A full body musculoskeletal model based on flexible multibody simulation approach utilised in bone strain analysis during human locomotion

Load-induced strains applied to bone can stimulate its development and adaptation. In order to quantify the incident strains within the skeleton, in vivo implementation of strain gauges on the surfaces of bone is typically used. However, in vivo strain measurements require invasive methodology that is challenging and limited to certain regions of superficial bones only such as the anterior surface of the tibia. Based on our previous study [Al Nazer et al. (2008) J Biomech. 41:1036-1043], an alternative numerical approach to analyse in vivo strains based on the flexible multibody simulation approach was proposed. The purpose of this study was to extend the idea of using the flexible multibody approach in the analysis of bone strains during physical activity through integrating the magnetic resonance imaging (MRI) technique within the framework. In order to investigate the reliability and validity of the proposed approach, a three-dimensional full body musculoskeletal model with a flexible tibia was used as a demonstration example. The model was used in a forward dynamics simulation in order to predict the tibial strains during walking on a level exercise. The flexible tibial model was developed using the actual geometry of human tibia, which was obtained from three-dimensional reconstruction of MRI. Motion capture data obtained from walking at constant velocity were used to drive the model during the inverse dynamics simulation in order to teach the muscles to reproduce the motion in the forward dynamics simulation. Based on the agreement between the literature-based in vivo strain measurements and the simulated strain results, it can be concluded that the flexible multibody approach enables reasonable predictions of bone strain in response to dynamic loading. The information obtained from the present approach can be useful in clinical applications including devising exercises to prevent bone fragility or to accelerate fracture healing.     

A full body musculoskeletal model based on flexible multibody simulation approach utilised in bone strain analysis during human locomotion

Load-induced strains applied to bone can stimulate its development and adaptation. In order to quantify the incident strains within the skeleton, in vivo implementation of strain gauges on the surfaces of bone is typically used. However, in vivo strain measurements require invasive methodology that is challenging and limited to certain regions of superficial bones only such as the anterior surface of the tibia. Based on our previous study [Al Nazer et al. (2008) J Biomech. 41:1036–1043], an alternative numerical approach to analyse in vivo strains based on the flexible multibody simulation approach was proposed. The purpose of this study was to extend the idea of using the flexible multibody approach in the analysis of bone strains during physical activity through integrating the magnetic resonance imaging (MRI) technique within the framework. In order to investigate the reliability and validity of the proposed approach, a three-dimensional full body musculoskeletal model with a flexible tibia was used as a demonstration example. The model was used in a forward dynamics simulation in order to predict the tibial strains during walking on a level exercise. The flexible tibial model was developed using the actual geometry of human tibia, which was obtained from three-dimensional reconstruction of MRI. Motion capture data obtained from walking at constant velocity were used to drive the model during the inverse dynamics simulation in order to teach the muscles to reproduce the motion in the forward dynamics simulation. Based on the agreement between the literature-based in vivo strain measurements and the simulated strain results, it can be concluded that the flexible multibody approach enables reasonable predictions of bone strain in response to dynamic loading. The information obtained from the present approach can be useful in clinical applications including devising exercises to prevent bone fragility or to accelerate fracture healing.     

Patterns of strain in the macaque tibia during functional activity.

The strain environment of the tibial midshaft of two female macaques was evaluated through in vivo bone strain experiments using three rosette gauges around the circumference of the bones. Strains were collected for a total of 123 walking and galloping steps as well as several climbing cycles. Principal strains and the angle of the maximum (tensile) principal strain with the long axis of the bone were calculated for each gauge site. In addition, the normal strain distribution throughout the cross section was determined from the longitudinal normal strains (strains in the direction of the long axis of the bone) at each of the three gauge sites, and at the corresponding cross-sectional geometry of the bone. This strain distribution was compared with the cross-sectional properties (area moments) of the midshaft. For both animals, the predominant loading regime was found to be bending about an oblique axis running from anterolateral to posteromedial. The anterior and part of the medial cortex are in tension; the posterior and part of the lateral cortex are in compression. The axis of bending does not coincide with the maximum principal axis of the cross section, which runs mediolaterally. The bones are not especially buttressed in the plane of bending, but offer the greatest strength anteroposteriorly. The cross-sectional geometry therefore does not minimize strain or bone tissue. Peak tibial strains are slightly higher than the peak ulnar strains reported earlier for the same animals (Demes et al. [1998] Am J Phys Anthropol 106:87-100). Peak strains for both the tibia and the ulna are moderate in comparison to strains recorded during walking and galloping activities in nonprimate mammals.     

