RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-11003-0151 |
Bilateral Variability of Quadriceps Angle and Impact of Height on it in Female Population of Uttarakhand
1–3Department of Anatomy, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
4Department of Pathology, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
Corresponding Author: Chanchal Sharma, Department of Anatomy, Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India, Phone: +91 8881022097, e-mail: chanchalsharma29jan@gmail.com
Received: 07 September 2024; Accepted: 15 October 2024; Published on: 31 December 2024
ABSTRACT
Background: The quadriceps angle (Q angle), an indicator of knee dysfunction, is formed by the line connecting the anterior superior iliac spine to the center of the patella and the line connecting the center of the patella to the tibial tuberosity. It is affected by the flexion and tonicity of the quadriceps femoris muscles. In females, the angle falls between 15 and 20°. The left and right legs are not always equal. Females tend to have a larger angle than men due to a broader pelvis. An increase in the angle is linked with instability of the patella and extensor dysfunction of the knee.
Materials and methods: The study was conducted in the anatomy department of a tertiary care center over 5 years, involving 370 females residing in the hilly and plain regions of Uttarakhand. The females were in the age-group of 18–65 years. Samples were collected in the supine position with the help of a universal goniometer.
Results: The Q angle was found to be higher in females from the plains compared to those from the hills. The mean value of the right Q angle was calculated as 12.02° in the hills and 13.27° in the plains. The mean value of the left Q angle was calculated as 11.49° in the hills and 12.62° in the plains.
Conclusion: In the plains, height has a nonsignificant correlation with the Q angle and may not be a strong predictor in this population. The left and right Q angles are highly correlated with each other. Height shows a weaker correlation with angle measurements in the hills.
Keywords: Bilateral, Female, Height, Q angle, Symmetry, Uttarakhand
How to cite this article: Sharma C, Ali S, Victor R, et al. Bilateral Variability of Quadriceps Angle and Impact of Height on it in Female Population of Uttarakhand. J Med Acad 2024;7(2):56–59.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
The Quadriceps angles (Q angle) are an important parameter for studying lower limb alignment and function. The angle is formed by one line drawn from the anterior superior iliac spine to the center of the patella and another from the center of the patella to the tibial tuberosity. This angle helps determine the lateral force exerted by the quadriceps on the patella and serves as a major tool in understanding knee pathology. Normally, the Q angle falls between 15 and 20° in females. An abnormal Q angle value may cause patellofemoral pain, patellar dislocation, and other knee injuries. It is crucial for understanding the mechanisms behind knee function, which affect patellar tracking and may lead to various knee problems. A larger Q angle results in greater lateral force, increasing the risk of patellar maltracking and dislocation. The angle is influenced by the width of the pelvis, the alignment of the femur, and the insertion point of the quadriceps on the tibia.
Quadriceps Angle
It is measured between the pull of the patellar ligament and the quadriceps muscles from the quadriceps tendon. The intersecting point formed between the line drawn from the center of the patella to the tibial tuberosity and the line drawn from the center of the patella to the anterior superior iliac spine is used to measure the angle (Fig. 1).
