Patterns in the knee flexion-extension moment profile during stair ascent and descent in patients with total knee arthroplasty

The aim of this study was to investigate the prevalence of abnormal knee biomechanical patterns in 40 patients with a modern TKA prosthesis, compared to 40 matched control participants when ascending and descending stairs. Fewer patients were able to ascend (65%) or descend stairs (53%) unassisted than controls (83%). Of the participants who could ascend and descend, cluster analysis classified most patients (up to 77%) as demonstrating a similar knee moment pattern as all controls. A small subgroup of patients who completed the tasks did so with distinctly abnormal biomechanics compared to other patients and controls. These findings suggest that recovery of normal stair climbing is possible. However, rehabilitation might be more effective if it were tailored to account for these differences between patients.     

Increased hip internal abduction moment and reduced speed are the gait strategies used by women with knee osteoarthritis

The purpose of this study was to identify the gait strategies in women with mild and moderate knee osteoarthritis (OA). Forty women diagnosed with OA of the knee and 40 healthy women participated in the study. Toe-out progression angle, trunk lateral lean, hip internal abduction moment and gait speed were measured using Qualisys ProReflex System and two force plates. Principal component analysis was applied to extract features from the gait waveforms data that characterized the waveforms main modes of temporal variation. Discriminant analysis with a stepwise model was conducted to determine which strategies could best discriminate groups. According to the discriminant model, the PC2 of the internal abduction moment of the hip and the gait speed were the most discriminatory variables between the groups. The OA group showed decreased gait speed, decreased hip internal abduction moment during the loading response phase, and increased hip internal abduction moment during the mid and terminal stance phases. Interventions that may increase hip internal abduction moment, such as the strengthening of the hip abductors muscles, may benefit women with knee OA. Training slower than normal gait speeds must be considered in light of potential adverse implications on overall physical function, daily tasks, and safety.     

The influence of step-down technique on lower extremity mechanics during curb descent

When stepping down from a curb, individuals typically make initial ground contact with either their rearfoot or forefoot. The purpose of this study was to compare vertical ground reaction forces, lower extremity mechanics, and intra-limb work distribution when individuals adopt a rearfoot technique vs. a forefoot technique, during simulated curb descent. Sixteen subjects stepped down from a platform with both a rearfoot and a forefoot technique. Vertical ground reaction forces and sagittal plane joint kinematics and kinetics were examined for the lead limb during the step-down task. Paired t-tests were used for comparison. Subjects demonstrated greater ankle joint power and negative work, and less hip joint power and negative work, with the forefoot technique vs. the rearfoot technique. Total lower extremity negative work was greater for the forefoot technique vs. the rearfoot technique. The percent contribution to the total negative work was greater for the ankle joint, and less for the hip and knee joints, with the forefoot technique vs. the rearfoot technique. The results of this study may provide insight into how curb descent technique can be modified to alter lower extremity loading.     

The influence of knee alignment on lower extremity kinetics during squats

The squat is an assessment of lower extremity alignment during movement, however there is little information regarding altered joint kinetics during poorly performed squats. The purpose of this study was to examine changes in joint kinetics and power from altered knee alignment during a squat. Thirty participants completed squats while displacing the knee medially, anteriorly, and with neutral alignment (control). Sagittal and frontal plane torques at the ankle, knee, and hip were altered in the descending and ascending phase of the squat in both the medial and anterior malaligned squat compared to the control squat. Ankle and trunk power increased and hip power decreased in the medial malaligned squat compared to the control squat. Ankle, knee, and trunk power increased and hip power decreased in the anterior malaligned squat compared to the control squat. Changes in joint torques and power during malaligned squats suggest that altered knee alignment increases ankle and trunk involvement to execute the movement. Increased anterior knee excursion during squatting may also lead to persistent altered loading of the ankle and knee. Sports medicine professionals using the squat for quadriceps strengthening must consider knee alignment to reduce ankle and trunk involvement during the movement.     