Validating a voxel-based finite element model of a human mandible using digital speckle pattern interferometry

Finite element analysis is a powerful tool for predicting the mechanical behaviour of complex biological structures like bones, but to be confident in the results of an analysis, the model should be validated against experimental data. In such validation experiments, the strains in the loaded bones are usually measured with strain gauges glued to the bone surface, but the use of strain gauges on bone can be difficult and provides only very limited data regarding surface strain distributions. This study applies the full-field strain measurement technique of digital speckle pattern interferometry to measure strains in a loaded human mandible and compares the results with the predictions of voxel-based finite element models of the same specimen. It is found that this novel strain measurement technique yields consistent, reliable measurements. Further, strains predicted by the finite element analysis correspond well with the experimental data. These results not only confirm the usefulness of this technique for future validation studies in the field of bone mechanics, but also show that the modelling approach used in this study is able to predict the experimental results very accurately.     

Computed-tomography-based finite-element models of long bones can accurately capture strain response to bending and torsion

Finite element (FE) models of long bones constructed from computed-tomography (CT) data are emerging as an invaluable tool in the field of bone biomechanics. However, the performance of such FE models is highly dependent on the accurate capture of geometry and appropriate assignment of material properties. In this study, a combined numerical-experimental study is performed comparing FE-predicted surface strains with strain-gauge measurements. Thirty-six major, cadaveric, long bones (humerus, radius, femur and tibia), which cover a wide range of bone sizes, were tested under three-point bending and torsion. The FE models were constructed from trans-axial volumetric CT scans, and the segmented bone images were corrected for partial-volume effects. The material properties (Young's modulus for cortex, density-modulus relationship for trabecular bone and Poisson's ratio) were calibrated by minimizing the error between experiments and simulations among all bones. The R(2) values of the measured strains versus load under three-point bending and torsion were 0.96-0.99 and 0.61-0.99, respectively, for all bones in our dataset. The errors of the calculated FE strains in comparison to those measured using strain gauges in the mechanical tests ranged from -6% to 7% under bending and from -37% to 19% under torsion. The observation of comparatively low errors and high correlations between the FE-predicted strains and the experimental strains, across the various types of bones and loading conditions (bending and torsion), validates our approach to bone segmentation and our choice of material properties.     

In situ comparison of A-mode ultrasound tracking system and skin-mounted markers for measuring kinematics of the lower extremity

Skin-mounted marker based motion capture systems are widely used in measuring the movement of human joints. Kinematic measurements associated with skin-mounted markers are subject to soft tissue artifacts (STA), since the markers follow skin movement, thus generating errors when used to represent motions of underlying bone segments. We present a novel ultrasound tracking system that is capable of directly measuring tibial and femoral bone surfaces during dynamic motions, and subsequently measuring six-degree-of-freedom (6-DOF) tibiofemoral kinematics. The aim of this study is to quantitatively compare the accuracy of tibiofemoral kinematics estimated by the ultrasound tracking system and by a conventional skin-mounted marker based motion capture system in a cadaveric experimental scenario. Two typical tibiofemoral joint models (spherical and hinge models) were used to derive relevant kinematic outcomes. Intra-cortical bone pins equipped with optical markers were inserted in the tibial and femoral bones to serve as a reference to provide ground truth kinematics. The ultrasound tracking system resulted in lower kinematic errors than the skin-mounted markers (the ultrasound tracking system: maximum root-mean-square (RMS) error 3.44° for rotations and 4.88 mm for translations, skin-mounted markers with the spherical joint model: 6.32° and 6.26 mm, the hinge model: 6.38° and 6.52 mm). Our proposed ultrasound tracking system has the potential of measuring direct bone kinematics, thereby mitigating the influence and propagation of STA. Consequently, this technique could be considered as an alternative method for measuring 6-DOF tibiofemoral kinematics, which may be adopted in gait analysis and clinical practice.     

