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 Journal of Applied Biomechanics, 2013, 29, 413-420

 © 2013 Human Kinetics, Inc.

Gender Differences in Lower Limb KinematicsDuring Stair Descent

Rodrigo de M. Baldon, Daniel F.M. Lobato, Leonardo Furlan, and Fábio V. Serrão

São Carlos Federal University

The purpose of this study was to compare lower limb kinematics between genders during stair descent. Fifteenfemales and fifteen males who were healthy and active were included in this study. The lower limb kinematics(pelvis, femur and knee) in the coronal and transversal planes were assessed during stair descent at 30°, 40°,50° and 60° of knee flexion. The study found that females showed greater knee medial rotation for all the kneeflexion angles (P = .02–.001), greater femoral adduction (P = .01 for all variables), with exception for 30° (P = .13), and greater femoral lateral rotation at 60° (P = .04). Females also showed a trend to have greater kneevalgus at all the knee flexion angles (P = .06–.11) as well as less contralateral pelvis elevation at 50° and 60°

(P = .10 and .12, respectively). This study showed that females carry out the stair descent with a lower limbalignment that might predispose them to develop overuse knee injuries, such as the iliotibial band syndromeand patellofemoral pain syndrome. Further prospective investigations should be carried out to verify whetherthese variables are factors that could predict these knee injuries.

 Keywords: stair descent, hip, iliotibial band syndrome, knee, patellofemoral pain syndrome

Rodrigo de M. Baldon, Daniel F.M. Lobato, Leonardo Furlan,

and Fábio V. Serrão (Corresponding Author)  are with the

Department of Physical Therapy, São Carlos Federal University,

São Carlos, SP, Brazil.

It has been reported that females are more likely to sustainoveruse knee injuries such as the iliotibial band syndrome(ITBS) and patellofemoral pain syndrome (PFPS) thantheir male counterparts.1  Some factors (anatomical,hormonal and biomechanical) have been investigatedin an attempt to clarify why females are more prone tosuch injuries. Recently, studies have focused on genderdifferences in lower limb biomechanics during functionalactivities in the belief that females could show uniquemovement characteristics that might play an importantrole in the greater incidence of knee injuries.2

In general, it has been observed that females carryout functional activities with greater hip adduction3,4 and medial rotation,5,6 as well as greater knee valgus3,7 and medial rotation8,9  than males. This typical lowerlimb alignment has been related to weakness of the hipabductor and lateral rotator muscles,3,10 and it has beenargued that such a lower limb alignment would increaseiliotibial band and patellofemoral joint stress.2 Thus it iscritical for clinicians engaged in preventing and treating

overuse knee injuries to quickly and easily identify thislower limb movement pattern that should be correctedto minimize stress on the knee joint.

The lower limb movement pattern cited above hasbeen observed in females during several weight-bearing

tasks such as the single-leg squat,3,4 drop landing,9,11 side-cutting maneuvers12 and running.5,6 However, there areno data regarding gender differences in the lower limbbiomechanics during the stair descent. Only one studycompared the genders with respect to lower extremitymovement during a similar functional task.13 It was veri-fied that females showed greater hip adduction and kneevalgus than males during the step-down task.

The stair descent is a weight-bearing activity carriedout daily by people in general. During the single-legstance of this activity, the hip abductor and lateral rotatormuscles are challenged to stabilize the pelvis and hip jointin the coronal and transversal planes.14 Since this activityis not very complex, almost all healthy people are able toperform it, whereas landing and cutting maneuvers arecarried out mainly by athletes. In addition, clinicians mayprefer to choose this task because it is slower and occursin a more controlled fashion than other functional tasks.Finally, this task seems to be clinically useful due to thecommon complaint of pain during stair walking reported

by patients with PFPS.15–17

Knowledge of the lower limb biomechanical fea-tures of both genders during the stair descent wouldprovide benchmark data for males and females toidentify the spectrum of what is “normal” as defined bysymptom-free subjects. Therefore, the purpose of thisstudy was to compare lower limb kinematics betweengenders during the stair descent. It was hypothesizedthat females, when compared with males, wouldexhibit greater femoral adduction and medial rotation,contralateral pelvic depression, and knee valgus and

An Official Journal of ISBwww.JAB-Journal.com

ORIGINAL RESEARCH

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414 Baldon et al.

medial rotation during the stance phase of the stairdescent.

