.06, 95% CI −0.68 to 0.56)48 or
remainder used isometric strength measurements. Figure 2A–F adduction strength, (SMD: 0.14, 95% CI −0.48 to 0.76).48
illustrates effect sizes and meta-analysis for abduction, adduc- Moderate evidence indicates lower eccentric hip external
tion, external rotation, internal rotation, extension and flexion rotation strength with medium ES, (1 HQ and 1 LQ, SMD:
strength. Figure 3 illustrates effect sizes for the effects of hip −0.61 95% CI −0.98 to −0.24, I2=0%, p=0.33),49 50 but no
strengthening on knee kinematics and joint torques. difference in concentric (2 LQ, SMD: −0.29, 95% CI −0.74 to
0.15, I2=0%, p=0.78)44 49 or eccentric (2 LQ, SMD: −0.21,
Hip strength—prospective studies 95% CI −0.66 to 0.123, I2=0%, p=0.81)44 49 hip extension
Moderate-to-strong evidence from three HQ studies found no strength measured isokinetically. Limited evidence indicates
association between lower isometric strength in hip abduction, lower eccentric isokinetic strength in hip abduction with
(SMD: 0.06, 95% CI −0.58 to 0.70, I2 = 0.75%, p=0.02), medium ES (1 HQ and 1 LQ studies: SMD: −0.74, 95% CI
extension (SMD: −0.24, 95% CI −0.50 to 0.02; I2=0%, −1.11 to −0.37, I2=0%, p=0.83) in individuals with PFP.49 50
p=0.97), external rotation (SMD: −0.19, 95% CI −0.46 to Very limited evidence indicates no difference in concentric hip
0.07, I2 = 0%, p=0.93) or internal rotation (SMD: −0.01 95% abduction (1 LQ, SMD: −0.15, 95% CI −0.77 to 0.47)49 and
CI −0.40 to 0.38, I2=39%, p=0.20), and risk of developing no difference for concentric hip external rotation strength
PFP (SMD: −0.24 to 0.06, I2=0–75%, p=0.02–0.93).6 35 36 (1 LQ study, SMD: −0.51, 95% CI −1.14 to 0.12)49 between
Moderate evidence from two HQ studies revealed no associ- individuals with and without PFP.
ation between lower isometric strength in hip adduction and
flexion and the risk of developing PFP (SMD: −0.06 to 0.19, Hip strength—cross-sectional studies, gender specific
I2=0–58%, p=0.12–0.41).35 36 Men
Limited evidence indicates reduced isometric hip abduction
Hip strength—cross-sectional studies, mixed gender strength with medium ES (1 HQ study: SMD: −0.74, 95% CI
Moderate evidence indicates lower isometric hip abduction −1.39 to −0.10)50 and lower isokinetic eccentric hip external
strength with a small effect size (ES) (4 HQ and 7 LQ studies: rotation with medium ES (1 HQ study: SMD: −0.98, 95% CI
SMD: −0.58, 95% CI −0.85 to −0.30, I2=53%, p=0.02)24 37–46 −1.64 to −0.32)50 in men with PFP. Limited evidence indicates
and lower hip extension strength with a small ES (2 LQ studies: no difference in isokinetic eccentric hip abduction strength
SMD: −0.56, 95% CI −1.04 to −0.08, I2=9%, p=0.29),37 43 as (1 HQ, SMD: −0.59, 95% CI −1.23 to 0.04)50 in men with PFP.

