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Tuesday, June 6, 2023

Hip Internal Rotation and Adduction Correlated with Knee Pain

Brent Brookbush

Brent Brookbush


Hip Internal Rotation and Adduction Correlated with Knee Pain

By Jon Snyder DPT, PT, CSCS

Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain . Medicine & Science in Sports & Exercise. 2013;45(6):1120–1124. ABSTRACT

Why is this relevant? Patellofemoral pain syndrome (PFP) is a condition resulting in significant anterior knee pain. This condition presents itself primarily in an athletic population, and is especially common in female endurance athletes. Previous research has found consistent changes in lower leg muscle activation in individuals with this condition, but no prospective studies have been conducted. This research provides evidence that excess femoral adduction and internal rotation correlate with PFP, but fails to make a correlations between rear foot eversion and the development of PFP. This information gives us direction in the treatment and prevention of PFP.

Examples of Dynamic Knee Valgus - http://bretcontreras.com/wp-content/uploads/Capture32.jpg

Study Summary

Study Design Prospective Cohort study
Level of Evidence 2b – Individual cohort study
Subject Demographics
  • Age: 15 subjects in the PFP group (age 27 +/- 10 years); 15 subjects in uninjured Control (CON) group

    (age 27 +/- 10 years)

  • Gender: Female
  • Characteristics: free from any current injuries, rear foot strikers, and running a minimum of 20 miles per week. Monthly mileage equal amongst both groups (165 +/- 53 vs 165 +/- 43 km).
  • Inclusion Criteria: Clinical diagnosis of PFP by a physician, physical therapist, or athletic trainer; experienced pain for at least 2 months; mechanism of injury related to running
  • Exclusion Criteria: Diagnosis of patella tendonitis, fat pad syndrome, or iliotibial band syndrome; previous history of patellofemoral pain syndrome; previous history of hip or knee injuries; pain due to trauma, or pain that started while participating in other activities.
Outcome Measures

Joint angles were calculated using Visual3D software during instrumented gait analysisParticipants ran along a 25m runway at a speed of 3.7 meters per second, striking a force plate at its center.

Anatomical markers were placed over the iliac crests, greater trochanters, medial and lateral femoral epicondyle, medial and lateral malleoli, first and fifth metatarsal heads, and the front end of the shoes. The first and fifth metatarsal head markers as well as medial and lateral malleoli were used to define the foot coordinate system. The coordinate system of the shank was defined from the medial and lateral malleoli markers as well as medial and lateral femoral epicondyle markers. For the femur’s coordinate system, the markers placed on the medial and lateral femoral condyle, the greater trochanter as well as from a virtual marker, which was determined as 25% of the distance between the trochanters was used. Lastly, the pelvis was defined by the bilateral greater trochanter markers and the markers placed on the iliac crests. Tracking markers for the pelvis were placed on the space between the fifth lumbar vertebrae and the sacrum and the anterior superior iliac spines.

  • between-day reliability intra-class correlation coefficients for the joint angles derived from these markers ranges from fair for hip internal rotation (0.54–0.58) and rear foot eversion (0.63–0.71) up to excellent for hip adduction (0.69–0.95)2,3.
  • Peak rear foot eversion, hip adduction, and hip internal rotation was measured
  • PFP group had a significantly greater hip adduction angle (P = 0.007)
  • No significant differences were found in rear foot eversion (P = 0.10)
  • The PFP group did have more hip adduction and less rear foot eversion throughout the stance period.
  • The PFP group landed in more hip internal rotation, but the difference was not significant (P = 0.47)
ConclusionsThis study shows a link between excessive femoral adduction and internal rotation, with no significant changes in rearfoot eversion. This finding implicates inadequate proximal stability in the development of patellofemoral pain syndrome.
Conclusions of the ResearchersThe finding of greater hip adduction in female runners who develop PFP is in agreement with previous cross-sectional studies. These results suggest that runners who develop PFP use a different proximal neuromuscular control strategy than those who remain healthy. Injury prevention and treatment strategies should consider addressing these altered hip mechanics.

Review & Commentary:

According to a retrospective case-control analysis by Taunton et al 4, of the 2,002 running-related injuries seen at a primary care sports injury facility, 42.1% (842/2,002) were knee injuries. Of these knee injuries, 39.3% (331/842) were due to patellofemoral pain syndrome (PFPS), which made PFPS far and away the most common diagnosis found in this large-scale study. Additionally, an older study done in 1984 found very similar results. Devereaux and colleagues 5 found that over a five-year period, 137 patients presented with PFPS, which accounted for 25% of all knee injuries seen at this sports injury clinic. Based on the prevalence of this injury, determining the etiology of patellofemoral pain should be a priority - with the goal of refining treatment and possibly prevention.