Methods

This cross-sectional study included 15 females (mean ±SD: age, 20.7 ± 1.7 y; height, 1.6 ± 0.1 m; body mass,57.7 ± 10.6 kg) and 15 males (mean ± SD: age, 21.8 ± 2.9years; height, 1.8 ± 0.1 m; body mass, 75.5 ± 9.3 kg) whowere active (anyone carrying out aerobic or athletic activi-ties at least 3 times per week) but not athletes. Anyonewith a current injury or previous surgery to the lowerlimb, or who had cardiovascular, pulmonary, neurologi-cal or systemic conditions that limited physical activity,were excluded from the study. Before participation, allsubjects signed an informed consent form approved bythe Institutional Review Board of the University.

Procedures

After the physical evaluation, a kinematic assessment ofthe dominant lower limb (determined by asking whichleg was used to kick a ball as far as possible) was carriedout during the stair descent task. The trials were recordedusing four digital cameras (Panasonic NV–GS180,Matsushita Group, Japan) adjusted to the acquisitionfrequency of 60 Hz and positioned so they could captureall the passive markers. For the calibration procedure, anobject with dimensions of 1 m × 1.8 m × 0.8 m was filmedin the area where the subjects would carry out the task.This object had 24 control points with known absolutepositions in relation to the Cartesian coordinate system.The global reference system was then defined withthis calibrated object, in which the Y axis was orientedupwards, the X axis was oriented anteriorly and the Zaxis oriented to the right of the subjects.18

In each evaluation, nine passive reflective mark-ers (10 mm in diameter) were positioned by the sameresearcher at the following anatomical landmarks: bothanterior superior iliac spines, first sacral vertebra, promi-nence of the greater trochanter of the femur, lateral andmedial epicondyle of the femur, head of the fibula, andthe lateral and medial malleolus.3 This marker distributionwas necessary to determine the hip and knee alignmentduring the stair descent. The raw marker coordinateswere tracked using the software Dvideow (Digital Videofor Biomechanics for Windows 32 bits),19 which usesthe direct linear transformation (DLT) method for 3D

representation.20

During the test, the subjects were instructed to go tothe top of a 3-step wooden staircase (height, depth andwidth of each step = 20.5, 27.5 and 60 cm, respectively)and stand on it with their arms crossed in front of thethorax. This static standing trial was registered and usedto determine the anatomical position of the dominanthip and knee in the coronal and transversal planes, withsubsequent measurements referenced to this position.Standing in bipedal support on the top step, the subjectswere asked to descend one step, initiating the movement

with the nondominant limb (dominant limb in support)and finishing the movement with the dominant limb. Theexecution time of the task was standardized at 3.0 ± 0.3s, controlled by a progressive digital stopwatch (Timexmarathon, Timex Group USA Inc, Middlebury, CT, USA).A slow velocity was chosen to challenge the lower limbmovement control. Each subject completed 3 attempts for

familiarization and 5 acceptable trials for the data analysis.If any of the evaluation requirements was not completed, theattempt was invalidated and a new one carried out. Theaverages of the dominant limb kinematic values obtainedduring the stance phase (defined as the period where thebody weight was only supported by the dominant lowerlimb) from the 5 acceptable trials were used in the sta-tistical analyses. Only the stance phase of the task wasconsidered because we were interested in challenging themain hip muscles responsible by stabilizing this joint inthe coronal and transversal planes during stair descent.

After recording the 3D coordinates for each marker,the data were submitted to the software Matlab (Math-works Inc., Natick, MA, USA) and analyzed using a

low-pass 4th-order Butterworth filter with a 5 Hz cutofffrequency. The local coordinate systems of the pelvis,femur and leg were then defined and algorithms createdto quantify the joint angles. The knee joint angles werecalculated with the mathematical convention of Eulerangles, using the coordinate system of the distal seg-ment relative to the coordinate system of the proximalsegment.21 Since the authors believe that isolated move-ments of the pelvis and femur are capable of altering theload on the patellofemoral joint and iliotibial band, themovement of these segments (femur and pelvis) werecalculated relative to themselves. For this purpose, thelocal coordinate systems of the pelvis and femur weredefined in the static standing trial, and the relative angles

(in relation to the initial orientation) calculated for thesubsequent time instants.3,22

The kinematic variables studied were as follows:contralateral pelvis elevation/depression and posterior/ anterior rotation; femoral adduction/abduction and medial/ lateral rotation; and knee varus/valgus and medial/lateralrotation. These variables represented the movements whichwere calculated by subtraction of the values acquired whenthe knee was at 30°, 40°, 50°, and 60° of flexion, from thatrecorded in the static standing position. By convention,positive kinematic values represented the contralateralpelvis elevation, contralateral pelvis posterior rotation,femoral adduction, femoral medial rotation, knee varusand knee medial rotation. The experimental error wasverified using a specific test described elsewhere.23  Inthis study the experimental error was 2.8 mm.