Dynamic simulation of tibial tuberosity realignment: model evaluation

This study was performed to evaluate a dynamic multibody model developed to characterize the influence of tibial tuberosity realignment procedures on patellofemoral motion and loading. Computational models were created to represent four knees previously tested at 40°, 60°, and 80° of flexion with the tibial tuberosity in a lateral, medial and anteromedial positions. The experimentally loaded muscles, major ligaments of the knee, and patellar tendon were represented. A repeated measures ANOVA with post-hoc testing was performed at each flexion angle to compare data between the three positions of the tibial tuberosity. Significant experimental trends for decreased patella flexion due to tuberosity anteriorization and a decrease in the lateral contact force due to tuberosity medialization were reproduced computationally. The dynamic multibody modeling technique will allow simulation of function for symptomatic knees to identify optimal surgical treatment methods based on parameters related to knee pathology and pre-operative kinematics.     

Effect of varus/valgus malalignment on bone strains in the proximal tibia after TKR: an explicit finite element study

Malalignment is the main cause of tibial component loosening. Implants that migrate rapidly in the first two post-operative years are likely to present aseptic loosening. It has been suggested that cancellous bone stresses can be correlated with tibial component migration. A recent study has shown that patient-specific finite element (FE) models have the power to predict the short-term behavior of tibial trays. The stresses generated within the implanted tibia are dependent on the kinematics of the joint; however, previous studies have ignored the kinematics and only applied static loads. Using explicit FE, it is possible to simultaneously predict the kinematics and stresses during a gait cycle. The aim of this study was to examine the cancellous bone strains during the stance phase of the gait cycle, for varying degrees of varus/valgus eccentric loading using explicit FE. A patient-specific model of a proximal tibia was created from CT scan images, including heterogeneous bone properties. The proximal tibia was implanted with a commercial total knee replacement (TKR) model. The stance phase of gait was simulated and the applied loads and boundary conditions were based on those used for the Stanmore knee simulator. Eccentric loading was simulated. As well as examining the tibial bone strains (minimum and maximum principal strain), the kinematics of the bone-implant construct are also reported. The maximum anterior-posterior displacements and internal-external rotations were produced by the model with 20 mm offset. The peak minimum and maximum principal strain values increased as the load was shifted laterally, reaching a maximum magnitude for -20 mm offset. This suggests that when in varus, the load transferred to the bone is shifted medially, and as the bone supporting this load is stiffer, the resulting peak bone strains are lower than when the load is shifted laterally (valgus). For this particular patient, the TKR design analyzed produced the highest cancellous bone strains when in valgus. This study has provided an insight in the variations produced in bone strain distribution when the axial load is applied eccentrically. To the authors' knowledge, this is the first time that the bone strain distribution of a proximal implanted tibia has been examined, also accounting for the kinematics of the tibio-femoral joint as part of the simulation. This approach gives greater insight into the overall performance of TKR.     