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Table 1 Patellofemoral pain diagnosis checklist
Inclusion items Exclusion items

Clear Insidious onset Symptoms Previous Other sources


definition of unrelated to consistent with knee Internal Ligamentous of anterior Total
Paper location trauma diagnosis surgery derangement instability knee pain score

Baldon et al 1 1 1 1 1 1 1 7
Bazett-Jones et al 1 1 1 0 1 1 1 6
Bolgla et al 1 1 1 1 1 1 0 6
Boling et al 1 1 1 0 1 1 0 5
Boling et al 1 1 1 1 1 0 1 6
Cichanowski et al U 1 U 1 1 1 1 5
Cowan et al 1 1 1 1 1 1 1 7
Dierks et al 1 0 1 0 1 1 0 4
Earl and Hoch 1 1 1 1 1 1 1 7
Ferber et al 1 1 1 1 1 1 1 7
Finnoff et al 1 0 1 1 0 0 0 3
Ireland et al 1 1 1 1 1 1 0 6
Magalhaes et al 1 0 1 1 1 1 1 6
McMoreland et al 1 1 1 1 1 1 0 6
Nakagawa et al 1 1 1 1 1 1 0 6
Nakagawa et al 1 1 1 1 1 1 0 6
Piva et al 1 1 1 1* 1 1 1 7
Rathleff et al 1 1 1 1 1 1 1 7
Roach et al 1 1 1 1 1 1 0 6
Robinson et al 1 1 1 1 1 1 0 6
Souza et al 1 0 1 1 1 1 1 6
Souza et al 1 0 1 1 1 1 1 6
Thijs et al 1 1 1 1 1 1 1 7
Willson et al 1 1 1 0 0 0 U 3
1=yes, 0=no and U=undetermined.
*Limited to previous 2 years.

Women prospective design while the other used a cross-sectional design.


Strong evidence indicates lower isometric hip external rotation An unadjusted analysis from the prospective HQ study indicates
(4 HQ and 2 LQ studies: SMD −0.83, 95% CI −1.08 to −0.57, higher hip abduction strength among those who developed PFP
I2=0%, p=0.46),45 51–55 isometric hip internal rotation (3 HQ (SMD: 1.06, 95% CI 0.15 to 1.97) but no association for hip
studies: SMD: −0.44, 95% CI −0.77 to −0.12, I2=0%, adduction, hip external or internal rotation or hip extension or
p=0.49)52 54 55 and isometric hip extension (2 HQ and 1 LQ flexion strength (SMD: −0.55 to 0.48).35 The cross-sectional
studies: SMD: −1.10, 95% CI −1.77 to −0.43, I2=58%, HQ study indicates no difference in hip strength between ado-
p=0.09)47 52 54 in women with PFP. Moderate evidence indi- lescents with PFP and pain-free adolescents (SMD: −0.06 to
cates lower isometric hip abduction strength (4 HQ and 3 LQ 0.26).48
studies: SMD: −1.10, 95% CI −1.65 to −0.55, I2=74%,
p<0.0001),47 50–55 isometric hip adduction strength (2 HQ The effect of hip strengthening on knee kinematics and
studies: SMD: −0.71, 95% CI −1.53 to −0.35, I2=0%, joint torques
p=0.86)52 54 and isometric hip flexion strength (2 HQ studies, Two LQ studies investigated the effect of hip strengthening on
SMD: −0.89, 95% CI −1.26 to −0.52, I2=0%, p=0.97)52 54 in knee kinematics and joint torques.24 57 Pooling of estimates
women with PFP. were not possible. Ferber et al24 found no significant effect on
Moderate evidence indicates lower eccentric hip abduction (2 two dimensional peak knee abduction (genu valgum) angle after
HQ studies: SMD: −1.21, 95% CI −1.76 to −0.65, I2=0%, 6 weeks of proximal strength training (SMD: 0.47, 95% CI
p=0.92)50 56 in women with PFP. Limited evidence indicates no −0.25 to 1.20). Earl and Hoch57 showed that peak internal
difference in eccentric hip adduction (1 HQ study: SMD: knee abduction moment was significantly reduced after a
−0.63, 95% CI −1.53 to 0.28),56 eccentric hip external rotation rehabilitation programme (SMD: −0.40, 95% CI −1.04 to
(2 HQ studies: SMD: −0.70, 95% CI −2.03 to 0.63, I2=82%, 0.24), however no significant change in knee abduction range of
p=0.02)50 56 or eccentric hip internal rotation strength (1 HQ motion (ROM) was found (SMD: 0.05, 95% CI −0.58 to 0.69).
study: SMD: −0.45, 95% CI −1.34 to 0.44)56 in women with
PFP. Sensitivity analysis
Results from the two sensitivity analyses (ie, excluding studies
Hip strength among adolescents scoring within the lowest 50% on the EAI or studies with a
No studies have specifically investigated the association between score of 5 or below on the diagnosis checklist) showed similar
hip strength and age. Only two HQ studies investigated hip findings and effect sizes (see online supplementary table S3).
strength among adolescents (<18 years of age).35 48 One used a The two studies investigating the effect of hip strengthening on

