Recurrent patellar dislocations in adolescents result in decreased knee flexion during the entire gait cycle



To evaluate the kinematics/kinetics of the ankle, knee, hip in the sagittal plane in adolescents with recurrent patellar dislocation in comparison to a healthy control.


Case–control study. Eighty-eight knees (67 patients) with recurrent patellar dislocation (mean age 14.8 years ± 2.8 SD) were compared to 54 healthy knees (27 individuals, 14.9 years  ± 2.4 SD). Kinematics/kinetics of ankle, knee, hip, and pelvis were captured using 3D-gait analysis (VICON, 12 cameras, 200 Hz, Plug-in-Gait, two force plates). One cycle (100%) consisted of 51 data-points. The mean of six trials was computed.


The loading-response increased by 0.02 s ± 0.01SE (10.8%) with dislocations (0.98% of total gait, P < 0.01). The mid-stance-phase decreased equally (P < 0.01). Dislocation decreased knee flexion during the entire gait cycle (P < 0.01), with the largest difference during mid-stance (9.0° ± 7.2 SD vs. 18.5° ± 6.7 SD). Dislocation increased plantar-flexion during loading response 4.1° ± 0.4 SE with (P < 0.01), afterward, the dorsal-extension decreased 3.2° ± 0.3 SE, (P < 0.01). Dislocation decreased hip flexion during all phases (P < 0.01). Maximal difference: 7.5° ± 0.5 SE during mid-stance. 80% of all patients developed this gait pattern.

Internal moments of the ankle increased, of the knee and hip decreased during the first part of stance.


Recurrent patellar dislocation decreases knee flexion during the loading-response and mid-stance phase. A decreased hip flexion and increased plantar-flexion, while adjusting internal moments, indicate a compensation mechanism.

Level of evidence


This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. 1.

    Alkjaer T, Simonsen EB, Peter Magnusson SP, Aagaard H, Dyhre-Poulsen P (2002) Differences in the movement pattern of a forward lunge in two types of anterior cruciate ligament deficient patients: copers and non-copers. Clin Biomech (Bristol, Avon) 17:586–593

    Google Scholar 

  2. 2.

    Amis AA (2007) Current concepts on anatomy and biomechanics of patellar stability. Sports Med Arthrosc 15:48–56

    PubMed  Google Scholar 

  3. 3.

    Amis AA, Oguz C, Bull AMJ, Senavongse W, Dejour D (2008) The effect of trochleoplasty on patellar stability and kinematics: a biomechanical study in vitro. J Bone Jt Surg Br 90:864–869

    CAS  Google Scholar 

  4. 4.

    Arnold AS, Anderson FC, Pandy MG, Delp SL (2005) Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: a framework for investigating the causes of crouch gait. J Biomech 38:2181–2189

    PubMed  Google Scholar 

  5. 5.

    Banke IJ, Kohn LM, Meidinger G, Otto A, Hensler D, Beitzel K, Imhoff AB, Schöttle PB (2014) Combined trochleoplasty and MPFL reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. Knee Surg Sports Traumatol Arthrosc 22:2591–2598

    PubMed  Google Scholar 

  6. 6.

    Barton CJ, Levinger P, Menz HB, Webster KE (2009) Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Gait Posture 30:405–416

    PubMed  Google Scholar 

  7. 7.

    Berchuck M, Andriacchi TP, Bach BR, Reider B (1990) Gait adaptations by patients who have a deficient anterior cruciate ligament. J Bone Jt Surg Am 72:871–877

    CAS  Google Scholar 

  8. 8.

    Brunner R, Dreher T, Romkes J, Frigo C (2008) Effects of plantar flexion on pelvis and lower limb kinematics. Gait Posture 28:150–156

    CAS  PubMed  Google Scholar 

  9. 9.

    Camathias C, Speth BM, Rutz E, Schlemmer T, Papp K, Vavken P, Studer K (2018) Solitary trochleoplasty for treatment of recurrent patellar dislocation. JBJS Essent Surg Tech 8(2):e11

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Camathias C, Studer K, Kiapour A, Rutz E, Vavken P (2016) Trochleoplasty as a solitary treatment for recurrent patellar dislocation results in good clinical outcome in adolescents. Am J Sports Med 44:2855–2863

    PubMed  Google Scholar 

  11. 11.