Finite element and experimental cortex strains of the intact and implanted tibia

Finite Element (FE) models for the simulation of intact and implanted bone find their main purpose in accurately reproducing the associated mechanical behavior. FE models can be used for preclinical testing of joint replacement implants, where some biomechanical aspects are difficult, if not possible, to simulate and investigate in vitro. To predict mechanical failure or damage, the models should accurately predict stresses and strains. Commercially available synthetic femur models have been extensively used to validate finite element models, but despite the vast literature available on the characteristics of synthetic tibia, numerical and experimental validation of the intact and implant assemblies of tibia are very limited or lacking. In the current study, four FE models of synthetic tibia, intact and reconstructed, were compared against experimental bone strain data, and an overall agreement within 10% between experimental and FE strains was obtained. Finite element and experimental (strain gauge) models of intact and implanted synthetic tibia were validated based on the comparison of cortex bone strains. The study also includes the analysis carried out on standard tibial components with cemented and noncemented stems of the P.F.C Sigma Modular Knee System. The overall agreement within 10% previously established was achieved, indicating that FE models could be successfully validated. The obtained results include a statistical analysis where the root-mean-square-error values were always <10%. FE models can successfully reproduce bone strains under most relevant acting loads upon the condylar surface of the tibia. Moreover, FE models, once properly validated, can be used for preclinical testing of tibial knee replacement, including misalignment of the implants in the proximal tibia after surgery, simulation of long-term failure according to the damage accumulation failure scenario, and other related biomechanical aspects.     

Computational modeling to predict mechanical function of joints: application to the lower leg with simulation of two cadaver studies

Computational models of musculoskeletal joints and limbs can provide useful information about joint mechanics. Validated models can be used as predictive devices for understanding joint function and serve as clinical tools for predicting the outcome of surgical procedures. A new computational modeling approach was developed for simulating joint kinematics that are dictated by bone/joint anatomy, ligamentous constraints, and applied loading. Three-dimensional computational models of the lower leg were created to illustrate the application of this new approach. Model development began with generating three-dimensional surfaces of each bone from CT images and then importing into the three-dimensional solid modeling software SOLIDWORKS and motion simulation package COSMOSMOTION. Through SOLIDWORKS and COSMOSMOTION, each bone surface file was filled to create a solid object and positioned necessary components added, and simulations executed. Three-dimensional contacts were added to inhibit intersection of the bones during motion. Ligaments were represented as linear springs. Model predictions were then validated by comparison to two different cadaver studies, syndesmotic injury and repair and ankle inversion following ligament transection. The syndesmotic injury model was able to predict tibial rotation, fibular rotation, and anterior/posterior displacement. In the inversion simulation, calcaneofibular ligament extension and angles of inversion compared well. Some experimental data proved harder to simulate accurately, due to certain software limitations and lack of complete experimental data. Other parameters that could not be easily obtained experimentally can be predicted and analyzed by the computational simulations. In the syndesmotic injury study, the force generated in the tibionavicular and calcaneofibular ligaments reduced with the insertion of the staple, indicating how this repair technique changes joint function. After transection of the calcaneofibular ligament in the inversion stability study, a major increase in force was seen in several of the ligaments on the lateral aspect of the foot and ankle, indicating the recruitment of other structures to permit function after injury. Overall, the computational models were able to predict joint kinematics of the lower leg with particular focus on the ankle complex. This same approach can be taken to create models of other limb segments such as the elbow and wrist. Additional parameters can be calculated in the models that are not easily obtained experimentally such as ligament forces, force transmission across joints, and three-dimensional movement of all bones. Muscle activation can be incorporated in the model through the action of applied forces within the software for future studies.     

Implementation of controlling strategy in a biomechanical lower limb model with active muscles for coupling multibody dynamics and finite element analysis

Computational biomechanics for human body modeling has generally been categorized into two separated domains: finite element analysis and multibody dynamics. Combining the advantages of both domains is necessary when tissue stress and physical body motion are both of interest. However, the method for this topic is still in exploration. The aim of this study is to implement unique controlling strategies in finite element model for simultaneously simulating musculoskeletal body dynamics and in vivo stress inside human tissues. A finite element lower limb model with 3D active muscles was selected for the implementation of controlling strategies, which was further validated against in-vivo human motion experiments. A unique feedback control strategy that couples together a basic Proportion-Integration-Differentiation (PID) controller and generic active signals from Computed Muscle Control (CMC) method of the musculoskeletal model or normalized EMG singles was proposed and applied in the present model. The results show that the new proposed controlling strategy show a good correlation with experimental test data of the normal gait considering joint kinematics, while stress distribution of local lower limb tissue can be also detected in real-time with lower limb motion. In summary, the present work is the first step for the application of active controlling strategy in the finite element model for concurrent simulation of both body dynamics and tissue stress. In the future, the present method can be further developed to apply it in various fields for human biomechanical analysis to monitor local stress and strain distribution by simultaneously simulating human locomotion.     