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Rathleff MS, et al. Br J Sports Med 2014;48:1088–1088. doi:10.1136/bjsports-2013-093305

Table 2 Quality ratings using the Epidemiological Appraisal Instrument

Black shading, ‘Yes’; grey shading, ‘Partial’; white (no shading), ‘No’ or ‘Unable to determine’; ‘e’, ‘Not applicable’, items removed from scoring and not included in percentage calculations.

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Figure 2 (A) Comparison of hip abduction, (B) comparison of hip adduction, (C) comparison of hip external rotation, (D) comparison of hip
internal rotation, (E) comparison of hip extension, (F) comparison of hip flexion.

knee kinematics pain were omitted in the sensitivity analyses needed to confirm this. Specifically, across women, men and
based on the EAI but kept in the analysis using the diagnosis mixed gender studies of adults, the meta-analysis of cross-
checklist. sectional studies indicates that individuals with PFP possess
weaker hip musculature compared to pain-free individuals.
DISCUSSION Contrary to this, our meta-analysis of a small number of pro-
This review provides a number of important findings regarding spective studies indicates no association between isometric hip
the association of hip muscle function and PFP. Most import- strength and risk of developing PFP, indicating that reduced iso-
antly, there appears to be a discrepancy between prospective and metric hip strength may be the result, rather than one of the
cross-sectional research findings, although further research is causes of PFP. However these findings are based on a small