Data Analysis

All statistical analyses were performed using the Statis-tica software (version 7.0, StatSoft Inc, Tulsa, OK, USA).Descriptive values (means, standard deviations) for eachvariable were first obtained. The data were analyzed asappropriate based on their statistical distribution and vari-ance homogeneity according to the Shapiro-Wilk W  and

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Gender Differences in Lower Limb Kinematics 415

Levene tests, respectively. With respect to the parametricdata, the Student t  test for independent samples was usedto verify gender differences at each knee flexion angle.Nonparametric analyses were performed for knee varus/ valgus at 50° of knee flexion, knee medial/lateral rotationat 40° of knee flexion, femoral adduction/abduction at 30°and 40° of knee flexion using the Mann-Whitney U  test.

Effect sizes (Cohen d ) were calculated to determine themeaningfulness of any differences.

Results

Females showed greater knee medial rotation than males(P = .02–.001; Cohen d  = 0.89–1.32) and a trend forgreater knee valgus (P = .06–.11; Cohen d  = 0.61–0.73)for all the knee flexion angles evaluated (Figure 1).Females also showed greater femoral adduction than

males for all the knee flexion angles (P  = .01 for allvariables; Cohen d  = 0.97–1), with exception for 30° (P =

Figure 1 — Knee kinematics profiles of women (dashed line) and men (solid line) during the stair descent task. *Significantdifference, P < .05.

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416 Baldon et al.

.13; Cohen d  = 0.70; Figure 2). Females also had greaterfemoral lateral rotation at 60° of knee flexion (P = .04;Cohen d  = 0.81) and a trend for greater femoral lateralrotation in the other angles of knee flexion (P = .06–.10;Cohen d  = 0.61–0.73; Figure 2). Finally, females showeda trend for smaller contralateral pelvis elevation at 50°and 60° of knee flexion (P = .10 and .12, respectively;

Cohen d  = 0.64 and 0.6, respectively; Figure 3). Therewere no differences between gender for contralateralpelvis posterior/anterior rotation (P  = .53–.99; Cohen

d  = 0–0.24) and elevation/depression at 30° and 40° ofknee flexion (P = .33 and .20, respectively; Cohen d  =0.37 and 0.49, respectively; Figure 3).

Discussion

It has been argued that gender differences in lowerlimb kinematics might play an important role in thegreater incidence of overuse knee injuries in females.3,4,6 

Figure 2 — Femur kinematics profiles of women (dashed line) and men (solid line) during the stair descent task. *Significantdifference, P < .05.

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Gender Differences in Lower Limb Kinematics 417

Therefore it is critical for the physiotherapist to recognizelower limb movement patterns that could predisposethe subjects to knee disorders to plan efficient clinicalstrategies as quickly as possible. The stair descent is afairly common activity carried out routinely by people ingeneral. Although the slow stair descent cadence chosenin the current article is not typical of people in general and

may not reflect usual movement patterns, we believe thatat this cadence the hip muscles responsible for stabilizingthis joint are more challenged to control the movement

of the femur. However, to the best of the authors’ knowl-edge, there are no data regarding the influence of genderon lower limb kinematics during this activity. Thus theaim of this study was to verify whether females showeddifferent lower limb kinematics during the stair descentwhen compared with males. The current results supportedthe original hypothesis that females would show greater

femoral adduction and knee medial rotation than malesthroughout a range of knee flexion angles. Moreover,greater knee valgus and femoral lateral rotation were

Figure 3 — Pelvis kinematics profiles of women (dashed line) and men (solid line) during the stair descent task.

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418 Baldon et al.

also observed in females, although these differenceswere not significant (only for femoral lateral rotation at60° of knee flexion).

The present results regarding knee kinematics arein agreement with several studies which evaluated morecomplex functional activities. Greater knee medial rota-tion was observed in females during the flight phase of

the vertical-stop jump8 and during the single limb droplanding.9 Moreover, greater knee valgus was shown infemales during the single leg squat,3 drop landing11 andcutting maneuvers.12 It has been suggested that increas-ing knee medial rotation could increase the strain on theiliotibial band. Fairclough et al24 showed that the iliotibialband compresses into the lateral femoral condyle withexcessive knee medial rotation. Indeed, cross-sectional25 and prospective26 studies showed that knee medial rota-tion was predictor of ITBS development. A prospectivestudy also observed that knee valgus was predictor ofPFPS.27 It has been suggested that excessive knee valgusincreases the Q-angle and consequently overloads theretropatellar articular cartilage.2 Thus the knee move-

ment pattern observed in females throughout a range ofknee flexion angles of stair descent may be related withthe higher incidence of ITBS and PFPS which has beenobserved in women.1