Quantifying the strain history of bone: spatial uniformity and self-similarity of low-magnitude strains

We hypothesize that when a broad spectrum of bone strain is considered, strain history is similar for different bones in different species. Using a data collection protocol with a fine resolution, mid-diaphyseal strains were measured in vivo for both weightbearing and non-weightbearing bones in three species: dog, sheep, and turkey, with strain information collected continuously while the animals performed their natural daily activities. The daily strain history was quantified by both counting cyclic strain events (to quantify the distribution of strains of different magnitudes) and by estimating the average spectral characteristics of the strain (to quantify the frequency content of the strain signals). Counting of the daily (12-24 h) strain events show that large strains (> 1000 microstrain) occur relatively few times a day, while very small strains (< 10 microstrain) occur thousands of times a day. The lower magnitude strains (< approximately 200 microstrain) are found to be more uniform around the bone cross-section than the higher magnitude, peak strains. Strain dynamics are found to be well described by a power-law relationship and exhibit self-similar characteristics. These data lead to the suggestion that the organization of bone tissue is driven by the continual barrage of activity spanning a wide but consistent range of frequency and amplitude, and until the mechanism of bone's mechanosensory system is fully understood, all portions of bone's strain history should be considered to possibly play a role in bone adaptation.     

A comparison of bone strain measurements at anatomically relevant sites using surface gauges versus strain gauged bone staples

Instrumented bone staples were first introduced as an alternative to surface-mounted strain gauges for use in human in vivo bone strain measurements because their fixation to bone is secure and requires not only minimally invasive surgery. Bench-top bone bending models have shown that the output from strain gauged bone staples compares favorably to that of traditional mounted gauges. However their within- and across-subject performance at sites typically instrumented in vivo has never been examined. This study used seven human cadaver lower extremities with an age range of 23-81 years old and a dynamic gait simulator to examine and compare axial strains in the mid tibial diaphysis and on the dorsal surface of the second metatarsal as measured simultaneously with strain gauged bone staples and with traditional surface-mounted gauges. Rosette configurations were used at the tibial site for deriving principal compression and tension, and shear strains. Axial outputs from the two gauge types demonstrated strong linear relationships for the tibia (r(2)=0.78-0.94) and the second metatarsal (r(2)=0.96-0.99), but coefficients (slopes) for the relationship were variable (range 7-20), across subjects and across sites. The apparent low reliability of strain gauged staples may be explained by the fact that both strain gauged staples and surface strain gauges are inexact to some degree, do not measure strains from exactly the same areas and strain gauged staples reflect surface strains as well as deformations within the cortex. There were no relationships for the principal tibia compression, tension or shear strain measurements derived from the two rosette gauge types, reflecting the very different anatomical areas measured by each of the constructs in this study. Strain gauged bone staples may be most useful in comparing relative axial intra-subject differences between activities, but inter-subject variability may require larger sample sizes to detect differences between populations.     