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Figure 2 Continued

number of heterogeneous studies and further research is needed identify isometric hip strength deficits as a risk factor in the
to confirm this. Second, the very few studies that investigated development of PFP. Considering that this was the only study to
men in isolation observed similar, albeit smaller, deficits in hip separate genders, further prospective gender-specific studies are
abduction and external rotation muscle strength to those seen in warranted to confirm these findings. A second consideration is
women. Additionally, limited evidence indicates that adolescents that all three prospective studies investigated isometric hip
with PFP may not possess the same hip strength deficits as strength.6 35 36 It is possible that isometric strength is not the
adults with PFP. optimal clinical measure of hip strength. However, based on this
meta-analysis there is no clear trend towards isokinetic measure-
Association of hip strength deficits with risk of PFP ments showing higher effect sizes compared to isometric mea-
development surements. Importantly, all prospective studies only investigated
Despite the meta-analysis indicating that hip strength deficits isometric strength and further research is needed to determine
are present in female, male and mixed gender cohorts with whether other measures of hip muscle strength such as endur-
PFP, decreased isometric hip strength was not found to be a ance and eccentric strength may be risk factors for the develop-
risk factor for PFP development. However, the meta-analysis ment of PFP.
did indicate a trend towards reduced isometric hip external
rotation and hip extension, although the effect sizes were very Hip strength deficits across genders
small (from −0.25 to −0.19). Additionally, when the Finnoff Effect sizes for gender-specific comparisons generally indicate
et al35 data, which includes adolescents, is taken from pooled larger hip strength deficits (ie, larger effect sizes) for female
effect sizes, isometric abduction strength deficits are found to populations compared to male and mixed gender populations.
be associated with increased risk of PFP development, but This finding supports previous assumptions that men and
again the effect size is very small (−0.29). This suggests that women represent distinct subgroups within PFP with distinct
hip strength deficits may play a small role in the development gender-specific risk factors and deficits.13 40 58 However, few
of PFP, but become more prominent following the develop- studies have evaluated hip strength in men and more studies are
ment of symptoms, possibly as a result of disuse and fear needed to explore hip muscle function in men. The best avail-
avoidance to movement.35 Considering favourable clinical out- able evidence indicates that addressing isometric hip strength
comes with hip strengthening protocols in individuals with deficits during rehabilitation may be more important in women
PFP,21–24 the findings of this review do not bring into question than in men with PFP.
the potential benefit of such programmes for symptom reduc-
tion. However, they do indicate that hip strengthening proto- Age and its association to hip strength
cols may not be sufficient to prevent the occurrence or Most studies investigated adults (ie, >18 years old), with only
reoccurrence of PFP. two studies, one prospective and one cross-sectional, investigat-
Limitations of previous prospective studies must be consid- ing hip strength among adolescents.35 48 Overall these studies
ered. First, two6 35 of the three36 prospective studies used a did not support the presence of hip strength deficits as a risk
mixed-gender population, which in light of gender differences factor for or as a feature of PFP among adolescents, with the
identified in cross-sectional findings may confound their results. authors concluding that PFP may have a different aetiology in
It is plausible that hip strength deficits may be a risk factor of adolescents than adults. This provides further evidence that the
PFP development in women but not in men. However, Thijs impairments in hip strength seen in adults may result from long-
et al’s36 prospective study investigated women only, and did not standing pain associated with PFP. Supporting this, Rathleff

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Figure 2 Continued

et al46 previously found reductions in knee extension strength protocols21–24 may be the correction of these mechanics. The
among adolescents aged 15–19 years but not in a younger two studies that investigated changes in the relevant knee valgus
cohort of adolescents aged 12–16,48 even though the same kinematics during running, found no changes in kinematics,
methodology was used and both groups were recruited from the despite significant symptom reduction.24 57 These results are
same closed population. Importantly, the adolescents with PFP consistent with findings from studies of asymptomatic indivi-
between 15 and 19 years of age were 3 years older and reported duals, which also indicate that hip strengthening programmes
a 1-year longer symptom duration.46 These findings are consist- do not alter peak hip or knee kinematics during running.59 60
ent with our finding that reduced isometric hip strength may be Although hip strengthening may not alter kinematics linked to
a result of PFP rather than a cause. PFP, findings from Earl and Hoch57 indicate a significant reduc-
tion in peak internal knee abduction moments during running.
Association between strength and kinematics This is consistent with previous research among pain-free indivi-
Previous research indicates that greater knee abduction duals showing similar positive benefits of hip strengthening on
moments,15 16 peak hip internal rotation6 and hip adduction reducing the knee abduction moment.59 Collectively these find-
motion18 (ie, mechanics associated with greater dynamic knee ings indicate that positive clinical outcomes in patients with
valgus) are risk factors for PFP development. Therefore, it is PFP21–24 may reflect a greater ability to attenuate forces at the
plausible that the mechanism for successful hip strengthening knee rather than changes to kinematics.

