Original research| Volume 97, ISSUE 7, P1115-1120, July 2016

Lower Amplitude of the Hoffmann Reflex in Women With Patellofemoral Pain: Thinking Beyond Proximal, Local, and Distal Factors

Published:January 04, 2016DOI:


      • Women with patellofemoral pain presented reduced vastus medialis Hoffman reflex (H-reflex) excitability.
      • Vastus medialis H-reflex presented large and balanced discriminatory capability values.
      • H-reflex modulation may be a factor to be considered in patellofemoral pain investigations.



      To investigate whether vastus medialis (VM) Hoffmann reflexes (H-reflexes) differ on the basis of the presence or absence of patellofemoral pain (PFP) and to assess the capability of VM H-reflex measurements in accurately discriminating between women with and without PFP.


      Cross-sectional study.


      Laboratory of biomechanics and motor control.


      Women (N=30) aged 18 to 35 years were recruited, consisting of 2 groups: women with PFP (n=15) and asymptomatic controls (n=15).


      Not applicable.

      Main Outcome Measures

      Maximum evoked responses were obtained by electrical stimulation applied to the femoral nerve, and peak-to-peak amplitudes of maximal Hoffmann reflex (Hmax) and maximal motor wave (Mmax) ratios were calculated. Independent samples t tests were performed to identify differences between groups, and a receiver operating characteristic curve was constructed to assess the discriminatory capability of VM H-reflex measurements.


      VM Hmax/Mmax ratios were significantly lower in participants with PFP than in pain-free participants (P=.007). In addition, the VM Hmax/Mmax ratios presented large and balanced discriminatory capability values (sensitivity, 73%; specificity, 67%).


      This study is the first to show that VM H-reflexes are lower in women with PFP than in asymptomatic controls. Therefore, increasing the excitation of the spinal cord in PFP participants may be essential to maintaining the gains acquired during the rehabilitation programs.


      List of abbreviations:

      Hmax (maximal Hoffmann reflex), H-reflex (Hoffmann reflex), ICC (intraclass correlation coefficient), Mmax (maximal motor wave), PFP (patellofemoral pain), ROC (receiver operating characteristic), VM (vastus medialis)
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        • Liao T.
        • Yang N.
        • Ho K.
        • et al.
        Femur rotation increases patella cartilage stress in females with patellofemoral pain.
        Med Sci Sports Exerc. 2015; 47: 1775-1780
        • Boling M.
        • Padua D.
        • Marshall S.
        • Guskiewicz K.
        • Pyne S.
        • Beutler A.
        Gender differences in the incidence and prevalence of patellofemoral pain syndrome.
        Scand J Med Sci Sports. 2010; 20: 725-730
        • Roush J.R.
        • Bay R.C.
        Prevalence of anterior knee pain in 18-35 year-old females.
        Int J Sports Phys Ther. 2012; 7: 396-401
        • Lankhorst N.E.
        • Bierma-Zeinstra S.M.
        • van Middelkoop M.
        Factors associated with patellofemoral pain syndrome: a systematic review.
        Br J Sports Med. 2013; 47: 193-206
        • Witvrouw E.
        • Callaghan M.J.
        • Stefanik J.J.
        • et al.
        Patellofemoral pain: consensus statement from the 3rd International Patellofemoral Pain Research Retreat held in Vancouver, September 2013.
        Br J Sports Med. 2014; 48: 411-414
        • Uliam Kuriki H.
        • Mícolis de Azevedo F.
        • de Faria Negrão Filho R.
        • Alves N.
        Comparison of different analysis techniques for the determination of muscle onset in individuals with patellofemoral pain syndrome.
        J Electromyogr Kinesiol. 2011; 21: 982-987
        • Rixe J.A.
        • Glick J.E.
        • Brady J.
        • Olympia R.P.
        A review of the management of patellofemoral pain syndrome.
        Phys Sportsmed. 2013; 41: 19-28
        • Barton C.
        • Levinger P.
        • Crossley K.
        • Webster K.
        • Menz H.
        The relationship between rearfoot, tibial and hip kinematics in individuals with patellofemoral pain syndrome.
        Clin Biomech. 2012; 27: 702-705
        • Rathleff M.S.
        • Rathleff C.R.
        • Crossley K.M.
        • Barton C.J.
        Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis.
        Br J Sports Med. 2014; 48: 1088-1099
        • Freedman B.R.
        • Sheehan F.T.
        Predicting three-dimensional patellofemoral kinematics from static imaging-based alignment measures.
        J Orthop Res. 2013; 31: 441-447
        • De Oliveira Silva D.
        • Briani R.V.
        • Pazzinatto M.F.
        • et al.
        Reliability and differentiation capability of dynamic and static kinematic measurements of rearfoot eversion in patellofemoral pain.
        Clin Biomech. 2015; 30: 144-148
        • Barton C.J.
        • Menz H.B.
        • Levinger P.
        • Webster K.E.
        • Crossley K.M.
        Greater peak rearfoot eversion predicts foot orthoses efficacy in individuals with patellofemoral pain syndrome.
        Br J Sports Med. 2011; 45: 697-701
        • Utting M.R.
        • Davies G.
        • Newman J.H.
        Is anterior knee pain a predisposing factor to patellofemoral osteoarthritis?.
        Knee. 2005; 12: 362-365
        • Crossley K.
        Is patellofemoral osteoarthritis a common sequela of patellofemoral pain?.
        Br J Sports Med. 2014; 48: 409-410
        • Hurley M.V.
        • Scott D.L.
        • Rees J.
        • Newham D.J.
        Sensorimotor changes and functional performance in patients with knee osteoarthritis.
        Ann Rheum Dis. 1997; 56: 641-648
        • Mezzarane R.A.
        • Elias L.A.
        • Magalhães F.H.
        • Chaud V.M.
        • Kohn A.F.
        Experimental and simulated EMG responses in the study of the human spinal cord.
        in: Turker H. Electrodiagnosis in new frontiers of clinical research. InTech, Croatia2013: 311
        • Millan-Guerrero R.
        • Trujillo-Hernandez B.
        • Isais-Millan S.
        • et al.
        H-reflex and clinical examination in the diagnosis of diabetic polyneuropathy.
        J Int Med Res. 2012; 40: 694-700
        • Stowe A.M.
        • Hughes-Zahner L.
        • Barnes V.K.
        • Herbelin L.L.
        • Schindler-Ivens S.M.
        • Quaney B.M.
        A pilot study to measure upper extremity H-reflexes following neuromuscular electrical stimulation therapy after stroke.
        Neurosci Lett. 2013; 535: 1-6
        • Aagaard P.
        • Simonsen E.B.
        • Andersen J.L.
        • Magnusson P.
        • Dyhre-Poulsen P.
        Neural adaptation to resistance training: changes in evoked V-wave and H-reflex responses.
        J Appl Physiol. 2002; 92: S135-S145
        • De Oliveira Silva D.
        • Briani R.V.
        • Pazzinatto M.F.
        • et al.
        Q-angle static or dynamic measurements, which is the best choice for patellofemoral pain?.
        Clin Biomech. 2015; 30: 1083-1087
        • De Oliveira Silva D.
        • Briani R.V.
        • Pazzinatto M.F.
        • Ferrari D.