Using digital image correlation to determine bone surface strains during loading and after adaptation of the mouse tibia

Previous models of cortical bone adaptation, in which loading is imposed on the bone, have estimated the strains in the tissue using strain gauges, analytical beam theory, or finite element analysis. We used digital image correlation (DIC), tracing a speckle pattern on the surface of the bone during loading, to determine surface strains in a murine tibia during compressive loading through the knee joint. We examined whether these surface strains in the mouse tibia are modified following two weeks of load-induced adaptation by comparison with contralateral controls. Results indicated non-uniform strain patterns with isolated areas of high strain (0.5%), particularly on the medial side. Strain measurements were reproducible (standard deviation of the error 0.03%), similar between specimens, and in agreement with strain gauge measurements (between 0.1 and 0.2% strain). After structural adaptation, strains were more uniform across the tibial surface, particularly on the medial side where peak strains were reduced from 0.5% to 0.3%. Because DIC determines local strains over the entire surface, it will provide a better understanding of how strain stimulus influences the bone response during adaptation.     

Comparison of the linear finite element prediction of deformation and strain of human cancellous bone to 3D digital volume correlation measurements

The mechanical properties of cancellous bone and the biological response of the tissue to mechanical loading are related to deformation and strain in the trabeculae during function. Due to the small size of trabeculae, their motion is difficult to measure. To avoid the need to measure trabecular motions during loading the finite element method has been used to estimate trabecular level mechanical deformation. This analytical approach has been empirically successful in that the analytical models are solvable and their results correlate with the macroscopically measured stiffness and strength of bones. The present work is a direct comparison of finite element predictions to measurements of the deformation and strain at near trabecular level. Using the method of digital volume correlation, we measured the deformation and calculated the strain at a resolution approaching the trabecular level for cancellous bone specimens loaded in uniaxial compression. Smoothed results from linearly elastic finite element models of the same mechanical tests were correlated to the empirical three-dimensional (3D) deformation in the direction of loading with a coefficient of determination as high as 97% and a slope of the prediction near one. However, real deformations in the directions perpendicular to the loading direction were not as well predicted by the analytical models. Our results show, that the finite element modeling of the internal deformation and strain in cancellous bone can be accurate in one direction but that this does not ensure accuracy for all deformations and strains.     

Does the graft-tunnel friction influence knee joint kinematics and biomechanics after anterior cruciate ligament reconstruction? A finite element study

Graft tissues within bone tunnels remain mobile for a long time after anterior cruciate ligament (ACL) reconstruction. However, whether the graft-tunnel friction affects the finite element (FE) simulation of the ACL reconstruction is still unclear. Four friction coefficients (from 0 to 0.3) were simulated in the ACL-reconstructed joint model as well as two loading levels of anterior tibial drawer. The graft-tunnel friction did not affect joint kinematics and the maximal principal strain of the graft. By contrast, both the relative graft-tunnel motion and equivalent strain for the bone tunnels were altered, which corresponded to different processes of graft-tunnel integration and bone remodeling, respectively. It implies that the graft-tunnel friction should be defined properly for studying the graft-tunnel integration or bone remodeling after ACL reconstruction using numerical simulation.     

In vitro modeling of human tibial strains during exercise in micro-gravity

Prolonged exposure to micro-gravity causes substantial bone loss (Leblanc et al., Journal of Bone Mineral Research 11 (1996) S323) and treadmill exercise under gravity replacement loads (GRLs) has been advocated as a countermeasure. To date, the magnitudes of GRLs employed for locomotion in space have been substantially less than the loads imposed in the earthbound 1G environment, which may account for the poor performance of locomotion as an intervention. The success of future treadmill interventions will likely require GRLs of greater magnitude. It is widely held that mechanical tissue strain is an important intermediary signal in the transduction pathway linking the external loading environment to bone maintenance and functional adaptation; yet, to our knowledge, no data exist linking alterations in external skeletal loading to alterations in bone strain. In this preliminary study, we used unique cadaver simulations of micro-gravity locomotion to determine relationships between localized tibial bone strains and external loading as a means to better predict the efficacy of future exercise interventions proposed for bone maintenance on orbit. Bone strain magnitudes in the distal tibia were found to be linearly related to ground reaction force magnitude (R(2)>0.7). Strain distributions indicated that the primary mode of tibial loading was in bending, with little variation in the neutral axis over the stance phase of gait. The greatest strains, as well as the greatest strain sensitivity to altered external loading, occurred within the anterior crest and posterior aspect of the tibia, the sites furthest removed from the neutral axis of bending. We established a technique for estimating local strain magnitudes from external loads, and equations for predicting strain during simulated micro-gravity walking are presented.     