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Figure 2 Continued

Clinical implications This limits external validity and makes it difficult to extrapolate to
Findings from this review suggest that hip strength is reduced whom these results are valid, and also decreases the internal valid-
following the development of PFP, but hip strength deficits may ity as the populations may be representative of different back-
not be a risk factor. This would indicate that hip strength testing grounds. Furthermore, the validity of the tools used for
as a screening tool may be of limited value, but is still important measurement of muscle strength was not assessed in this review.
in individuals currently experiencing PFP. Considering favour- Statistical heterogeneity was evaluated where data pooling was
able clinical21–24 and kinetic outcomes57 following hip strength- completed. Heterogeneity existed for some of the comparisons,
ening protocols in individuals with PFP, their implementation in which provides some limitations to the validity of data pooling. To
clinical practice is recommended. Additionally, this review indi- account for this, we incorporated the existence of heterogeneity
cates the addition of hip strengthening may be particularly into our predetermined levels of evidence, with lower levels allo-
important in female adults, but less so in male adults and ado- cated to the findings of comparisons with statistical heterogeneity.
lescents of both genders. Only four studies used a blinded rater (the individual taking
When developing rehabilitation programmes, clinicians must strength measurement).6 36 48 52 This may cause a detection bias
consider hip strengthening may have no effect on knee kine- towards overestimating the difference between individuals with
matics, and current prospective findings indicate strength deficits PFP and pain-free individuals, which may inflate the effect size.
themselves are not a risk factor for PFP development. To reduce the chance of detection bias, blinding of the examiner
Therefore, strength is only one aspect that should be targeted in future studies is recommended. Less than half of the studies
during rehabilitation. Retraining control of hip movement might provided a sample size calculation.24 39 40 45 50 52 53 57 While
be equally or more important than focusing on hip strengthen- lack of sample size may have affected the power of individual
ing during rehabilitation, especially considering greater peak hip studies to detect a between-group difference, pooling of data in
adduction angle and hip internal rotation angle during running the current meta-analysis counteracts this limitation. Likewise,
and landing, respectively, have been linked to increased risk of less than half of the included studies conducted a reliability ana-
PFP development.6 18 Indeed, retraining runners with excessive lysis of their measurements.6 40 41 45 48–51 54–56 Generally, most
peak hip adduction to reduce this motion has been reported to studies provided good information on inclusion and exclusion
reduce pain associated with PFP.61 62 criteria with the majority scoring high on the diagnostic check-
list in table 1. Furthermore, a large number of the studies
Methodological considerations and considerations for future reported basic demographics and measures of pain intensity and
research pain duration which increases description of which sample is
There was a large heterogeneity in the results from the included being studied. Both sensitivity analyses showed similar results
studies. Based on the study details in online supplementary table which further strengthens the robustness of our results.
S2 some of this heterogeneity may be caused by large variations This review highlights that isometric strength testing is the
in the populations being studied. Some populations are represen- most commonly used measurement to assess hip strength among
tative of individuals active in sports,24 35–37 39 40 45 52 53 55 57 individuals with PFP. However, isometric strength may not be
while other are representative of sedentary individuals.54 Some the best descriptor of dynamic muscle function and future pro-
studies did not account for where the population being studied was spective studies should consider investigating eccentric hip
recruited from or how controls were selected.38 41 42 47 49–51 56 strength and endurance along with more functional

Figure 3 Effects of hip strengthening on knee kinematics and joint torques.