    Chmielewski TL, Rudolph KS, Fitzgerald GK, Axe MJ, Snyder-Mackler L (2001) Biomechanical evidence supporting a differential response to acute ACL injury. Clin Biomech (Bristol, Avon) 16:586–591

    CAS  Google Scholar 

  12. 12.

    Chotel F, Bérard J, Raux S (2014) Patellar instability in children and adolescents. Orthop Traumatol Surg Res 100:S125–S137

    CAS  PubMed  Google Scholar 

  13. 13.

    Christensen TC, Sanders TL, Pareek A, Mohan R, Dahm DL, Krych AJ (2017) Risk factors and time to recurrent ipsilateral and contralateral patellar dislocations. Am J Sports Med 45:2105–2110

    PubMed  Google Scholar 

  14. 14.

    Colvin AC, West RV (2008) Patellar instability. J Bone Jt Surg Am 90:2751–2762

    Google Scholar 

  15. 15.

    Dejour H, Walch G, Nove-Josserand L, Guier C (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26

    CAS  PubMed  Google Scholar 

  16. 16.

    Dunn DM (1952) Anteversion of the neck of the femur; a method of measurement. J Bone Jt Surg Br 34-B:181–186

    CAS  Google Scholar 

  17. 17.

    Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220

    PubMed  Google Scholar 

  18. 18.

    Fithian DC (2004) Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 32:1114–1121

    PubMed  Google Scholar 

  19. 19.

    Hart JM, Ko J-WK, Konold T, Pietrosimone B, Pietrosimione B (2010) Sagittal plane knee joint moments following anterior cruciate ligament injury and reconstruction: a systematic review. Clin Biomech (Bristol, Avon) 25:277–283

    Google Scholar 

  20. 20.

    Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM (1998) Medial soft tissue restraints in lateral patellar instability and repair. Clin Orthop Relat Res 349:174–182

    Google Scholar 

  21. 21.

    Hawkins RJ, Bell RH, Anisette G (1986) Acute patellar dislocations. The natural history. Am J Sports Med 14:117–120

    CAS  PubMed  Google Scholar 

  22. 22.

    Hurd WJ, Snyder-Mackler L (2007) Knee instability after acute ACL rupture affects movement patterns during the mid-stance phase of gait. J Orthop Res 25:1369–1377

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Insall J, Goldberg V, Salvati E (1972) Recurrent dislocation and the high-riding patella. Clin Orthop Relat Res 88:67–69

    CAS  PubMed  Google Scholar 

  24. 24.

    Kadaba MP, Ramakrishnan HK, Wootten ME (1990) Measurement of lower extremity kinematics during level walking. J Orthop Res 8:383–392

    CAS  PubMed  Google Scholar 

  25. 25.

    Kainz H, Graham D, Edwards J, Walsh HPJ, Maine S, Boyd RN, Lloyd DG, Modenese L, Carty CP (2017) Reliability of four models for clinical gait analysis. Gait Posture 54:325–331

    PubMed  Google Scholar 

  26. 26.

    Kimmel SA, Schwartz MH (2006) A baseline of dynamic muscle function during gait. Gait Posture 23:211–221

    PubMed  Google Scholar 

  27. 27.

    Knoll Z, Kocsis L, Kiss RM (2004) Gait patterns before and after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 12:7–14

    PubMed  Google Scholar 

  28. 28.

    Lindström M, Felländer-Tsai L, Wredmark T, Henriksson M (2010) Adaptations of gait and muscle activation in chronic ACL deficiency. Knee Surg Sports Traumatol Arthrosc 18:106–114

    PubMed  Google Scholar 

  29. 29.

    Maenpaa H, Lehto MU (1997) Patellar dislocation. The long-term results of nonoperative management in 100 patients. Am J Sports Med 25:213–217

    CAS  PubMed  Google Scholar 

  30. 30.

    Mentiplay BF, Clark RA (2018) Modified conventional gait model versus cluster tracking: test-retest reliability, agreement and impact of inverse kinematics with joint constraints on kinematic and kinetic data. Gait Posture 64:75–83

    PubMed  Google Scholar 

  31. 31.

    Nadeau S, Gravel D, Hébert LJ, Arsenault AB, Lepage Y (1997) Gait study of patients with patellofemoral pain syndrome. Gait Posture 5:21–27

    Google Scholar 

  32. 32.