Fig. 1 Lines measuring Q angle
An angle greater than 15–20° is thought to increase the risk of overuse injuries to the knee.1 Q angle of the left and right legs are not always the same.2 Higher degrees of femoral internal rotation,3 a broader pelvis,4 and other anatomical factors cause a larger angle in females. The strength of the quadriceps muscle and its flexion also affect the Q angle. Isometric contraction reduces the Q angle compared to measurements made during relaxation.5
This may explain the bilateral variation in the angle, specifically in athletes and sportspersons where the stronger leg is the dominant one. During the running gait cycle, females exhibit larger angles of hip adduction and knee abduction, which means a higher Q angle. It has been determined that the average Q angle in men ranges from 11.2 to 12.7°.6,7 The average Q angle in females has been reported to be 15.8° in the supine position6 and 17° in the standing position.7 During activities like running, females have been reported to have an average Q angle that is 11.5° larger than that of males. Comparing females to males, it is concluded that females have lower hamstring activity and greater quadriceps muscle activity.8
Quadriceps angle greater than 20° is associated with an increased risk of knee injury. Athletes with a difference of >4° between the right and left limbs have a higher chance of injury to the lower limb and foot. A high risk of damage is also associated with a difference of >2 cm in limb length between the right and left sides.9
There is less data on the mechanism and function of the knee in association with variations in the Q angle, whereas several studies have examined the relationship between the Q angle and injuries in the lower limb.10
A high Q angle means more stress during repetitive knee activity, as it works with the smooth surface of the patella in the groove of the femur.11,12 Muscle imbalance may occur during sports,13 leading to erosion of cartilage on the undersurface of the patella, which can result in the loss of the articular surface of the knee.14 This may cause severe damage that cannot be recovered.
High Q angle causes excessive pronation of the foot, and prolonged pronation causes the tibia to rotate more on the medial side, changing the quadriceps function and lateral tracking of the patella.15 Rapid increase in dysfunction of the knee develops arthritis into osteoarthritis. Limitation in pronating the foot can reduce Q angle.16
AIMS AND OBJECTIVES
Aim
To measure the Q angle in the supine position in the female population of the hilly and plain regions of Uttarakhand.
Objectives
Look for variation in Q angle of the right and left limbs and their mean to study whether there is any difference in the hilly and plain regions of the female population of Uttarakhand and the impact of height on it.
MATERIALS AND METHODS
Type of Study
A cross-sectional study was conducted over 5 years, involving 370 healthy females from the plain and hilly regions. Of these, 200 females were from the hilly region, and 170 females were from the plain region. The age of these females ranged from 18 to 65 years. All participants had no history of injury to their lower limbs, bone abnormalities, or diagnosed knee disorders, such as fractures, acute or chronic knee pain, patellar dislocation, or previous surgeries in the lower extremities. The clearance was given by the Institutional Ethics Committee. Participants were informed about the research, and written consent was obtained. Height in centimeters was measured and grouped as 140–150, 150–160, and 160–170 for statistical analysis. The Q angle in degrees was recorded, and measurements of both limbs were taken in the supine position.
Measurement Procedure
For measuring the angle, the anterior superior iliac spine, the center of the patella, and the center of the tibial tuberosity were marked. The center of the patella was located, and the highest prominence of the tibial tuberosity was marked as the center. A line was drawn from the center of the patella to the anterior superior iliac spine, and from the center of the patella to the center of the tibial tuberosity. The point where these lines met formed an angle called the Q angle. The center of the goniometer was placed at the point of intersection, with the movable arm on the line facing toward the anterior superior iliac spine and the fixed arm kept straight, facing upward on the line drawn from the center of the patella to the tibial tuberosity. The angle was then measured. Height in centimeters and Q angle in degrees were measured. Data were collected using a goniometer (Mitutoyo South Asia Private Limited, New Delhi, India), weighing machine, inch-tape, measuring scale, and marker pen.
Data Analysis
Data were analyzed using an independent t-test and analysis of variance (ANOVA) to analyze the difference among means. The F-value in ANOVA was calculated by dividing two mean squares, which indicates whether the variances of two populations are equal or not. Pearson correlation coefficients were used to measure the correlation between the two sets of data, with results categorized as weak positive or strongly positive. The data were analyzed using the mean and standard deviation. A t-test was applied to check for significant differences in the Q angle of the left and right limbs of the female population from both the hills and plains of Uttarakhand, as well as the impact of height on it.