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measurements of hip muscle function such as a single legged 8 Rathleff MS, Rasmussen S, Olesen JL. Unsatisfactory long-term prognosis of
squat.63 In the context of rehabilitation of individuals who have conservative treatment of patellofemoral pain syndrome. Ugeskr Laeger
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already developed PFP, hip-strengthening programmes can 9 Collins NJ, Bierma-Zeinstra SM, Crossley KM, et al. Prognostic factors for
relieve pain, but there is a need to study the effect of patellofemoral pain: a multicentre observational analysis. Br J Sports Med
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11 Nimon G, Murray D, Sandow M, et al. Natural history of anterior knee pain: a 14- to
Conclusion 20-year follow-up of nonoperative management. J Pediatr Orthop 1998;18:118–22.
This review highlights a possible discord between prospective 12 Witvrouw E, Callaghan MJ, Stefanik JJ, et al. Patellofemoral pain: consensus
and cross-sectional research findings. Cross-sectional studies statement from the 3rd International Patellofemoral Pain Research Retreat held in
indicate that both adult males and adult females with PFP have Vancouver, September 2013. Br J Sports Med 2014;48:411–14.
13 Powers CM, Bolgla LA, Callaghan MJ, et al. Patellofemoral pain: proximal, distal,
lower hip strength compared to pain-free individuals. Contrary and local factors, 2nd International Research Retreat. J Orthop Sports Phys Ther
to this, there may be no association between isometric hip 2012;42:A1–54.
strength and risk of developing PFP, indicating that reduced iso- 14 Lankhorst NE, Bierma-Zeinstra SM, van Middelkoop M. Risk factors for
metric hip strength may be a result of PFP rather than a cause. patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther
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This finding, combined with the absence of a link between hip
15 Stefanyshyn DJ, Stergiou P, Lun VM, et al. Knee angular impulse as a predictor of
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with risk of PFP development, indicates a changing focus in 16 Myer GD, Ford KR, Barber Foss KD, et al. The incidence and potential
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17 Powers CM. The influence of abnormal hip mechanics on knee injury: a
with strengthening may improve PFP patient outcomes clinically biomechanical perspective. J Orthop Sports Phys Ther 2010;40:42–51.
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19 Prins MR, van der Wurff P. Females with patellofemoral pain syndrome have weak
hip muscles: a systematic review. Aust J Physiother 2009;55:9–15.
What are the new findings? 20 Barton CJ, Lack S, Malliaras P, et al. Gluteal muscle activity and patellofemoral pain
syndrome: a systematic review. Br J Sports Med 2013;47:207–14.
21 Fukuda TY, Melo WP, Zaffalon BM, et al. Hip posterolateral musculature
▸ Hip strength deficits are more likely the result of rather than strengthening in sedentary females with patellofemoral pain syndrome: a
the cause of patellofemoral pain (PFP). randomized controlled clinical trial with 1-year follow-up. J Orthop Sports Phys Ther
▸ Both men and women with PFP possess hip strength 2012;42:823–30.
22 Khayambashi K, Mohammadkhani Z, Ghaznavi K, et al. The effects of isolated hip
deficits. abductor and external rotator muscle strengthening on pain, health status, and hip
▸ Hip strengthening programmes do not appear to change strength in females with patellofemoral pain: a randomized controlled trial. J Orthop
kinematics at the knee linked to PFP risk. Sports Phys Ther 2012;42:22–9.
23 Dolak KL, Silkman C, Medina McKeon J, et al. Hip strengthening prior to functional
exercises reduces pain sooner than quadriceps strengthening in females with
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Contributors MSR, CRR, KMC and CJB were responsible for the idea of the review
24 Ferber R, Kendall KD, Farr L. Changes in knee biomechanics after a hip-abductor
and discussed the results. MSR and CRR performed the literature search and critical
strengthening protocol for runners with patellofemoral pain syndrome. J Athl Train
appraisal of the included study. MSR and CJB performed the meta-analyses. MSR
2011;46:142–9.
and CRR wrote the first draft of the manuscript while KMC and CJB helped revise
25 Heintjes E, Berger MY, Bierma-Zeinstra SM, et al. Exercise therapy for patellofemoral
the manuscript. All authors approved the final version of the manuscript.
pain syndrome. Cochrane Database Syst Rev 2003(4):CD003472.
Competing interests None. 26 Maher CG, Sherrington C, Elkins M, et al. Challenges for evidence-based physical
Provenance and peer review Not commissioned; externally peer reviewed. therapy: accessing and interpreting high-quality evidence on therapy. Phys Ther
2004;84:644–54.
Data sharing statement All data used in the review are available upon request. 27 Genaidy AM, Lemasters GK, Lockey J, et al. An epidemiological appraisal instrument
—a tool for evaluation of epidemiological studies. Ergonomics 2007;50:920–60.
28 Nix SE, Vicenzino BT, Collins NJ, et al. Characteristics of foot structure and footwear
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