    Nietosvaara Y, Aalto K, Kallio PE (1994) Acute patellar dislocation in children: incidence and associated osteochondral fractures. J Pediatr Orthop 14:513–515

    CAS  PubMed  Google Scholar 

  33. 33.

    Perry J, Burnfield JM (2010) Gait analysis. SLACK Incorporated, New Jersey

    Google Scholar 

  34. 34.

    Redler LH, Wright ML (2018) Surgical management of patellofemoral instability in the skeletally immature patient. J Am Acad Orthop Surg 26:e405–e415

    PubMed  Google Scholar 

  35. 35.

    Reed-Jones RJ, Vallis LA (2008) Kinematics and muscular responses to a ramp descent in the ACL deficient knee. Knee 15:117–124

    PubMed  Google Scholar 

  36. 36.

    Roberts CS, Rash GS, Honaker JT, Wachowiak MP, Shaw JC (1999) A deficient anterior cruciate ligament does not lead to quadriceps avoidance gait. Gait Posture Elsevier 10:189–199

    CAS  Google Scholar 

  37. 37.

    Rudolph KS, Eastlack ME, Axe MJ, Snyder-Mackler L (1998) 1998 Basmajian Student Award Paper: movement patterns after anterior cruciate ligament injury: a comparison of patients who compensate well for the injury and those who require operative stabilization. J Electromyogr Kinesiol 8:349–362

    CAS  PubMed  Google Scholar 

  38. 38.

    Schwartz M, Lakin G (2003) The effect of tibial torsion on the dynamic function of the soleus during gait. Gait Posture 17:113–118

    PubMed  Google Scholar 

  39. 39.

    Senavongse W, Amis AA (2005) The effects of articular, retinacular, or muscular deficiencies on patellofemoral joint stability: a biomechanical study in vitro. J Bone Jt Surg Br 87:577–582

    CAS  Google Scholar 

  40. 40.

    Senavongse W, Farahmand F, Jones J, Andersen H, Bull AMJ (2006) Quantitative measurement of patellofemoral joint stability: force–displacement behavior of the human patella in vitro. J Orthop Res 21:780–786

    Google Scholar 

  41. 41.

    Stief F, Böhm H, Michel K, Schwirtz A, Döderlein L (2013) Reliability and accuracy in three-dimensional gait analysis: a comparison of two lower body protocols. J Appl Biomech 29:105–111

    PubMed  Google Scholar 

  42. 42.

    Torry MR, Decker MJ, Ellis HB, Shelburne KB, Sterett WI, Steadman JR (2004) Mechanisms of compensating for anterior cruciate ligament deficiency during gait. Med Sci Sports Exerc 36:1403–1412

    PubMed  Google Scholar 

  43. 43.

    Torry MR, Decker MJ, Viola RW, O'Connor DD, Steadman JR (2000) Intra-articular knee joint effusion induces quadriceps avoidance gait patterns. Clin Biomech (Bristol, Avon) 15:147–159

    CAS  Google Scholar 

  44. 44.

    Vavken P, Wimmer MD, Camathias C, Quidde J, Valderrabano V, Pagenstert G (2013) Treating patella instability in skeletally immature patients. Arthroscopy 29:1410–1422

    PubMed  Google Scholar 

  45. 45.

    Werner S (2014) Anterior knee pain: an update of physical therapy. Knee Surg Sports Traumatol Arthrosc 22:2286–2294

    PubMed  Google Scholar 

  46. 46.

    Wexler G, Hurwitz DE, Bush-Joseph CA, Andriacchi TP, Bach BR (1998) Functional gait adaptations in patients with anterior cruciate ligament deficiency over time. Clin Orthop Relat Res 348:166–175

    Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Carlo Camathias.

Ethics declarations

Conflicts of interest

All authors have nothing to disclose that could have direct or potential influence or impart bias on the work.


No external source of funding was used.

Ethical approval

This research has been performed with the approval of the local ethics committee (ethics committee of Basel, No. 2013/104).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Camathias, C., Ammann, E., Meier, R.L. et al. Recurrent patellar dislocations in adolescents result in decreased knee flexion during the entire gait cycle. Knee Surg Sports Traumatol Arthrosc 28, 2053–2066 (2020).

Download citation


  • Patella dislocation
  • Patellar dislocation
  • Recurrent dislocation
  • Knee
  • Kinematics
  • Kinetics
  • Gait analysis
  • Quadriceps avoidance
  • Adolescents
  • Trochlear dysplasia