title: The Role of Cartilage Stress in Patellofemoral Pain.
abstract: OBJECTIVE
  Elevated cartilage stress has been identified as a potential mechanism for retropatellar pain; however, there are limited data in the literature to support this mechanism. Females are more likely to develop patellofemoral pain than males, yet the causes of this dimorphism are unclear. We used experimental data and computational modeling to determine whether patients with patellofemoral pain had elevated cartilage stress compared with pain-free controls and test the hypothesis that females exhibit greater cartilage stress than males.
  
  
  METHODS
  We created finite element models of 24 patients with patellofemoral pain (11 males and 13 females) and 16 pain-free controls (8 males and 8 females) to estimate peak patellar cartilage stress (strain energy density) during a stair climb activity. Simulations took into account cartilage morphology from magnetic resonance imaging, joint posture from weight-bearing magnetic resonance imaging, and muscle forces from an EMG-driven model.
  
  
  RESULTS
  We found no difference in peak patellar strain energy density between those with patellofemoral pain (1.9 ± 1.23 J·m(-3)) and control subjects (1.66 ± 0.75 J·m(-3), P = 0.52). Females exhibited greater cartilage stress compared with males (2.2 vs 1.3 J·m(-3), respectively; P = 0.0075), with large quadriceps muscle forces (3.7 body weight in females vs 3.3 body weight in males) and 23% smaller joint contact area (females, 467 ± 59 mm2, vs males, 608 ± 95 mm2).
  
  
  CONCLUSIONS
  Patients with patellofemoral pain did not display significantly greater patellar cartilage stress compared with pain-free controls; however, there was a great deal of subject variation. Females exhibited greater peak cartilage stress compared with males, which might explain the greater prevalence of patellofemoral pain in females compared with that in males, but other mechanical and biological factors are clearly involved in this complex pathway to pain.
authors.affiliation: 1Auckland Bioengineering Institute, University of Auckland, Auckland, NEW ZEALAND; 2Department of Engineering Science, University of Auckland, Auckland, NEW ZEALAND; 3College of Engineering, California Polytechnic State University, San Luis Obispo, CA; 4Department of Bioengineering, Stanford University, Stanford, CA; 5Department of Orthopaedics, Stanford University, Stanford, CA; 6Department of Radiology, Stanford University, Stanford, CA; and 7VA Palo Alto Rehabilitation Research and Development Center, Palo Alto, CA.
authors.forename: Thor F
authors.initials: TF
authors.lastname: Besier
authors.forename: Saikat
authors.initials: S
authors.lastname: Pal
authors.forename: Christine E
authors.initials: CE
authors.lastname: Draper
authors.forename: Michael
authors.initials: M
authors.lastname: Fredericson
authors.forename: Garry E
authors.initials: GE
authors.lastname: Gold
authors.forename: Scott L
authors.initials: SL
authors.lastname: Delp
authors.forename: Gary S
authors.initials: GS
authors.lastname: Beaupré
mesh_terms: D000328:Adult; D018771:Arthralgia / Q000209:etiology*; D002358:Cartilage, Articular / Q000473:pathology / Q000503:physiopathology*; D003198:Computer Simulation; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D057071:Patellofemoral Joint / Q000473:pathology / Q000503:physiopathology*; D052097:Quadriceps Muscle / Q000503:physiopathology; D012737:Sex Factors; D013314:Stress, Mechanical; D055815:Young Adult