        • Aragão F.A.
        • de Azevedo F.M.
        Reduced knee flexion is a possible cause of increased loading rates in individuals with patellofemoral pain.
        Clin Biomech. 2015; 30: 971-975
        • De Oliveira Silva D.
        • Briani R.
        • Pazzinatto M.
        • Ferrari D.
        • Aragão F.
        • Azevedo F.
        Vertical ground reaction forces are associated with pain and self-reported functional status in recreational athletes with patellofemoral pain.
        J Appl Biomech. 2015; 31: 409-414
        • Floeter M.K.
        • Kohn A.F.
        H-reflexes of different sizes exhibit differential sensitivity to low frequency depression.
        Electroencephalogr Clin Neurophysiol. 1997; 105: 470-475
        • Doguet V.
        • Jubeau M.
        Reliability of H-reflex in vastus lateralis and vastus medialis muscles during passive and active isometric conditions.
        Eur J Appl Physiol. 2014; 114: 2509-2519
        • Alrowayeh H.N.
        • Sabbahi M.A.
        Vastus medialis H-reflex reliability during standing.
        J Clin Neurophysiol. 2006; 23: 79-84
        • Palmieri R.M.
        • Ingersoll C.D.
        Intersession reliability of a protocol to assess reflex activation history in the vastus medialis.
        Int J Neurosci. 2005; 115: 735-740
        • Perkins N.J.
        • Schisterman E.F.
        The inconsistency of “optimal” cut-points using two ROC based criteria.
        Am J Epidemiol. 2006; 163: 670-675
        • Park J.
        • Hopkins J.T.
        Induced anterior knee pain immediately reduces involuntary and voluntary quadriceps activation.
        Clin J Sport Med. 2013; 23: 19-24
        • Grenholm A.
        • Stensdotter A.K.
        • Häger-Ross C.
        Kinematic analyses during stair descent in young women with patellofemoral pain.
        Clin Biomech. 2009; 24: 88-94
        • Héroux M.E.
        • Tremblay F.
        Corticomotor excitability associated with unilateral knee dysfunction secondary to anterior cruciate ligament injury.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 823-833
        • Aminaka N.
        • Pietrosimone B.G.
        • Armstrong C.W.
        • Meszaros A.
        • Gribble P.A.
        Patellofemoral pain syndrome alters neuromuscular control and kinetics during stair ambulation.
        J Electromyogr Kinesiol. 2011; 21: 645-651
        • Palmieri-Smith R.M.
        • Thomas A.C.
        A neuromuscular mechanism of posttraumatic osteoarthritis associated with ACL injury.
        Exerc Sport Sci Rev. 2009; 37: 147-153
        • Hart J.M.
        • Pietrosimone B.
        • Hertel J.
        • Ingersoll C.D.
        Quadriceps activation following knee injuries: a systematic review.
        J Athl Train. 2010; 45: 87-97
        • Barton C.J.
        • Lack S.
        • Hemmings S.
        • Tufail S.
        • Morrissey D.
        The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning.
        Br J Sports Med. 2015; 49: 923-934
        • Taube W.
        • Kullmann N.
        • Leukel C.
        • Kurz O.
        • Amtage F.
        • Gollhofer A.
        Differential reflex adaptations following sensorimotor and strength training in young elite athletes.
        Int J Sports Med. 2007; 28: 999-1005
        • Perez M.A.
        • Field-Fote E.C.
        • Floeter M.K.
        Patterned sensory stimulation induces plasticity in reciprocal ia inhibition in humans.
        J Neurosci. 2003; 23: 2014-2018
        • Master S.
        • Tremblay F.
        Task-specific increase in corticomotor excitability during tactile discrimination.
        Exp Brain Res. 2009; 194: 163-172
        • Thompson A.K.
        • Wolpaw J.R.
        The simplest motor skill: mechanisms and applications of reflex operant conditioning.
        Exerc Sport Sci Rev. 2013; 18: 1199-1216
        • Motta-Oishi A.A.
        • Magalhães F.H.
        • Mícolis de Azevedo F.
        Neuromuscular electrical stimulation for stroke rehabilitation: is spinal plasticity a possible mechanism associated with diminished spasticity?.
        Med Hypotheses. 2013; 81: 784-788
        • Selfe J.
        • Callaghan M.
        • Witvrouw E.
        • et al.
        Targeted interventions for patellofemoral pain syndrome (TIPPS): classification of clinical subgroups.
        BMJ Open. 2013; 3: e003795
        • Briani R.V.
        • De Oliveira Silva D.
        • Pazzinatto M.F.
        • et al.
        Comparison of frequency and time domain electromyography parameters in women with patellofemoral pain.
        Clin Biomech. 2015; 30: 302-307
        • Mezzarane R.A.
        • Magalhães F.H.
        • Chaud V.M.
        • Elias L.A.
        • Kohn A.F.
        Enhanced D1 and D2 inhibitions induced by low-frequency trains of conditioning stimuli: differential effects on H- and T-reflexes and possible mechanisms.
        PLoS One. 2015; 10: e0121496
        • Dafkin C.
        • Green A.
        • Kerr S.
        • Veliotes D.
        • McKinon W.
        The accuracy of subjective clinical assessments of the patellar reflex.
        Muscle Nerve. 2013; 47: 81-88