Energy optimization is a major objective in the real-time control of step width in human walking

People prefer to move in energetically optimal ways during walking. We recently found that this preference arises not just through evolution and development, but that the nervous system will continuously optimize step frequency in response to new energetic cost landscapes. Here we tested whether energy optimization is also a major objective in the nervous system’s real-time control of step width using a device that can reshape the relationship between step width and energetic cost, shifting people’s energy optimal step width. We accomplished this by changing the walking incline to apply an energetic penalty as a function of step width. We found that people didn’t spontaneously initiate energy optimization, but instead required experience with a lower energetic cost step width. After initiating optimization, people adapted, on average, 3.5 standard deviations of their natural step width variability towards the new energy optimal width. Within hundreds of steps, they updated this as their new preferred width and rapidly returned to it when perturbed away. This new preferred width reduced energetic cost by roughly 14%, however, it was slightly narrower than the energetically optimal width, possibly due to non-energy objectives that may contribute to the nervous system’s control of step width. Collectively, these findings suggest that the nervous systems of able-bodied people can continuously optimize energetic cost to determine preferred step width.     

The effects of antagonist moment on the resultant knee joint moment during isokinetic testing of the knee extensors

The purpose of this study was to examine the effects of moment of antagonistic muscle on the resultant joint moment during isokinetic eccentric and concentric efforts of the knee extensors. Ten males performed maximum eccentric and concentric knee extension and flexion efforts on a Biodex dynamometer at 0.52 rad · s⁻¹ (30° · s⁻¹). Electromyographic (EMG) activity of vastus medialis and biceps femoris (hamstrings) was also recorded. The antagonistic moment of the hamstrings was determined by recording the integrated EMG (iEMG)/moment relationship at different levels of muscle effort. The iEMG/moment curves were fitted using second-degree polynomials. The polynomials were then used to predict the antagonistic moment exerted by the hamstrings from the antagonist iEMG. The antagonistic moment had a maximum of 42.92 Nm and 28.97 Nm under concentric and eccentric conditions respectively; paired t-tests indicated that this was a significant difference (P < 0.05). These results indicate that the resultant joint moment of knee extensors is the result of both agonist and antagonist muscle activation. The greater antagonist muscle activity under concentric activation conditions may be partly responsible for the lower resultant joint concentric moment of knee extensors compared with the corresponding eccentric activation. The antagonist moment significantly affects comparisons between the isokinetic moments and agonist EMG and in vitro force measurements under different testing (muscle action and angular velocity) conditions. Accepted: 25 February 1997     

Mechanism of reducing knee adduction moment by shortening of the knee lever arm via medio-lateral manipulation of foot center of pressure: A pilot study

Prominent conservative treatment options for medial-compartment knee osteoarthritis include footwear that reduces knee adduction moment (KAM) correlated with detrimental loads in the medial compartment of the knee, thus providing clinical benefit. The proposed mechanism by which they reduce KAM is a lateral shift in foot center of pressure (COP) and a consequent shortening of the knee lever arm (KLA), thereby reducing KAM, which can be simply calculated as KLA multiplied by the frontal plane ground reaction force (FP-GRF). The present study investigated this mechanism for a unique biomechanical device capable of shifting COP by means of moveable convex elements attached to the shoe. Fourteen healthy young male subjects underwent gait analysis in two COP configurations of the device for comparison: (1) laterally and (2) medially deviated. Average midstance KLA and KAM were decreased by 8.2% and 8.7%, respectively, in the lateral COP compared to medial. Ground reaction force parameters, frontal plane knee angle (FP-KA), and spine lateral flexion angle (SLF) did not differ between COP configurations. No study parameters differed for terminal stance. Linear mixed effects models showed that COP and FP-GRF components, but not FP-KA and SLF, were significant predictors of KLA. In addition, KLA and FP-GRF were significant predictors of KAM; although, FP-GRF did not change significantly with medio-lateral COP shift, while KLA did. This suggests that the mechanism by which the study device reduces KAM is primarily through shortening of KLA brought on by a lateral shift in COP.     