Comparison of strain measurement in the mouse forearm using subject-specific finite element models,strain gaging,and digital image correlation

Mechanical loading in bone leads to the activation of bone-forming pathways that are most likely associated with a minimum strain threshold being experienced by the osteocyte. To investigate the correlation between cellular response and mechanical stimuli, researchers must develop accurate ways to measure/compute strain both externally on the bone surface and internally at the osteocyte level. This study investigates the use of finite element (FE) models to compute bone surface strains on the mouse forearm. Strains from three FE models were compared to data collected experimentally through strain gaging and digital image correlation (DIC). Each FE model was assigned subject-specific bone properties and consisted of one-dimensional springs representing the interosseous membrane. After three-point bending was performed on the ulnae and radii, moment of inertia was determined from microCT analysis of the bone region between the supports and then used along with standard beam analyses to calculate the Young’s modulus. Non-contact strain measurements from DIC were determined to be more suitable for validating numerical results than experimental data obtained through conventional strain gaging. When comparing strain responses in the three ulnae, we observed a 3–14% difference between numerical and DIC strains while the strain gage values were 37–56% lower than numerical values. This study demonstrates a computational approach for capturing bone surface strains in the mouse forearm. Ultimately, strains from these macroscale models can be used as inputs for microscale and nanoscale FE models designed to analyze strains directly in the osteocyte lacunae.     

Direct in vivo strain measurements in human bone-a systematic literature review

Bone strain is the governing stimuli for the remodeling process necessary in the maintenance of bone's structure and mechanical strength. Strain gages are the gold standard and workhorses of human bone experimental strain analysis in vivo. The objective of this systematic literature review is to provide an overview for direct in vivo human bone strain measurement studies and place the strain results within context of current theories of bone remodeling (i.e. mechanostat theory). We employed a standardized search strategy without imposing any time restriction to find English language studies indexed in PubMed and Web of Science databases that measured human bone strain in vivo. Twenty-four studies met our final inclusion criteria. Seven human bones were subjected to strain measurements in vivo including medial tibia, second metatarsal, calcaneus, proximal femur, distal radius, lamina of vertebra and dental alveolar. Peak strain magnitude recorded was 9096 με on the medial tibia during basketball rebounding and the peak strain rate magnitude was -85,500 με/s recorded at the distal radius during forward fall from standing, landing on extended hands. The tibia was the most exposed site for in vivo strain measurements due to accessibility and being a common pathologic site of stress fracture in the lower extremity. This systematic review revealed that most of the strains measured in vivo in different bones were generally within the physiological loading zone defined by the mechanostat theory, which implies stimulation of functional adaptation necessary to maintain bone mechanical integrity.     

What do we currently know from in vivo bone strain measurements in humans?

Bone strains are the most important factors for osteogenic adaptive responses. During the past decades, scientists have been trying to describe the relationship between bone strain and bone osteogenic responses quantitatively. However, only a few studies have examined bone strains under physiological condition in humans, owing to technical difficulty and ethical restrictions. The present paper reviews previous work on in vivo bone strain measurements in humans, and the various methodologies adopted in these measurements are discussed. Several proposals are made for future work to improve our understanding of the human musculoskeletal system. Literature suggests that strains and strain patterns vary systematically in response to different locomotive activities, foot wear, and even different venues. The principal compressive, tension and engineering shear strain, compressive strain rate and shear strain rate in the tibia during running seem to be higher than those during walking. The high impact exercises, such as zig-zag hopping and basketball rebounding induced greater principal strains and strain rates in the tibia than normal activities. Also, evidence suggests an increase of tibia strain and strain rate after muscle fatigue, which strongly supports the opinion that muscle contractions play a role on the alteration of bone strain patterns.