Coordination Variability During Walking and Running in Individuals With and Without Patellofemoral Pain Part 1: Lower Limb Intersegmental Coordination Variability



Although it has been proposed that individuals with patellofemoral pain show less lower limb intersegmental coordination variability, the evidence to support this hypothesis is rare. The purpose of this study was, therefore, to evaluate whether individuals with patellofemoral pain exhibit less intersegmental coordination variability compared with healthy individuals during walking and running. Also, it was hypothesized that increasing task demand would exacerbate group differences regarding coordination variability measures.


Three-dimensional kinematics were collected while 17 females with patellofemoral pain and 17 healthy females walked at preferred speed, and ran at preferred and fixed speed on a treadmill, each trial for 30 seconds. An approach involving Hilbert transform was used to quantify the Continuous Relative Phase as a method to calculate the coordination variability of the thigh-shank and shank-foot couplings in different motion planes during stance and swing. Intersegmental coordination variability was compared between groups during 3 gait trials using a mixed-model repeated-measures ANOVA.


The patellofemoral pain group was significantly less variable compared with the control group in the following couplings: thigh sagittal-shank transverse, thigh transverse-shank transverse, shank transverse-foot sagittal, shank sagittal-foot transverse at both running speeds, thigh frontal-shank transverse at preferred speed running, and shank transverse-foot transverse at fixed speed running, all during stance phase. No between-group difference was observed during walking. Only the patellofemoral pain group showed changes in coordination variability by increasing task demand, in a way that they showed less coordination variability at running trials compared with the walking and also at fixed speed compared with the preferred speed running for some of the examined couplings.


Based on the results, less lower limb intersegmental coordination variability may be characteristic of females with patellofemoral pain during treadmill running. Increasing task demand from walking to running and also from preferred speed to fixed speed running which mainly resulted from increasing gait speed could exacerbate this altered coordination variability.

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  1. 1.

    Crossley, K. M., Stefanik, J. J., Selfe, J., Collins, N. J., Davis, I. S., Powers, C. M., et al. (2016). 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. British Journal of Sports Medicine, 50(14), 844–852.

    Article  Google Scholar 

  2. 2.

    Smith, B. E., Selfe, J., Thacker, D., Hendrick, P., Bateman, M., Moffatt, F., et al. (2018). Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis. PloS One, 13(1), e0190892.

    Article  Google Scholar 

  3. 3.

    Rabin, A., Kozol, Z., Moran, U., Efergan, A., Geffen, Y., & Finestone, A. S. (2014). Factors associated with visually assessed quality of movement during a lateral stepdown test among individuals with patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy, 44(12), 937–946.

    Article  Google Scholar 

  4. 4.

    Nakagawa, T. H., Moriya, É. T., Maciel, C. D., & Serrão, F. V. (2012). Trunk, pelvis, hip, and knee kinematics, hip strength, and gluteal muscle activation during a single-leg squat in males and females with and without patellofemoral pain syndrome. Journal of Orthopaedic & Sports Physical Therapy, 42(6), 491–501.

    Article  Google Scholar 

  5. 5.

    Powers, C. M. (2003). The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. Journal of Orthopaedic & Sports Physical Therapy, 33(11), 639–646.

    Article  Google Scholar 

  6. 6.

    Tiberio, D. (1987). The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. Journal of Orthopaedic & Sports Physical Therapy, 9(4), 160–165.

    Article  Google Scholar 

  7. 7.

    Powers, C. M. (2010). The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 42–51.

    Article  Google Scholar 

  8. 8.

    Hamill, J., Palmer, C., & Van Emmerik, R. E. (2012). Coordinative variability and overuse injury. BMC Sports Science, Medicine and Rehabilitation, 4(1), 45.

    Article  Google Scholar 

  9. 9.

    Hamill, J., van Emmerik, R. E., Heiderscheit, B. C., & Li, L. (1999). A dynamical systems approach to lower extremity running injuries. Clinical Biomechanics, 14(5), 297–308.

    Article  Google Scholar 

  10. 10.