RESULTS
Out of the total 370 females included, a small percentage (5.4%) have a height in the 140–150 cm range, 74.9% in the 150–160 cm range, and 19.7% in the 160–170 cm range. This summarizes the distribution of the group based on these factors, likely for demographic or health-related analysis. The hilly region is home to 54.1% of the individuals, while 45.9% reside in the plain regions (Table 1).
| Height in centimeters | No. of cases | Percentage |
|---|---|---|
| 140–150 | 20 | 5.4 |
| 150–160 | 277 | 74.9 |
| 160–170 | 73 | 19.7 |
| Region | ||
| Hills | 200 | 54.1 |
| Plains | 170 | 45.9 |
The mean Q angle of the left lower limb in the plains was 12.6°, and in the hills, it was 11.49°. The mean Q angle of the right lower limb in the plains was 13.27°, and in the hills, it was 12.02°. The female population of the plains had a higher Q angle in both limbs than the hills. The result was statistically significant. Meanwhile, the mean height of the female population in the hills was greater than in the plains, with a p-value of <0.001 (Table 2).
| Parameters | Hills | Plains | t-value | p-value |
|---|---|---|---|---|
| Left Q angle | 11.49 | 12.62 | 5.97 | <0.001 |
| Right Q angle | 12.02 | 13.27 | 7.01 | <0.001 |
| Height in centimeters | 157.3 | 156.94 | 4.03 | <0.001 |
The effect of height on the left Q angle in females of the hills had an F-value of 6.96 with a p-value of <0.001, while in the plains, it had an F-value of 0.394 with a p-value of 0.675. Height in the hills was statistically significant, whereas in the plains, the result was statistically nonsignificant (Table 3).
| Angle (LT) | F-value | p-value | |
|---|---|---|---|
| Hills | |||
| Variable | Mean ± SD | 6.96 | 0.001 |
| Height | 0.001 | ||
| 140–150 | 13.10 ± 2.76 | ||
| 150–160 | 11.64 ± 1.68 | ||
| 160–170 | 12.63 ± 1.5 | ||
| Plain | |||
| Variable | |||
| Height | 0.394 | 0.675 | |
| 140–150 | 12.60 ± 2.01 | ||
| 150–160 | 12.07 ± 2.29 | ||
| 160–170 | 12.31 ± 1.83 |
The effect of height on the right Q angle in females of the hills had an F-value of 9.47 with a p-value of <0.001, while in the plains, it had an F-value of 0.394 with a p-value of 0.675. Height in the hills was statistically significant, whereas in the plains, the result was statistically nonsignificant (Table 4).
| Angle (RT) | F-value | p-value | |
|---|---|---|---|
| Hills | |||
| Variable | Mean ± SD | 9.47 | <0.001 |
| Height | |||
| 140–150 | 13.50 ± 2.83 | ||
| 150–160 | 12.14 ± 1.74 | ||
| 160–170 | 13.48 ± 1.85 | ||
| Plain | |||
| Variable | |||
| Height | 0.394 | 0.675 | |
| 140–150 | 12.90 ± 2.23 | ||
| 150–160 | 12.66 ± 2.25 | ||
| 160–170 | 13.10 ± 1.90 |
The Pearson correlation matrix for 200 females living in hilly areas showed that the right and left Q angles were highly correlated with each other, indicating that they likely measure related aspects. Height had weaker correlations with the angle measurements (Table 5).
| Column 2 | Hills | Height | Angle (RT) | Angle (LT) |
|---|---|---|---|---|
| Height | Pearson correlation | 1 | 0.274** | 0.282** |
| Sig. (2-tailed) | 0.000 | 0.000 | ||
| N | 200 | 200 | 200 | |
| Angle (RT) | Pearson correlation | 0.274** | 1 | 0.883** |
| Sig. (2-tailed) | 0.000 | 0.000 | ||
| N | 200 | 200 | 200 | |
| Angle (LT) | Pearson correlation | 0.282** | 0.883** | 1 |
| Sig. (2-tailed) | 0.000 | 0.000 | ||
| N | 200 | 200 | 200 |
**p value <0.05 generally suggest that correlation is significant
The Pearson correlation matrix for 170 females of the plains also showed that the left and right Q angles were highly correlated with each other. Height may not be a strong predictor of the Q angle in this population (Table 6).