This has been an area of interest for multiple clinicians and researchers with many conflicting opinions. One of the most common and supported biomechanical influences is the influence of the hip musculature (gluteus medius and gluteus maximus ). In agreement with the reviewed study by Noehren and colleagues, several other authors have found impaired hip biomechanics in runners suffering from PFP. During weight bearing, the femur moves about a fixed patella and therefore excessive femoral internal rotation results in increased contact directed primarily at the lateral facet of the patella (Powers et al 6). In fact, just 10° of IR can lead to a substantial decrease in patellofemoral joint (PFJ) contact area and a 50% increase in joint stress. Additionally, Souza et al 7 found that females with PFPS demonstrated greater peak hip internal rotation compared to the control group during running, drop jumps, and step downs. The PFPS group also demonstrated 14% weaker hip abductor strength and 17% weaker hip extensor strength. Wilson et al 8, Noehren et al 9, and Nakagawa et al 10 found that individuals presenting with PFPS demonstrated increased hip adduction during running, jumping, and single-leg squats. This adduction creates an increased valgus force about the knee joint, which in turn causes increased loading of the lateral PFJ.

Why is this study important?

There is a bounty of research to support the implication that proximal instability on femoral adduction and internal rotation, which has a negative influence on joint loading and the onset of PFP. With this information, clinicians can work on improving gluteal neuromuscular control following injury or as part of a comprehensive injury prevention program.

How does it affect practice?

Our current understanding of proximal lumbopelvic musculature on running and lower extremity biomechanics implies special attention should be given to the hip joint and gluteal musculature for patients presenting with knee pain. Often, during evaluation, clinicians focus their interest solely on local factors (tight musculature, strength deficits, inflammation, etc.), however local deficits are rarely the sole cause of disability. This is true not only of patellofemoral pain syndrome, as excess femoral adduction and internal rotation have been found in individuals suffering from iliotibial band syndrome11 , anterior cruciate ligament rupture12 , and Achilles tendinopathy13 . With this knowledge, clinicians should begin incorporating proximal strengthening and neuromuscular control drills for the GMED and GMAX in addition to local interventions.

How does it relate to Brookbush Institute Content?

This research study, and the additional studies cited in this article support the propensity of the hip to adopt a dysfunctional compensatory pattern that includes excessive hip internal rotation and adduction. This trend is noted in both the Lower Leg Dysfunction (LLD) and Lumbo-Pelvic Hip Complex Dysfunction (LPHCD) models. Although careful assessment should always precede intervention, this study and the models mentioned above highlight additional considerations when treating individuals with knee pain. Further, the research supports the assertion that that LLD and LPHCD may be the cause of, or result from knee pathology. The Brookbush Institute uses an integrated model of treatment, that includes mobility, activation, integration and neuromuscular re-education. Mentioned in this study and several supporting studies is the implication that activation of the gluteus maximus and gluteus medius may improve hip kinematics and aid in rehabilitation of PFPS, and or prevent PFPS in those who are showing signs of increased internal rotation and adduction, but are not yet experiencing pain. Below you will find several videos covering techniques used to activate these commonly under-active muscles.

Related Videos:

Gluteus Maximus Isolated Activation

Gluteus Maximus and TVA Activation Progressions

Gluteus Medius Isolated Activation

Gluteus Medius Activation Progression

Quick Glute Activation Circuit

Gluteus Medius Reactive Activation

Gluteus Maximus Reactive Activation


  1. Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain . Medicine & Science in Sports & Exercise. 2013;45(6):1120–1124.
  2. Ferber R, Davis IM, Williams DS, Laughton C. A comparison of within- and between-day reliability of discrete 3D lower extremity variables in runners . J Orthop Res. 2002;20(6):1139–45.
  3. Noehren B, Manal K, Davis I. Improving between-day kinematic reliability using a marker placement device . J Orthop Res. 2010;28: 1405–10.
  4. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002; 36: 95–101.
  6. Powers CM. The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective . Journal of Orthopaedic & Sports Physical Therapy. 2010;40(2):42–51. doi:10.2519/jospt.2010.3337.
  7. Powers CM, Ho K-Y, CHEN Y-J, Souza RB, Farrokhi S. Patellofemoral Joint Stress During Weight-Bearing and Non—Weight-Bearing Quadriceps Exercises . Journal of Orthopaedic & Sports Physical Therapy. 2014;44(5):320–327. doi:10.2519/jospt.2014.4936.
  8. Willson JD, Davis IS. Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands . Clin Biomech. 2008; 23(2): 203-11.
  9. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome . Br J Sports Med. 2011; 45(9): 691-6.
  10. Nakagawa TH, et al. Frontal Plane Biomechanics in Males and Females with and without Patellofemoral Pain . Medicine & Science in Sports & Exercise. 2012; 44(9): 1747-1755.
  11. Qi W. Effect of Increased Iliotibial Band Load on Tibiofemoral Kinematics and Force Distributions: A Direct Measurement in Cadaveric Knees . Journal of Orthopaedic & Sports Physical Therapy. 2013;43(7):478–485.
  12. Hewett TE, et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study . American Journal of Sports Medicine. 2005;33(4):492–501.
  13. Franettovich, SM, Honeywill, C, Wyndow N, Crossley KM, Creaby MW. Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Medicine and science in sports and exercise. 2014; 46(3): 594-599.

© 2015 Brent Brookbush

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