    Bernstein, N. A. (1967). The co-ordination and regulation of movements. (A Collection of Papers Translated from Russian and German.)[With Plates]. Pergamon Press.

  11. 11.

    Turvey, M. T. (1990). Coordination. American Psychologist, 45(8), 938.

    Article  Google Scholar 

  12. 12.

    Kelso, J. S. (1995). Dynamic patterns: The self-organization of brain and behavior: MIT press.

  13. 13.

    Kelso, J. (1984). Phase transitions and critical behavior in human bimanual coordination. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 246(6), R1000–R1004.

    Article  Google Scholar 

  14. 14.

    Cunningham, T. J., Mullineaux, D. R., Noehren, B., Shapiro, R., & Uhl, T. L. (2014). Coupling angle variability in healthy and patellofemoral pain runners. Clinical Biomechanics, 29(3), 317–322.

    Article  Google Scholar 

  15. 15.

    Heiderscheit, B. C., Hamill, J., & van Emmerik, R. E. (2002). Variability of stride characteristics and joint coordination among individuals with unilateral patellofemoral pain. Journal of applied biomechanics, 18(2), 110–121.

    Article  Google Scholar 

  16. 16.

    Jewell, C., Weir, G., Hamill, J., & Boyer, K. A. (2018). The influence of patellofemoral pain on coordination variability over a prolonged treadmill run. ISBS Proceedings Archive, 36(1), 634.

    Google Scholar 

  17. 17.

    Arjun, R., Kishan, R., Dhillon, M., & Chouhan, D. (2017). Reliability of clinical methods in evaluating patellofemoral pain syndrome with malalignment. International Journal of Research in Orthopaedics, 3(3), 334–338.

    Article  Google Scholar 

  18. 18.

    Watson, C. J., Propps, M., Ratner, J., Zeigler, D. L., Horton, P., & Smith, S. S. (2005). Reliability and responsiveness of the lower extremity functional scale and the anterior knee pain scale in patients with anterior knee pain. Journal of Orthopaedic & Sports Physical Therapy, 35(3), 136–146.

    Article  Google Scholar 

  19. 19.

    Cappozzo, A., Cappello, A., Croce, U. D., & Pensalfini, F. (1997). Surface-marker cluster design criteria for 3-D bone movement reconstruction. IEEE Transactions on Biomedical Engineering, 44(12), 1165–1174.

    Article  Google Scholar 

  20. 20.

    Rotstein, A., Inbar, O., Berginsky, T., & Meckel, Y. (2005). Preferred transition speed between walking and running: effects of training status. Medicine and Science in Sports and Exercise, 37(11), 1864.

    Article  Google Scholar 

  21. 21.

    Alvim, F., Cerqueira, L., Netto, A. D. A., Leite, G., & Muniz, A. (2015). Comparison of five kinematic-based identification methods of foot contact events during treadmill walking and running at different speeds. Journal of Applied Biomechanics, 31(5), 383–388.

    Article  Google Scholar 

  22. 22.

    Lamb, P. F., & Stöckl, M. (2014). On the use of continuous relative phase: Review of current approaches and outline for a new standard. Clinical Biomechanics, 29(5), 484–493.

    Article  Google Scholar 

  23. 23.

    Stergiou, N., Jensen, J. L., Bates, B. T., Scholten, S. D., & Tzetzis, G. (2001). A dynamical systems investigation of lower extremity coordination during running over obstacles. Clinical Biomechanics, 16(3), 213–221.

    Article  Google Scholar 

  24. 24.

    Stergiou, N., Scholten, S. D., Jensen, J. L., & Blanke, D. (2001). Intralimb coordination following obstacle clearance during running: the effect of obstacle height. Gait & Posture, 13(3), 210–220.

    Article  Google Scholar 

  25. 25.

    Hodges, P. W., & Tucker, K. (2011). Moving differently in pain: a new theory to explain the adaptation to pain. Pain, 152(3), S90–S98.

    Article  Google Scholar 

  26. 26.

    Stergiou, N., Harbourne, R. T., & Cavanaugh, J. T. (2006). Optimal movement variability: A new theoretical perspective for neurologic physical therapy. Journal of Neurologic Physical Therapy, 30(3), 120–129.