Partitioning of knee joint internal forces in gait is dictated by the knee adduction angle and not by the knee adduction moment

Medial knee osteoarthritis is a debilitating disease. Surgical and conservative interventions are performed to manage its progression via reduction of load on the medial compartment or equivalently its surrogate measure, the external adduction moment. However, some studies have questioned a correlation between the medial load and adduction moment. Using a musculoskeletal model of the lower extremity driven by kinematics–kinetics of asymptomatic subjects at gait midstance, we aim here to quantify the relative effects of changes in the knee adduction angle versus changes in the adduction moment on the joint response and medial/lateral load partitioning. The reference adduction rotation of 1.6° is altered by ±1.5° to 3.1° and 0.1° or the knee reference adduction moment of 17 N m is varied by ±50% to 25.5 N m and 8.5 N m. Quadriceps, hamstrings and tibiofemoral contact forces substantially increased as adduction angle dropped and diminished as it increased. The medial/lateral ratio of contact forces slightly altered by changes in the adduction moment but a larger adduction rotation hugely increased this ratio from 8.8 to a 90 while in contrast a smaller adduction rotation yielded a more uniform distribution. If the aim in an intervention is to diminish the medial contact force and medial/lateral load ratio, a drop of 1.5° in adduction angle is much more effective (causing respectively 12% and 80% decreases) than a reduction of 50% in the adduction moment (causing respectively 4% and 13% decreases). Substantial role of changes in adduction angle is due to the associated alterations in joint nonlinear passive resistance. These findings explain the poor correlation between knee adduction moment and tibiofemoral compartment loading during gait suggesting that the internal load partitioning is dictated by the joint adduction angle.     

Bilateral knee osteoarthritis does not affect inter-joint coordination in older adults with gait deviations during obstacle-crossing

Fifteen elderly subjects with bilateral medial knee osteoarthritis (OA) and 15 healthy elderly subjects walked and crossed obstacles with heights of 10%, 20%, and 30% of their leg lengths while sagittal angles and angular velocities of each joint were measured and their phase angles () calculated. Continuous relative phase (CRP) were also obtained, i.e., _hip−knee and _knee−ankle. The standard deviations of the CRP curve points were averaged to obtain deviation phase (DP) values for the stance and swing phases. Significant differences between the OA and control groups were found in several of the peak and crossing angles, and angular velocities at the knee and ankle. Both groups had similar CRP patterns, and the DP values of the hip–knee and knee–ankle CRP curves were not significantly different between the two groups. Despite significant changes in the joint kinematics, knee OA did not significantly change the way the motions of the lower limb joints are coordinated during obstacle-crossing. It appears that the OA groups adopted a particular biomechanical strategy among all possible strategies that can accommodate the OA-induced changes of the knee mechanics using unaltered inter-joint coordination control. This enabled the OA subjects to accommodate reliably the mechanical demands related to bilateral knee OA in the sagittal plane during obstacle-crossing. Maintaining normal and reliable inter-joint coordination may be considered a goal of therapeutic intervention, and the patterns and variability of inter-joint coordination can be used for the evaluation of treatment effects.     

Real-time biofeedback can increase and decrease vertical ground reaction force,knee flexion excursion,and knee extension moment during walking in individuals with anterior cruciate ligament reconstruction

Individuals with anterior cruciate ligament reconstruction (ACLR) often exhibit a “stiffened knee strategy” or an excessively extended knee during gait, characterized by lesser knee flexion excursion and peak internal knee extension moment (KEM). The purpose of this study was to determine the effect of real-time biofeedback (RTBF) cuing an acute change in peak vertical ground reaction force (vGRF) during the first 50% of the stance phase of walking gait on: (1) root mean square error (RMSE) between actual vGRF and RTBF target vGRF; (2) perceived difficulty; and (3) knee biomechanics. Acquisition and short-term recall of these outcomes were evaluated. Thirty individuals with unilateral ACLR completed 4 separate walking sessions on a force-measuring treadmill that consisted of a control (no RTBF) and 3 experimental loading conditions using RTBF including: (1) 5% vGRF increase (high-loading), (2) 5% vGRF decrease (low-loading) and (3) symmetric vGRF between limbs. Bilateral biomechanical outcomes were analyzed during the first 50% of the stance phase, and included KEM, knee flexion excursion, peak vGRF, and instantaneous vGRF loading rate (vGRF-LR) for each loading condition. Peak vGRF significantly increased and decreased during high-loading and low-loading, respectively compared to control loading. Instantaneous vGRF-LR, peak KEM and knee flexion excursion significantly increased during the high-loading condition compared to low-loading. Perceived difficultly and RMSE were lower during the symmetrical loading condition compared to the low-loading condition. Cuing an increase in peak vGRF may be beneficial for increasing KEM, knee flexion excursion, peak vGRF, and vGRF-LR in individuals with ACLR. Clinical Trials Number: NCT03035994.     