| Column 1 | Plain | Height | Angle (RT) | Angle (LT) |
|---|---|---|---|---|
| Height | Pearson correlation | 1 | 0.027 | –0.018 |
| Sig. (2-tailed) | 0.728 | 0.813 | ||
| N | 170 | 170 | 170 | |
| Angle (RT) | Pearson correlation | 0.027 | 1 | 0.887** |
| Sig. (2-tailed) | 0.728 | 0.000 | ||
| N | 170 | 170 | 170 | |
| Angle (LT) | Pearson correlation | –0.018 | 0.887** | 1 |
| Sig. (2-tailed) | 0.813 | 0.000 | ||
| N | 170 | 170 | 170 |
**p value <0.05 generally suggest that correlation is significant
DISCUSSION
Hahn et al.17 stated a large Q angle on the right limb and some on the left limb. Two studies showed significant differences2,18 compared to Livingston and Spaulding, but why this is so is still not known.19 Differences in the right and left limbs are related to muscle tone in the dominant limb, which increases the lateral force on the patella, displacing it and reducing the angle.20 In our study, the results were similar to Choudhary et al. in relation to height, and the comparison of angles in both limbs was similar to Shantanu et al. The present study showed no similarity to Khasawneh et al., who stated a higher Q angle in taller people. Tella et al. stated a high Q angle on the left lower limb. This difference may be due to geographical changes in the population.
Choudhary et al. in 2019 concluded that the Q angle was higher on the left lower limb than on the right. The Q angle increases from the supine to the standing position. Height and the Q angle had no correlation.21
Livingston and Mandigo in 1997 concluded that females had a higher Q angle on the left side than the right and also found a difference of 4–8° between the right and left Q angles.19
Herrington and Nester conducted a study on 109 subjects (51 male and 58 female). The angle measured in the standing position showed a higher Q angle for the left limb than the right. The ratio of laterally displaced patellae was higher in females, showing a statistically significant increase in the angle, while the ratio of medially displaced patellae was higher in males. Increased quadriceps strength decreases the magnitude of the angle.22
Khasawneh et al. in 2019 studied the Q angle with respect to various parameters in the young Arab population and concluded an insignificant increase in the dominant side of the Q angle. Tall people had a larger Q angle.23
Shantanu et al. in 2023 conducted a study in the 18–35 years age-group from Uttar Pradesh and recorded a higher Q angle on the right side than the left side in females. The present study also showed right-side dominance. This helps in assessing the pull of the quadriceps muscle, which affects knee function. Any incorrect alignment of the Q angle will affect the normal functioning of the knee joint. It is important for physically active individuals and athletes, as it helps in predicting knee problems.24
Veeramani et al. in 2009 conducted a study on 100 subjects (50 males and 50 females) in the age-group of 18–43 years. They concluded that the Q angle in the lateral placement of the patellar tuberosity was significantly higher in females.25
Tella et al. in 2010 conducted a study on 800 subjects (400 females and 400 males) in the age-group of 18–30 years in the Nigerian population. They found that the left lower limb had a higher Q angle than the right limb and concluded bilateral asymmetry in an individual.26
In our study, the Q angle was measured in the supine position only. It can also be measured in the standing position to observe the difference in the value of the Q angle with a change in position. Along with height, other parameters like weight and body mass index may also be included, as they are interrelated with each other.
CONCLUSION
The Q angle does not have any correlation with height in the plains and a weaker correlation in the hills; therefore, height may not be a strong predictor. The Q angle in the population of the plains was higher than in the hills. The left and right Q angles are highly correlated with each other in both regions. A large Q angle can cause knee problems and may predispose females to sport-related injuries.
ORCID
Chanchal Sharma https://orcid.org/0009-0008-1321-8734
Rubina Victor https://orcid.org/0009-0003-4261-4027
Brijesh Thakur https://orcid.org/0000-0002-4600-5267
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