    Article  Google Scholar 

  27. 27.

    Fox, A., Ferber, R., Saunders, N., Osis, S., & Bonacci, J. (2018). Gait kinematics in individuals with acute and chronic patellofemoral pain. Journal of Science and Medicine in Sport, 21, S15.

    Article  Google Scholar 

  28. 28.

    Noehren, B., Pohl, M. B., Sanchez, Z., Cunningham, T., & Lattermann, C. (2012). Proximal and distal kinematics in female runners with patellofemoral pain. Clinical Biomechanics, 27(4), 366–371.

    Article  Google Scholar 

  29. 29.

    Noehren, B., Sanchez, Z., Cunningham, T., & McKeon, P. O. (2012). The effect of pain on hip and knee kinematics during running in females with chronic patellofemoral pain. Gait & Posture, 36(3), 596–599.

    Article  Google Scholar 

  30. 30.

    Willson, J. D., & Davis, I. S. (2008). Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands. Clinical Biomechanics, 23(2), 203–211.

    Article  Google Scholar 

  31. 31.

    Souza, R. B., & Powers, C. M. (2009). Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 12–19.

    Article  Google Scholar 

  32. 32.

    Bazett-Jones, D. M., Cobb, S. C., Huddleston, W. E., O’connor, K. M., Armstrong, B. S., & Earl-Boehm, J. E. (2013). Effect of patellofemoral pain on strength and mechanics after an exhaustive run. Medicine & Science in Sports & Exercise, 45(7), 1331–1339.

    Article  Google Scholar 

  33. 33.

    Wirtz, A. D., Willson, J. D., Kernozek, T. W., & Hong, D.-A. (2012). Patellofemoral joint stress during running in females with and without patellofemoral pain. The Knee, 19(5), 703–708.

    Article  Google Scholar 

  34. 34.

    Levinger, P., & Gilleard, W. (2004). An evaluation of the rearfoot posture in individuals with patellofemoral pain syndrome. Journal of sports science & medicine, 3(YISI 1), 8.

  35. 35.

    Powers, C. M., Chen, P.-Y., Reischl, S. F., & Perry, J. (2002). Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot & Ankle international, 23(7), 634–640.

    Article  Google Scholar 

  36. 36.

    Dierks, T. A., Manal, K. T., Hamill, J., & Davis, I. (2011). Lower extremity kinematics in runners with patellofemoral pain during a prolonged run. Medicine and Science in Sports and Exercise, 43(4), 693–700.

    Article  Google Scholar 

  37. 37.

    Powers, C. M., Witvrouw, E., Davis, I. S., & Crossley, K. M. (2017). Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3. Br J Sports Med, bjsports-2017-098717.

  38. 38.

    Miller, R. H., Chang, R., Baird, J. L., Van Emmerik, R. E., & Hamill, J. (2010). Variability in kinematic coupling assessed by vector coding and continuous relative phase. Journal of Biomechanics, 43(13), 2554–2560.

    Article  Google Scholar 

  39. 39.

    Mehdizadeh, S., & Glazier, P. S. (2018). Order error in the calculation of continuous relative phase. Journal of Biomechanics, 73, 243–248.

    Article  Google Scholar 

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The current article was extracted from the Ph.D. thesis written by Farzaneh Haghighat. We thank the scientific and financial support from Shiraz University of Medical Sciences, the Deputy for Research Affairs, and the School of Rehabilitation Sciences.


This work was financially supported by Shiraz University of Medical Sciences (Grant Number: 97-01-04-17431).

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Correspondence to Alireza Motealleh.

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Ethical approval was granted by the local Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REHAB.REC.1397.006).

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Haghighat, F., Rezaie, M., Ebrahimi, S. et al. Coordination Variability During Walking and Running in Individuals With and Without Patellofemoral Pain Part 1: Lower Limb Intersegmental Coordination Variability. J. Med. Biol. Eng. (2021).

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  • Variability
  • Coordination
  • Dynamical system
  • Overuse injury
  • Patellofemoral pain