Dynamic contact mechanics on the tibial plateau of the human knee during activities of daily living

Despite significant advances in scaffold design, manufacture, and development, it remains unclear what forces these scaffolds must withstand when implanted into the heavily loaded environment of the knee joint. The objective of this study was to fully quantify the dynamic contact mechanics across the tibial plateau of the human knee joint during gait and stair climbing. Our model consisted of a modified Stanmore knee simulator (to apply multi-directional dynamic forces), a two-camera motion capture system (to record joint kinematics), an electronic sensor (to record contact stresses on the tibial plateau), and a suite of post-processing algorithms. During gait, peak contact stresses on the medial plateau occurred in areas of cartilage–cartilage contact; while during stair climb, peak contact stresses were located in the posterior aspect of the plateau, under the meniscus. On the lateral plateau, during gait and in early stair-climb, peak contact stresses occurred under the meniscus, while in late stair-climb, peak contact stresses were experienced in the zone of cartilage–cartilage contact. At 45% of the gait cycle, and 20% and 48% of the stair-climb cycle, peak stresses were simultaneously experienced on both the medial and lateral compartment, suggesting that these phases of loading warrant particular consideration in any simulation intended to evaluate scaffold performance. Our study suggests that in order to design a scaffold capable of restoring ‘normal’ contact mechanics to the injured knees, the mechanics of the intended site of implantation should be taken into account in any pre-clinical testing regime.     

Effect of prosthetic alignment changes on socket reaction moment impulse during walking in transtibial amputees

The alignment of a lower limb prosthesis affects the way load is transferred to the residual limb through the socket, and this load is critically important for the comfort and function of the prosthesis. Both magnitude and duration of the moment are important factors that may affect the residual limb health. Moment impulse is a well-accepted measurement that incorporates both factors via moment–time integrals. The aim of this study was to investigate the effect of alignment changes on the socket reaction moment impulse in transtibial prostheses. Ten amputees with transtibial prostheses participated in this study. The socket reaction moment impulse was measured at a self-selected walking speed using a Smart Pyramid™ in 25 alignment conditions, including a nominal alignment (clinically aligned by a prosthetist), as well as angle malalignments of 2°, 4° and 6° (abduction, adduction, extension and flexion) and translation malalignments of 5 mm, 10 mm and 15 mm (lateral, medial, anterior and posterior). The socket reaction moment impulse of the nominal alignment was compared for each condition. The relationship between the alignment and the socket reaction moment impulse was clearly observed in the coronal angle, coronal translation and sagittal translation alignment changes. However, this relationship was not evident in the sagittal angle alignment changes. The results of this study suggested that the socket reaction moment impulse could potentially serve as a valuable parameter to assist the alignment tuning process for transtibial prostheses. Further study is needed to investigate the influence of the socket reaction moment impulse on the residual limb health.     

Effects of bilateral medial knee osteoarthritis on intra- and inter-limb contributions to body support during gait

Patients with knee OA show altered gait patterns, affecting their quality of living. The current study aimed to quantify the effects of bilateral knee OA on the intra-limb and inter-limb sharing of the support of the body during gait. Fifteen patients with mild, 15 with severe bilateral knee OA, and 15 healthy controls walked along a walkway while the kinematic and kinetic data were measured. Compared with the controls, the patients significantly reduced their knee extensor moments and the corresponding contributions to the total support moment in the sagittal plane (p<0.05). For compensation, the mild OA group significantly increased the hip extensor moments (p<0.05) to maintain close-to-normal support and a more symmetrical inter-limb load-sharing during double-limb support. The severe OA group involved compensatory actions of both the ankle and hip, but did not succeed in maintaining a normal sagittal total support moment during late stance, nor a symmetrical inter-limb load-sharing during double-limb support. In the frontal plane, the knee abductor moments and the corresponding contributions to the total support moment were not affected by the changes in the other joints, regardless of the severity of the disease. The observed compensatory changes suggest that strengthening of weak hip muscles is essential for body support during gait in patients with knee OA, but that training of weak ankle muscles may also be needed for patients with severe knee OA.     

