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Effects of two gait retraining programs on pain, function, and lower limb kinematics in runners with patellofemoral pain: A randomized controlled trial

PainSci » bibliography » Júnior et al 2024
Tags: etiology, treatment, prevention, patellar pain, running, good news, biomechanics, barefoot, pro, arthritis, aging, pain problems, knee, leg, limbs, overuse injury, injury, exercise, self-treatment, foot

One article on PainSci cites Júnior 2024: The Complete Guide to Patellofemoral Pain Syndrome

PainSci commentary on Júnior 2024: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This small but good test of two gait retraining programs produced truly fine results for patellofemoral pain, both from running softer or dialing up cadence. And for a dorky bonus prize? These benefits came without a flicker of change in kinematics — which tickles my bias. News that I can feel good and smug about is not exactly the usual fare around here. I’ve got chills!

Brazilian researchers de Souza Júnior et al. recruited thirty runners and divvied them up into a three groups — so not huge — one focusing on easing impact, the other on a quicker cadence, while the third served as a control group. The runners did eight gait-retraining runs over two weeks, ramping up from 15 to 30 minutes, and they were evaluated for pain, function, and the details of their lower limb movement right before, right after, and then again after another six months of running.

Impact was eased with forefoot running and — this is cool — by working with a real-time display of how hard they were hitting the treadmill, from an accelerometer on the shin. It’s a lot easier to run softer when you can see the literal impact of every step.

The cadence group wasn’t quite as cool, but they still got a gadget: a metronome! They used that to increase their cadence by about 10%. Running cadence and speed are related, but they’re not the same thing. Cadence is your rhythm, how fast you put your feet down, like the beats per minute in a song — hence the metronome.

How fast you go depends on how big those steps are. You could have a high cadence with short strides and not be moving very fast, or a lower cadence with longer strides and be cruising along pretty quickly. So changing one doesn't exactly mean changing the other, but they do affect each other quite a bit, and most runners naturally increase both at the same time in the short term — e.g. a sprint naturally needs both, and long haul running tends to reduce both. The highest cadences require shorter steps, because a longer step just takes longer, and therefore also less hinging of the knee … which is one obvious reason why higher cadence may have been helpful.

The image displays a person running on a treadmill facing a monitor that provides real-time visual feedback on their performance. The monitor shows a graphical representation with blue bars indicating the force of impact in

“How hard are you hitting yourself?” Runners were shown exactly how hard they were hitting themselves with the ground with a display powered by a shin-mounted accelerometer. By de Souza Júnior et al., CC BY 4.0 DEED.

Less pain without kinematics changes

Pain and knee function improved more in both kinds of gait-tinkerers than the control-group runners — but, notably, without any change to how the lower limb was moving. This flies directly in the face of the almost unanimous assumption in this business that changes in pain and function are the result of improvements in biomechanics. But that’s not what we see here. What we see instead is real change in pain and function … without the slightest signal in the kinematics. The authors write:

“two-weeks of using a strategy that does not address lower limbs kinematics directly may not be sufficient to modify these variables in individuals with patellofemoral pain.”

Mayhaps not. And maybe those variables don’t really matter at all. 🤯 And the authors do acknowledge this.

Decent effect size? Check!

But just how “real” were those pain and function changes? The changes were happy changes, but… how happy? Normally I would expect to see underwhelming results, and probably overstated based on “statistical significance.” But no!

Júnior et al report an equally “large” reduction in running pain with both groups, while function improvements were “moderate.” With a larger sample size, it would be kind of a big deal. As it is, it’s just legitimately promising.

There are some problems, of course

The perfect scientific trial has never been done. There are always concerns, and in this case there are two particularly obvious problems:

  1. The strong effect on running pain could be a research artifact caused by a lack of blinding.
  2. Regardless, pain when not running barely changed at all.

I explore those concerns in more detail in my book about patellofemoral pain … but still basically conclude that it’s a good-news study.

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND: Patellofemoral Pain (PFP) is one of the main injuries in runners. Consistent evidence support strengthening programs to modulate symptoms, however, few studies investigated the effects of gait retraining programs.

OBJECTIVE: To investigate the effects of two different two-week partially supervised gait retraining programs on pain, function, and lower limb kinematics of runners with PFP.

METHODS: Randomized controlled trial. Thirty runners were allocated to gait retraining groups focusing on impact (n = 10) or cadence (n = 10), or to a control group (n = 10). Impact group received guidance to reduce tibial acceleration by 50%, while cadence group was asked to increase cadence by 7.5-10%. The control group did not receive any intervention. Usual and running pain, knee function, and lower limb kinematics (contralateral pelvic drop, hip adduction, knee flexion, ankle dorsiflexion, tibia inclination, and foot inclination) were evaluated before (T0), immediately after the intervention (T2), and six months after the protocol (T24).

RESULTS: A significant group x time interaction was found for running pain (p = 0.010) and knee function (p = 0.019). Both programs had greater improvements in running pain compared to no intervention at T24 (Impact x Control-mean difference (MD) -3.2, 95% CI -5.1 to -1.3, p = 0.001; Cadence x Control-MD -2.9, 95% CI -4.8 to -1.0, p = 0.002). Participants of the impact group had greater improvements in knee function compared to no intervention at T2 (Impact x Control-MD 10.8, 95% CI 1.0 to 20.6, p = 0.027). No between-group differences in usual pain and lower limb kinematics were found (p>0.05).

CONCLUSION: Compared to no intervention, both programs were more effective in improving running pain six months after the protocol. The program focused on impact was more effective in improving knee function immediately after the intervention. Clinical trial registry number: RBR-8yb47v.

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