It was also verified that females carried out the stairdescent with greater femoral adduction throughout arange of knee angles and with a trend toward smallercontralateral pelvis elevation at 60° and 50° of kneeflexion. Greater femoral adduction in females was alsoverified in several studies during more complex functionalactivities.3,6,28 Iliotibial band strain is supposed to increasewith hip adduction due to the proximal attachments at thepelvis and the distal attachments at the lateral femoralcondyle.25 Thus, both excessive femoral adduction and

decreased contralateral pelvis elevation would contributeto increased hip adduction, and consequently to highstrain on the iliotibial band. Moreover, knee valgus duringdynamic weight-bearing activities is associated with theamount of femoral adduction movement29 and poor con-trol of the femur in the coronal plane might increase thedynamic Q-angle and patellofemoral stress.2 It is knownthat the gluteus medius and the upper portion of the glu-teus maximus are important hip abductor muscles.30,31 Weakness of these muscles could result in increasingthe hip adduction as well as over-activation and tight-ness of the tensor fascia lata and iliotibial band,32 sincethis muscle is a secondary hip abductor. Therefore, the

current results highlight the importance of evaluating thehip joint movements in the screening process of subjectsduring the stair descent to identify risk for developmentof ITBS and PFPS.

Although women only showed significantly greaterfemoral lateral rotation at 60° of knee flexion, theyshowed a trend for greater femoral lateral rotation at allknee flexion angles evaluated. Conflicting findings havebeen reported for the dynamic lower limb movement pat-tern in females in the transversal plane. Several studieshave shown greater femoral medial rotation in females

during more demanding activities such as running,5,6 landing from a jump,33 and cutting maneuvers.34 On theother hand, Baldon et al3 and Zeller et al4 verified greaterfemoral lateral rotation in females during the single legsquat. To minimize the effects caused by greater femo-ral adduction and knee valgus, it is possible that duringslower activities females might carry out greater femoral

lateral rotation as a compensation mechanism to avoidlarger Q-angles.3 However, increased femoral lateralrotation associated with greater knee medial rotation hasbeen seen in subjects with ITBS.26 As discussed above,this misalignment could increase strain on the iliotibialband and contribute to the development of ITBS.

Only one study comparing lower limb kinematicsbetween genders in stair activities was found. Earl etal13 verified that females showed greater knee valgus andmedial rotation as well as greater hip adduction during thestep-down task. However, no difference between genderswas observed in the hip transversal plane. It is importantto emphasize that during the step-down task the subjectsare oriented to stand on the lower limb under evaluation,

and lower the contralateral foot to lightly touch the floorwith the heel, before returning to the starting position.On the other hand, during the stair descent carried outin the current study, the subjects were oriented to standin bipedal support on the top step of the stair, and thendescend one step slowly, initiating the movement withthe nonevaluated limb and finishing the movement withthe dominant limb in the next step. Thus, the presentresults reveal that in comparison with the literature thereare no apparent differences in the lower limb kinematicsbetween the step-down task and the stair descent.

The authors recognize there were some limitationsin this study. Firstly, the sample used in this study con-sisted only of healthy active subjects. Thus, the resultscannot be extrapolated to people with knee disorders.Secondly, the small sample size may have contributed tothe absence of significant differences in some variables,so the presence of type II error should not be ruled out.However, the moderate effect sizes indicated that thedifferences between genders for these variables weremeaningful. Thirdly, the slow velocity of the task is notat all reflective of the natural descent condition and mayhave reflected a movement pattern that would not exist ifthe natural speed was adopted. Thus, caution is needed togeneralize the current results for all descent stair caden-cies. Finally, there is an inherent inaccuracy in carryingout motion measurements in the transversal plane with

anatomical passive reflective markers, mainly due to theexcessive movement of the skin. However, we believe thisproblem was minimized since most reflective markerswere positioned at bone structures where skin movementwas small. Thus, future studies should be addressed toan attempt to confirm the present results.

The main findings of the current study indicate thatfemales carry out the stair descent with greater kneemedial rotation and femoral adduction then males. More-over, greater knee valgus and femoral lateral rotation aswell as smaller contralateral pelvis elevation were also

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Gender Differences in Lower Limb Kinematics 419

observed in females. The findings of this study identifiedgender differences that are reflective of patterns observedin women who experience ITBS and PFPS although adirect comparison is required to affirm the nature of therelationship.

Acknowledgments

The Fundação de Amparo à Pesquisa do Estado de São Paulo

and the Coordenação de Aperfeiçoamento de Pessoal de Nível

Superior provided financial support for this research.

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