Fatigue injury risk in anterior cruciate ligament of target side knee during golf swing

A golf-related ACL injury can be linked with excessive golf play or practice because such over-use by repetitive golf swing motions can increase damage accumulation to the ACL bundles. In this study, joint angular rotations, forces, and moments, as well as the forces and strains on the ACL of the target-side knee joint, were investigated for ten professional golfers using the multi-body lower extremity model. The fatigue life of the ACL was also predicted by assuming the estimated ACL force as a cyclic load. The ACL force and strain reached their maximum values within a short time just after ball-impact in the follow-through phase. The smaller knee flexion, higher internal tibial rotation, increase of the joint compressive force and knee abduction moment in the follow-through phase were shown as to lead an increased ACL loading. The number of cycles to fatigue failure (fatigue life) in the ACL might be several thousands. It is suggested that the excessive training or practice of swing motion without enough rest may be one of factors to lead to damage or injury in the ACL by the fatigue failure. The present technology can provide fundamental information to understand and prevent the ACL injury for golf players.     

Kinematic evaluation of cruciate-retaining total knee replacement patients during level walking: A comparison with the displacement-controlled ISO standard

Differences between wear-scar features of simulator-tested and retrieved tibial total knee replacement (TKR) liners have been reported. This disagreement may result from differences between in vivo kinematic profiles and those defined by the International Organization for Standardization (ISO). The purpose of this study was to determine the knee kinematics of a TKR subject group during level walking and compare them with the motion profiles defined by the ISO standard for a displacement-controlled knee wear testing simulator. Twenty-nine patients with a posterior cruciate ligament-retaining TKR design were gait tested using the point cluster technique to obtain flexion–extension (FE) rotation, anterior–posterior (AP) translation and internal–external (IE) rotation knee motions during a complete cycle of level walking. Relative ranges of motion and timing of key points within the in vivo motion data were compared against the same ranges and same key points from the input profiles of the displacement-controlled wear testing standard ISO14243-3. The subjects exhibited a FE pattern similar to ISO, with an insignificant difference in range of FE rotation from midstance to terminal stance. However, the subjects had a significantly higher range of knee flexion from terminal stance into swing. The subjects also exhibited a phase delay for the entire gait cycle. For AP translation, the standard profile had statistically significant lower magnitudes than seen in vivo. Opposite pattern of AP motion was also apparent from midstance and swing. Similarly, ISO specified a smaller IE total range of rotation with a motion pattern in complete opposition to that seen in vivo. In conclusion, significant differences were found in both the magnitudes and pattern of in vivo motion compared with ISO.     

The effect of patella taping on vastus medialis oblique and vastus laterialis EMG activity and knee kinematic variables during stair descent

The purpose of this study was to evaluate the effect of patella taping in normal subjects. Previous work has established positive effects of patella taping on patellofemoral pain syndrome patients, but the mode of action remains unclear. It has been hypothesized that taping brings about subtle changes in the internal physiological environment of the joint. It could be expected that in normal joints taping would bring about a measurable change in function, as the joint is no longer operating in an optimal physiological environment. 10 normal female subject’s (21.4 ± 1.2 years) vastus medialis oblique (VMO) and vastus laterialis (VL) EMG activity and knee kinematics (peak stance flexion angle and angular velocity) were assessed during a step descent, with and without a taped patella. The effect of taping was to significantly decrease VMO and VL EMG activity. Taping also significantly reduced peak stance phase knee flexion and peak stance phase knee flexion angular velocity. In normal asymptomatic subjects patella taping created a situation in which their performance was changed to one similar to that of the pathological patellofemoral pain syndrome population. It would appear that taping caused the joint to function sub-optimally supporting the hypothesis that taping could change the functioning of the patellofemoral joint.     

