Kinematic and kinetic gait characteristics in people with patellofemoral pain: a systematic review and meta-analysis

Key points

1. 01People with PFP walk and run slower (moderate evidence, SMD -0.50) and have reduced cadence (limited evidence, SMD -0.43) and shorter stride length (limited evidence, SMD -0.46)
2. 02Reduced peak knee flexion angle (moderate evidence, SMD -0.30) and smaller knee extension moments (limited evidence, SMD -0.44) are consistently seen across studies
3. 03Greater contralateral pelvic drop during running (moderate evidence, SMD -0.46) distinguishes people with PFP from pain-free controls
4. 04Females with PFP specifically show greater hip flexion (moderate evidence, SMD 0.83) and greater rearfoot eversion (limited evidence, SMD 0.59) compared with pain-free females
5. 05Hip adduction and internal rotation angles during gait are NOT consistently different between people with and without PFP, contrary to earlier assumptions

How it was conducted

Design

Systematic review and meta-analysis (PRISMA)

Studies included

55 studies (49 with poolable data for meta-analysis); 3 prospective, 42 case-control, 10 cross-sectional

Participants

1300 people with PFP and 1393 pain-free controls across all studies; mean age 27.9 years for PFP group

Tasks covered

Walking (45.5%), running (58.2%), fast walking (7.3%), and ramp ascent/descent (5.3%)

Primary outcomes

Spatiotemporal gait variables, lower-extremity kinematics, and joint kinetics; pooled as standardized mean differences (SMD) with 95% CIs using random-effects models

Quality assessment

Modified Newcastle-Ottawa Scale; 2 high-quality, 37 moderate-quality, 13 low-quality case-control studies; inter-rater agreement 95%

What they found

• Gait velocity: moderate evidence of lower velocity in PFP (I-squared 72%, SMD -0.50, 95% CI -0.72 to -0.27, small effect); females showed a medium effect (SMD -0.64, 95% CI -1.04 to -0.25)
• Cadence: limited evidence of lower cadence in PFP overall (I-squared 72%, SMD -0.43, 95% CI -0.74 to -0.12, small effect); females showed medium effect (SMD -0.75, 95% CI -1.20 to -0.31)
• Stride length: limited evidence of shorter stride in PFP overall (I-squared 72%, SMD -0.46, 95% CI -0.80 to -0.12, small effect); walking subgroup SMD -0.44 (95% CI -0.82 to -0.06)
• Contralateral pelvic drop: moderate evidence of greater pelvic drop in PFP (I-squared 62%, SMD -0.46, 95% CI -0.90 to -0.03, small effect); effect confined to running
• Peak knee flexion angle: moderate evidence of smaller angle in PFP (I-squared 51%, SMD -0.30, 95% CI -0.52 to -0.08, small effect); mixed-sex subgroup SMD -0.41 (95% CI -0.64 to -0.18)
• Knee extension moment: limited evidence of smaller internal knee extension moment in PFP (I-squared 56%, SMD -0.44, 95% CI -0.76 to -0.09, small effect); walking subgroup showed medium effect (SMD -0.67, 95% CI -1.28 to -0.05)
• Peak hip flexion in females with PFP: moderate evidence of greater hip flexion (I-squared 0%, SMD 0.83, 95% CI 0.30 to 1.36, medium effect)
• Rearfoot eversion in females: limited evidence of greater eversion (I-squared 52%, SMD 0.59, 95% CI 0.03 to 1.14, small effect)
• Hip adduction angle: moderate evidence of NO difference between PFP and controls overall, or in any sex or task subgroup
• Hip internal rotation angle: moderate evidence of NO difference between PFP and controls overall or across sexes

Limitations

• Only 3 prospective studies included out of 55 total, making it impossible to determine whether biomechanical differences precede or follow PFP onset
• Most included studies were of moderate quality on the modified Newcastle-Ottawa Scale, limiting confidence in pooled estimates
• High inter-study variability in biomechanical methodology and reporting (e.g., joint centre definitions absent in most papers) reduced homogeneity and confidence
• Review restricted to English-language publications and publication bias was not formally assessed; PFP diagnostic criteria varied across studies

Why it matters

For patients

If you have patellofemoral pain you may naturally slow down and take shorter steps to reduce discomfort, but no single movement pattern defines all cases, so individualized assessment is important.

For clinicians

Gait velocity, cadence, and knee flexion angles are clinically measurable targets; increasing cadence can reduce knee loads, and restoring knee flexion through pain and fear-management strategies may be worthwhile intervention goals.

For readers

This is the most comprehensive meta-analysis of walking and running biomechanics in PFP to date, but the predominance of cross-sectional, moderate-quality studies means causal conclusions remain premature.