Computational stability of human knee joint at early stance in Gait: Effects of muscle coactivity and anterior cruciate ligament deficiency

As one of the most complex and vulnerable structures of body, the human knee joint should maintain dynamic equilibrium and stability in occupational and recreational activities. The evaluation of its stability and factors affecting it is vital in performance evaluation/enhancement, injury prevention and treatment managements. Knee stability often manifests itself by pain, hypermobility and giving-way sensations and is usually assessed by the passive joint laxity tests. Mechanical stability of both the human knee joint and the lower extremity at early stance periods of gait (0% and 5%) were quantified here for the first time using a hybrid musculoskeletal model of the lower extremity. The roles of muscle coactivity, simulated by setting minimum muscle activation at 0–10% levels and ACL deficiency, simulated by reducing ACL resistance by up to 85%, on the stability margin as well as joint biomechanics (contact/muscle/ligament forces) were investigated. Dynamic stability was analyzed using both linear buckling and perturbation approaches at the final deformed configurations in gait. The knee joint was much more stable at 0% stance than at 5% due to smaller ground reaction and contact forces. Muscle coactivity, when at lower intensities (<3% of its maximum active force), increased dynamic stability margin. Greater minimum activation levels, however, acted as an ineffective strategy to enhance stability. Coactivation also substantially increased muscle forces, joint loads and ACL force and hence the risk of further injury and degeneration. A deficiency in ACL decreases total ACL force (by 31% at 85% reduced stiffness) and the stability margin of the knee joint at the heel strike. It also markedly diminishes forces in lateral hamstrings (by up to 39%) and contact forces on the lateral plateau (by up to 17%). Current work emphasizes the need for quantification of the lower extremity stability margin in gait.     

Altered biomechanical strategies and medio-lateral control of the knee represent incomplete recovery of individuals with injury during single leg hop

Anterior cruciate ligament (ACL) injury can result in failure to return to pre-injury activity levels and future osteoarthritis predisposition. Single leg hop is used in late rehabilitation to evaluate recovery and inform treatment but biomechanical understanding of this activity is insufficient.     

The effect of fixed charge density and cartilage swelling on mechanics of knee joint cartilage during simulated gait

The effect of swelling of articular cartilage, caused by the fixed charge density (FCD) of proteoglycans, has not been demonstrated on knee joint mechanics during simulated walking before. In this study, the influence of the depth-wise variation of FCD was investigated on the internal collagen fibril strains and the mechanical response of the knee joint cartilage during gait using finite element (FE) analysis. The FCD distribution of tibial cartilage was implemented from sodium (²³Na) MRI into a 3-D FE-model of the knee joint (“Healthy model”). For comparison, models with decreased FCD values were created according to the decrease in FCD associated with the progression of osteoarthritis (OA) (“Early OA” and “Advanced OA” models). In addition, a model without FCD was created (“No FCD” model). The effect of FCD was studied with five different collagen fibril network moduli of cartilage. Using the reference fibril network moduli, the decrease in FCD from “Healthy model” to “Early OA” and “Advanced OA” models resulted in increased axial strains (by +2 and +6%) and decreased fibril strains (by −3 and −13%) throughout the stance, respectively, calculated as mean values through cartilage depth in the tibiofemoral contact regions. Correspondingly, compared to the “Healthy model”, the removal of the FCD altogether in “NoFCD model” resulted in increased mean axial strains by +16% and decreased mean fibril strains by −24%. This effect was amplified as the fibril network moduli were decreased by 80% from the reference. Then mean axial strains increased by +6, +19 and +49% and mean fibril strains decreased by −9, −20 and −32%, respectively. Our results suggest that the FCD in articular cartilage has influence on cartilage responses in the knee during walking. Furthermore, the FCD is suggested to have larger impact on cartilage function as the collagen network degenerates e.g. in OA.     

Analysis of muscle activation patterns during transitions into and out of high knee flexion postures

Increased risk of medial tibiofemoral osteoarthritis (OA) is linked to occupations that require frequent transitions into and out of postures which require high knee flexion (>90°). Muscle forces are major contributors to joint loading, and an association between compressive forces due to muscle activations and the degeneration of joint cartilage has been suggested. The purpose of this study was to evaluate muscle activation patterns of muscles crossing the knee during transitions into and out of full-flexion kneeling and squatting, sitting in a low chair, and gait. Both net and co-activation were greater when transitioning out of high flexion postures, with maximum activation occurring at knee angles greater than 100°. Compared to gait, co-activation levels during high flexion transitions were up to approximately 3 times greater. Co-activation was significantly greater in the lateral muscle group compared to the medial group during transitions into and out of high flexion postures. These results suggest that compression due to activation of the medial musculature of the knee may not be the link between high knee flexion postures and increased medial knee OA observed in occupational settings. Further research on a larger subject group and workers with varying degrees of knee OA is necessary.